Case Discussion for CME
-
Upload
vivek-bhat -
Category
Documents
-
view
219 -
download
0
Transcript of Case Discussion for CME
-
8/10/2019 Case Discussion for CME
1/19
Clinical case 1
-
8/10/2019 Case Discussion for CME
2/19
History
A 45 y male presented with:
high-grade fever, intermittent,
moderately severe headache lasting 6 days associated with multiple
episodes of vomiting,
and altered sensorium for 2 days
Patient was not a known case of TB, Diabetes, HTN, no surgery performed in
the past.
He was diagnosed with HIV -1 infection 2 yrs ago and was started on ARVs.
-
8/10/2019 Case Discussion for CME
3/19
History & Examination
On examination:
Glasgow coma scale of E1M5V1.fever of 100C,
pallor, cachexic
Systemic:
-CNS: Patient had altered sensorium,
showing signs of meningitis (Kernigssign,
Brudzinskissign positive)
-RS, CVS, P/A normal
Relatives informed that the patient would NOTtake his Anti-Retroviral Therapy
medication regularly. Patient was not on any other drugs.
-
8/10/2019 Case Discussion for CME
4/19
Investigations
CBC, S. electrolytes, Renal function tests, Liver function tests A lumbar puncture was done & CSF collected
CSF Routine, microscopy, biochemical parameters
CSF for bacterial and fungal cultures
-
8/10/2019 Case Discussion for CME
5/19
Labs
Laboratory investigations revealed:
Total leukocyte count = 12,900/cumm with 86% neutrophils. Serum electrolytes, renal function tests, and liver function
tests were within normal limits.
The cerebrospinal fluid (CSF) examination revealed 80 WBCs,predominantly lymphocytes (90%)
with protein of 54.7 mg/dl
Glucose of 38 mg/dl (corresponding blood glucose was 136 mg/dl).
A computerized tomography (CT) scan of the head and a chest X raywere both normal
-
8/10/2019 Case Discussion for CME
6/19
Microbiology
Bacterial cultures: negative
India Ink examination of the CSF
-
8/10/2019 Case Discussion for CME
7/19
Culture on SDA after 72h incubation at 30C.
Urease positive
Colonies on Sabouraud dextrose agar are cream to
beige and mucoid due to the capsule surrounding
the yeast cells. This was also confirmed with the
Vitek 2 yeast identification system.
Diagnosis: cryptococcal meningitis
-
8/10/2019 Case Discussion for CME
8/19
Appearance Protein
( mg/dl)
Glucose
(mg/dl)
WBC /
cumm
Micro/Sero/Other
Normal -
LP
Clear, colorless 10- 45 45 - 80 0 - 5
Acutepyogenic
meningitis
Purulent,slightly yellow,
delicate clot
501500(100- 500
common)
0 - 45 25- 10,000most PMNs
( 80 %)
Grams -60-90 % sens.Culture 80% sens & 100
% specific.
DirectAg up to 70 %
sens, 99 % specific.
TB
meningitis
Opalescent,
clot /cobweb
45 - 500 10 -45 10 -100
most
Lympho-
cytes
AFB25 % sens Culture
-75 % sens PCR is 100%
specific.
Aseptic
Meningitis
Clear, turbid or
xantho-chromic
20 - >200 N 500
usually; first
PMN, later
mono
All bact. culturesve
Seroconversion Specific
IgM Direct Antigen/
PCR Cultures - viral
Fungal
meningitis
Normal 50- 300 Moderate
in 55 %
800
(lympho >
PMN)
India ink50 % sens
Crypto Ag90 %
Culture90 % sens.
-
8/10/2019 Case Discussion for CME
9/19
Clinical Case 2
-
8/10/2019 Case Discussion for CME
10/19
History
A 25 year old female came with history of
fever since 4 days (continuous and high grade)
headache since 4 days abdominal discomfort & constipation since 3 days
Patient was not a known case of TB, Diabetes, HTN,
no surgery performed in the past. Not on any
medication.
-
8/10/2019 Case Discussion for CME
11/19
On examination
On examination:
Fever of 102C
Pulse rate of 90/min
No other significant findings in general or systemic
examination.
USG abdomen showed mild splenomegaly
-
8/10/2019 Case Discussion for CME
12/19
Investigations CBC with ESR
PS for MP Widal test
Dengue serology
Blood for C/S
-
8/10/2019 Case Discussion for CME
13/19
Labs
The CBC showed WBC count per 6800/ mm3(N =57%, L= 36%,M=04%, E= 03%)
platelet count 220000/L
Hemoglobin 10.2 g/dl.
ESR 60 mm at 1h.
Serum urea and creatinine normal
Urinalysis normal.
Dengue IgM, IgG, NS1 Ag Negative
PS for Malaria- Negative
Widal : O/neg; H/1:20, AH & BH neg.
-
8/10/2019 Case Discussion for CME
14/19
Cultures
The next day the bottle
flashed positive in the
automated Blood culture
system
Grams stained smear was
prepared. Showed Gram
negative bacilli. Subcultured
on to Blood agar,
MacConkey agar plates
Sensitivity and identification
performed
-
8/10/2019 Case Discussion for CME
15/19
MacConkey Agar
Blood Agar
-
8/10/2019 Case Discussion for CME
16/19
Biochemical Reactions Indole
TSI: K/A with H2S Glucose fermented, Gas
Urease
Citrate
Lysine decarboxylase +
Arginine dehydrolase
Ornithine decarboxylase
Oxidase
Motility +
Methyl Red +
Voges proskauer
-
8/10/2019 Case Discussion for CME
17/19
Widal test
Significant titer of 1: 160 or more for O and H or either isaccepatable in India (in some countries 1:80 and
greater).
It is important to demonstrate a rising titer after 5-7
days. Single Widal may not be useful in endemic areas Widal may be negative in 1stweek of fever.
Accuracy of widal test has been shown to range form
50% to 85% approx. It is a non specific test
Inferior to Blood cultures for specific diagnosis. Blood
cultures usually positive in 1stweek of fever
Still popular because of cost factor & quick results
-
8/10/2019 Case Discussion for CME
18/19
Management
SalmonellaTyphi was reported after confirmation with antisera.
Antimicrobial susceptibility testing was done for
ampicillin,
ceftriaxone,
ciprofloxacin,
co-trimoxazole,
chloramphenicol,
cefixime,
azithromycin.
Found to be Susceptible to cotrimoxazole, ceftriaxone, ampicillin and
azithromycin, intermediate to ciprofloxacin. Patient started onCeftriaxone.
-
8/10/2019 Case Discussion for CME
19/19
THANK YOU