Patient evaluation –a clinical perspective

Eskild Petersen

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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 !

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Differential diagnosis

Measles

Salmonella typhi

Dengue fever

Malaria

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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 ?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Signal changes in the

right side of the brain

stem with

enhancement after

administration of

contrast

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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 ?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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 ?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Tuberculin Skin test ?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

010989-3641

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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].

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Danish male, Travelled 6 months

in PeruDevelop slowly

growing sore at leftUpper arm 3 months

after returnNo fever

Lab. test : i.a.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Patient Q 2010

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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)

?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Diagnosis

HIV

Previous syfilis

Eosinophilia and elevated IgE: unexplained

No TB

Hypertesnion

Develops astma after 6 months

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Patient from west Africa. Eosinophilia and elevatred IgE

Diagnosis ?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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 ?

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Cutaneous larvae migrans

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

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.

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Endoskopy

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The ferry to Djenné, Niger river, Mali

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor