Patient evaluation –a clinical perspective
Eskild Petersen
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The febrile patient/imigrant/returning travellers
Questions ? Destination
Immunizations
Malaria prophylaxis
Activity/exposure
Physical examination Rash
Cough
Abdomen, hepato-splenomegaly
UTI symptoms
CNS status
Glands
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Initial laboratory tests
Blood culture
Hb, Leucocyte and differential count, thrombocytes
CRP, ESR
Liver enzymes (ALAT)
Na, K, creatinine, BUN
Chest X –ray
Urine for leucocytes, blood, protein and culture
Feces culture
Thick blood film for malaria microscopy x 3 (if appropriate)
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Special tests
Total IgE
Ultrasound abdomen; CT Thorax, abdomen
Mantoux or Quantiferon®
Antibodies:
Schistosomiasis, Dengue, HIV, HBV, HAV, rickettsia and others...
Sputum:
Culture, PCR for virus and atypical bacteria, legionella
And many others !
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Nelly is 14 months and has been 4 weeks in Ghana with her mother
Returned 10 days ago, she has now had fever for more than a week
Nellys mother and her doctor thought the fever was due to new teeth
On day 7, 39,8 C and admitted.
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Differential diagnosis
Measles
Salmonella typhi
Dengue fever
Malaria
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Kwasiorkor & scabies
23 months old girl adopted from Peru.
Diffuse rash, apparently itching
No fever
Lab.:
Haematocrit 30
Leucocytters 9,8 (normal)
Differential count: Normal
Creatinine 63 (normal)
Urine. No protein, cells or blood.
Diagnosis ?
Scabies
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46 year old women, travelled 4 ½ week in Kenya.
Returned 2 months before admission
The first week after return diarrhoea. Micrscopy shows
Blastocystis and she recveive Metronidazol 500 mg x 3 for 7 days.
Some improvement.
Over the past 3 to 4 weeks increasing headacke, poor appetite and
lost 4 kilo’s in weight.
Over the past 3 to 4 days progressing reduced power in right upper
arm, ”feeling cold” in right leg, hoarse and problems swallowing
and the day before admission double sight.
Investigations ? Lab. Tests ?
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Signal changes in the
right side of the brain
stem with
enhancement after
administration of
contrast
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Spinal tap shows 130 cells with 106 mononuclear, protein 0.66 (<0.5)10 days later 22 cells with protein 0.48.
L+D 8.6 eos 3.0 (<0.5) CRP 5.2 (<8 mg/l) total IgE 39 (<150 IU/ml)
The patnet is awake, oriented
Cranial nerve 2: Normal visual fields for fingers on both eyes.Cranial nerve s3,4,6: sligth ptose on the right eye. Right pupil sligthly smaller compared to left. Normal reaction for light. Normal eye movements, but slight doubble sight wehn looking at left.Cranial nerve 5: Slight dysarthria, normal sensitivity for touch in the face , normal corneal reflexCranial nerve 7: Discrete fascialis paresisCranial nerve 8: Normal hearing (finger snapping)Cranial nerves 9,10: Palate paresis, hoarse,Cranial nerve 11: Lift shoulders with good force and no side differenceCranial nerve 12: No deviation of the tongue
Reduced force whih dorsal flexion of the right hand Reduced force whith dorsal flexion of the right foot.Right side reflexes weakther than left siden. Pos. bilateral Babinski
Reduced sensitivity for touch entire right upper arm
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Tests
Blood culture x 2: negative
Malaria microscopy x 3: negative
Feces microscopy for parasites x 8: Negative
Feces culture: No pathogens incl. Clostidium difficily
Respiratory secretions: Negative by PCR for influenza A og B,
adenovirus, RSV-virus, chlamydia pneumoniae , mycoplasma
and legionella.
Spinal tap: Nagative by PCR for Tuberculosis
What else to test for ?
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10th March 2011
Pt. Has a positive GAA-antibody test (Schistosomiasis). GAA = Gut
Associated Antigen, titer 1:512 (Cutt off 1:16)
Treated with tabl. Praziquantel 2400 mg daily for 3 days
´Discharged with minor symptoms to out patient follow up
The patients son was also diagnosed with Schistosomiasis (not CNS)
and treated.
Diagnosis: CNS schistosomiasis
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Gut Associated AntigenAntibodies against GAA is associatedwith acute infection
Membrane Bound AntigenAntibodies against MBAis associated with chronicinfection
Tarp et al. Trop Med Intl Hlth 2000,5:185-91
We see about 50 Danes with fresh schistosomiasisinfections every year
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18 year old Somali male, immigrated to DK in 2003
March 2008 abdominal pains, normaal stools, no diarrhoea
Physical examination at admission
Afebrile
No glads on the neck, in axilla or groins
Cardiac and lung stetoscopy: normal
Abdomen: sligth tendernes in the right fossa
Lab tests? Other test ?
Differential diagnosis ?
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Tuberculin Skin test ?
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010989-3641
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History: 45 year old woman with a 2 year history of progressive development of slightly tender papules and nodules that continue to appear throughout the body including face, neck, trunk, scalp, and extremities. On no medications. No ulceration or discharge from any lesions. Sporadic headaches – some lasting for days – have occurred in the past 4 years. No fever, weight loss or systemic symptoms. No past illnesses.Epidemiology: Born and lives in Lima. Sporadic visits to rural farming areas in the highlands to visit family. No known TB exposures or HIV risk factors. Physical Examination: Afebrile. BP 110/60, HR 70, RR 16. Multiple firm mobile subcutaneous nodules of 1-2 cm on the scalp, trunk, extremities, and face, with normal overlying skin [Images A(leg) and B]. Chest clear. CVS normal. No organomegaly or lymphadenopathy. CNS: no fundus abnormalities or papilledema, normal cranial nerves, normal motor and sensation. Laboratory Results: Hematocrit 35%. WBC 7.5 (50 PMN, 30 lymphs, 8 monos, 10 eosinophils, 2 basophils). Liver function normal. A biopsy of a skin lesion was performed [Image C].
