|
| Case of the Week Thursday 4/10/2005 |
Presented by Dr. Shereef Mousa.
Fever of Unkown Origin
Click here to download a power point presentation for the case.
STAFF ROUND PRESENTATION
Prof Dr Nabeel El-Kady
Prof Dr Iman Ramzy
Dr Wahid Doss
Dr Iman Hamza
Dr Dalia Omran
Dr Amr AbdelBary
Dr Amr El-Deeb
Dr Tamer El -Baz
Tamer Ismail
Marwa AbdelBary
Hossam El-Gebaly
Presented by :
Resident: Sherief Musa
PERSONAL HISTORY
• Ismail Mahmoud Ismail , 38 years old male
• Married 21 years ago with 7 offsprings the youngest is 4 years old .
• Farmer.
• Born and living in BeniSuef.
• History of contact with canal water; he received oral anti-schistosomal therapy .
• Smokes 20 cigarettes daily for 20 years.
COMPLAINT
Fever of one year ' s duration
HISTORY OF PRESENT ILLNESS
• The condition started one year ago in the form of acute onset of fever reaching 40 C, which was initially continuous but responded partially to antibiotics and antipyretics .
• Fever was associated with sweating, rigors, malaise, anorexia, headache and generalized bony aches .He lost weight ( about 15 kg )
• There were no cardio-pulmonary complaints in the form of cough, expectoration, hemoptysis , dyspnea or chest pain.
• The condition was not associated with skin rash, no joint pain or swelling , no bleeding tendency
or body masses.
• No abdominal , neurological or renal manifestations
• He complains of diminished hearing and purulent discharge from the left ear for the last 6 months
• No history of foreign travel.
PAST HISTORY
• The patient is not known to be diabetic or hypertensive.
• No history of blood transfusion or surgery.
FAMILY HISTORY
• No similar conditions
• Negative consanguinity
Summary
Male patient 38 y.
Fever of 1 year ' s duration
Rigors, Sweating, Headache, Weight loss
Diminution of hearing
EXAMINATION
General examination :
• The patient is fully conscious, of average intelligence, lying comfortably in bed.
• Pulse :96/min, regular
• Blood pressure :125/85
• Temperature : fever chart
Temperature
Complexion
• Pallor
• No jaundice
• No cyanosis
E.N.T EXAMINATION
• The left drum is perforated , discharging.
• The right drum shows healed perforation.
ABDOMINAL EXAMINATION
• Normal shape and contour
• Right subcostal angle, no divarication of recti
• No visible abdominal wall veins
• No scars or pigmentation
• Liver:
- upper border: 5th space MCL
- lower border: right lobe: not felt
left lobe: not felt
CARDIOLOGICAL EXAMINATION
• Inspection and Palpation :
Apex : in the 5th space
hyperdynamic
• Auscultation :
Muffled 1st heart sound
Murmur :
-pansystolic
-soft
-over the apex
-radiating to the axilla
Summary
38 y old male patient
Fever of one year ' s duration
Cardiac abnormality
Bilateral ear drum perforation
Splenomegaly
DIFFERENTIAL DIAGNOSIS
( FUO of 1 year ' s duration )
• OTHER CAUSES :
• Sarcoidosis
• Familial Mediterranean fever
• Hyperthyroidism , thyroiditis
• Recurrent pulmonary emboli
• Drug fevers
• Factitious fever
INVESTIGATIONS
Urine analysis
• Proteins: (+)
• Glucose: nil
• Acetone: nil
• Bile pigments: nil
• Pus cells: 4-6 /HPF
• RBCs: over 100 /HPF
• Casts: nil
• crystals: nil
24-hours urinary proteins
• Urine volume : 1600 ml/24 h
• Urine proteins : 0.016 g/ dL
• Urine proteins : 0.27 g/24 h (up to 0.15)
Stool analysis :
• NAKED EYE:
-consistency: formed
-reaction: alkaline
-mucus: traces
-blood: nil
-undigested food: nil
-odor: offensive
-color: brown
-pus: nil
-parasites: nil
• MICROSCOPICALLY:
1)Cytology:
-pus cells: rare
-RBCs: rare
-macrophages: rare
2)Digestion:
-vegetable cells: ++
-fat globules: nil
-starch globules: nil
-undigested muscle fibres: nil
CBC
• W. B.Cs : 5100
B 0
E 1
Staf 4
Seg 74
Lymph 19
Mono 2
• RBCs: 4.1 millions
- HGB: 10.4 gm %
- HCT: 29.0
- MCV: 70.7 mild microcytic
- MCH: 25.3 hypochromic anemia
- MCHC: 35.8
• PLATELETS : 138000
ESR
• 1st hour: 66 mm
• 2nd hour: 100 mm
• Serum iron : 68 mcg/dl (37-157)
• TIBC : 300 mcg/dl (250-380)
• Ferritin :89 mcg/dl (16-300 )
Liver biochemical profile
• ALT: 14
• AST: 14
• ALP: 45
• T.BIL: 0.52
• Total proteins: 5.2
• Albumin: 2.9
• A/G ratio: 1.0
Renal functions
• Urea: 22
• Creatinine: 0.9
Electrolytes
• Sodium : 135 mEq / L
• Potassium : 3.8 mEq / L
Coagulation profile
• PT: 13.9 sec
• Control: 12.2 sec
• PC: 78.2%
• INR:1.24
Abdominal Ultrasound
• Liver : average size, homogenous echopattern , smooth surface and normal hepatic veins . There is moderate portal tract thickening, an echogenic focal lesion 6x2cm is seen in area 4 mostly focal fat area .No dilated IHBR . Portal vein is not dilated .
• Gall bladder : average size and wall thickness ,no stones or mud inside . CBD is not dilated.