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Discussion: The biopsy showed a large cystic structure with a homogenous histiocytic wall and eosinophils surrounding the cystic space. Western blot was positive for cysticercosis. MRI of the brain showed at least 30 cysts with perilesional edema and a hyperintense intracystic point on FLAIR images corresponding to the scolex of the larvae [Images D and E]. No intraventricular lesions or signs of intracranial hypertension were seen. No calcified lesions were seen on CT scan (not shown). Cysticercosis is infection with the larval stages of the human pork tapeworm Taenia solium. Humans acquire cysticercosis after ingesting eggs of T. solium in material contaminated with feces originating in human tapeworm carriers. Humans that do not eat pork can get cysticercosis. Ingestion of contaminated pork results in humans getting an adult intestinal tapeworm – not cysticercosis. Cysticercosis is common in many developing countries
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73 year-old male admitted with a-16-day history of abdominal pain, initially diffuse but then localizing to the right upper quadrant, high fever and chills. Four days after onset, he noticed dark urine followed by jaundice, and 2 days later he developed vomiting and increasingly severe abdominal pain.
Physical Examination: 37.0°C oral, pulse 86, normal BP. Mild scleral icterus, no rash; no lymphadenopathy. Decreased respiratory sounds in the base of the right lung. Liver palpated 3 cm below the right costal margin, no splenomegaly. Laboratory: (hospital Day 3) Hemoglobin 10.6 g/dl; WBC 14,200 (84% neutrophils, no bands, no eos); normal platelets. ALT 56 (N <40), Alk Phosp elevated at 395; total bilirubin 7.6 mg/dl (direct 4.8 mg/dl); total protein 5.8 g/dl with a low albumin of 2.3 g/dl. Abdominal CT is shown [Image A]. Stool examination was negative for ova and parasites.
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An ultrasound guided percutaneous aspiration [Image B] of the liver was performed and yielded 600cc of a brown-red material [Image C]. The material had very few PMNs but mostly cellular detritus. No trophozoites were seen in the abscess material; a typical situation which is a result of the invasive trophozoites being localized only to the periphery of the cavity in contact with viable liver tissue.
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29-year old Danish women, travelling for 4 months in India and Nepal
Received relevant immunizations and malaria prophylaxis
Returned to DK 4 weeks ago
Now 6 to 10 loose stools daily, no blood
Lab. test: normal
Tests?
Differential diagnosis
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Danish male, Travelled 6 months
in PeruDevelop slowly
growing sore at leftUpper arm 3 months
after returnNo fever
Lab. test : i.a.
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Patient Q 2010
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Rash and fever in a returning traveller
Returned 3 days ago
From a 14 days visit
to Thailand
Fever on the day of
departure
Thrombocytes
32.000. (>350.000)
?
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37 year old refugee from Congo
Arrived 1 week ago from a refugee camp in Uganda, where she has beenliving for 8 years.
History: No fever, no specific symptoms except a slight cough withwhite sputum
Perhaps a slight weight loss of 5 kg over the last 6 months (w. 59 kg).
Phys ex. BT 180/100, Tp. 37,0 A few glands in the groinsStet. p. et c.: normal
Hb 6,5 SR 34 Leukocytter 7,6 Eosinofile 1,86 (<0,5)
PositivHIV
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Other investigations ?
CT cerebrum: normal
Spinal tap: 22 cells, glucose 2,8, protein 0,62
PCR for HSV, VZV and enterovirus: negative
CD 4 cell count: 240
Total IgE: 1034 (<150)
Borderline pos. Syfilis test in blod, neg. i CSF
Feces cysts and eggs: negative
Serology: Strongyloides and filariasis: negative
Mantoux test: negative
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Diagnosis
HIV
Previous syfilis
Eosinophilia and elevated IgE: unexplained
No TB
Hypertesnion
Develops astma after 6 months
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Patient from west Africa. Eosinophilia and elevatred IgE
Diagnosis ?
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You receive a call from amother an early morning.
She has found a 15 cm long worm in the toilet after her 3 year old son
The child is apparently healthy
The family has been visiting Tenerifa 2 months ago
and Thailand 1 years ago
Diagnostics
Diagnosis ?
Treatment ?
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Cutaneous larvae migrans
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41 old, HIV positive male with not feeling
well for about 2 weeks,
Unspecific rash
CRP 39 (<8), SR 42 (<20)
Primarily suspected
reaction to his HIV drugs
What do you ask him about?
Differential diagnosis
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History: Previously very healthy 62-year old female with 3 months of
fever, severe general malaise, loss of appetite, 10 kg weight loss, right
upper quadrant pain and initially some icterus.
Physical Examination: Pale. Afebrile. Liver non-tender 3 cm below
costal margin. No splenomegaly.
Laboratory Examination: Hematocrit 31. WBC 15,600 with 21%
neutrophils, 18% lymphs and 56% eosinophils.
Blood cultures negative.
Hepatitis A, B, C, serology negative.
Stool O & P and serological tests were ordered.
Available CT image is from 3 months later but is representative of
findings throughout the illness.
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Endoskopy
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The ferry to Djenné, Niger river, Mali
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