• Spleen : Enlarged ( longest axis is 18.5 cm) , homogenous echopattern . Splenic vein is dilated (14 mm) .
• Kidneys :Both are of average size with grade II parenchymal echogenicity.
Right kidney measures 14x4.3x1.8 cm.
Left kidney measures 15x5.1x1.8 cm, no typical calculi or back pressure changes.
• Pancreas & Midline structures are normal.
• No ascitis.
Conclusion
• Portal tract thickening.
• Focal fat area in liver.
• Splenomegaly.
• Bilateral parenchymal renal disease.
Upper GI endoscopy report:
• Normal findings
Serology
For:
• EBV
• CMV
• HIV
NEGATIVE
To exclude T.B
• Tuberculin test : Negative
WIDAL TEST
• Typhoid ‘ H ” Negative
• Typhoid “ O ” Negative
• Paratyphoid A Negative
• Paratyphoid B Negative
Malta test
Brucella abortus : 1/320
Brucella melitensis : 1/320
Autoimmune profile
• ANA: -ve
• Anti-dsDNA: -ve
• Rheumatoid Factor: +ve
Echo-Doppler Study
Summary
• Severe degree of mitral valve prolapse;
large, redundant anterior leaflet with severe degree of systolic prolapse.Its tip is directed toward the cavity of the L.A. ( flail anterior leaflet) . Color Doppler examination showed moderate to severe degree incompetence with eccentrically directed jet (toward the lateral wall) . An abnormal mass , freely mobile is seen attached to the chorda of the anterior leaflet (vegetation of SBE &ruptured chorda).
Dilated left ventricular internal dimensions with normal global contractile function, the ejection fraction is 63%.No regional wall motion abnormalities.
Dilated left atrial dimension.
Mildly thickened aortic valve with mild incompetence.
Normal tricuspid valve with mild incompetence.
Pulmonary hypertension, the predicted systolic pulmonary artery pressure is 47mmHg.
Normal right ventricle and atrium
Conclusion
• Flail anterior mitral valve leaflet secondary to ruptured chorda due to vegetation of SBE . Color Doppler shows moderate to severe degree of incompetence.
• Dilated L.V. internal dimensions with normal systolic function. T.R. with pulmonary hypertension .
Blood culture
• Brucella
DIAGNOSIS
INFECTIVE ENDOCARDITIS
Diagnosis of Infective Endocarditis
( Modified Duke Criteria )
Major Criteria
• Positive blood culture
Typical microorganism for infective endocarditis from two separate blood cultures(Viridans streptococci, Streptococcus bovis, HACEK group or Staphylococcus aureus or community acquired enterococci in the absence of a primary focus), or
Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from:Blood cultures (>2)drawn more than 12hr apart, or
All of three or a majority of four or more separate blood cultures, with first and last drawn at least 1hr apart
Single positive blood culture for Coxiella burnetti or antiphase I IgG antibody titre>1:800
• Evidence of endocardial involvement
-Positive echocardiogram [ TEE advised for PVE or complicated IE ].
Oscillating intracardiac mass, on valve or supporting structures, or in the path of regurgitant jets, or on implanted material, in the absence of alternative anatomical explanation, or
Abscess, or
New partial dehiscence of prosthetic valve, or
-New valvular regurgitation [ increase or change in preexisting murmur not sufficient ].
Minor Criteria
• Predisposition : predisposing heart condition or IV drug use .
• Fever > 38.0 C ( 100.4 F ) .
• Vascular phenomena : major arterial emboli , septic pulmonary infarcts , mycotic aneurysm , intracranial hemorrhage , conjunctival hemorrhages , Janeway lesions .
• Immunological phenomena : glomerulonephritis, Osler nodes , Roth spots , rheumatoid factor .
• Microbiological evidence : positive blood culture but not meeting major criterion OR serologic evidence of active infection with organism consistent with infective endocarditis .
DEFINITIVE INFECTIVE ENDOCARDITIS
• Pathological criteria
Microorganisms: demonstrated by culture or histology in a vegetation, or in a vegetation that has embolized, or in an intracardiac abscess,or
Pathological lesions: vegetation or intracardiac abscess present, confirmed by histology showing active endocarditis
• Clinical criteria
Two major criteria, or
One major and three minor criteria, or
Five minor criteria
POSSIBLE INFECTIVE ENDOCARDITIS
• One major criterion and one minor criterion or three minor criteria
REJECTED
• Firm alternative diagnosis for manifestations of endocarditis , or
• Sustained resolution of manifestations of endocarditis, with antibiotic therapy for 4 days or less, or
• No pathological evidence of infective endocarditis at surgery or autopsy, after antibiotic therapy for 4 days or less
• The disease has two distinct phases ; the bacteraemic phase & the intracellular phase.
• Therefore , the effectiveness of any form of therapy depends on the eradication of the circulating organisms & on the ability of the drug to reach the intracellular organisms in effective concentration.
• So , effective treatment of brucellosis requires the use of at least 2 antibiotics , given concomitantly .
• Anticoagulant therapy has not been shown to prevent embolization in infective endocarditis and may increase the risk of intracerebral hemorrhage. Anticoagulant therapy for native-valve endocarditis is restricted to patients with a clear indication separate from infective endocarditis ; in the presence of intracranial hemorrhage or mycotic aneurysm, anticoagulant therapy should be suspended until the complications have resolved. In general, patients with infective endocarditis involving a prosthetic heart valve that requires maintenance anticoagulation are cautiously given continued anticoagulant therapy during treatment of prosthetic-valve endocarditis . However, in the presence of central nervous system emboli with hemorrhage, temporary discontinuation of anticoagulant therapy is appropriate.
|
|
