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Presentation shows some real cases from infection diseases hospital and allow you to challenge your knowledge in medicine. After presentation of each case you will see a slide with a question about diagnosis. Try to answer and if you would have problems go to next slide where you will find a hint. Goodluck! If you would interested in new cases please contact Dr Andrey Dyachkov [email protected]
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Botkin's hospital was found in 1882
Clinical cases - Whatch it!
Case 1: 23 y.o. women with jaundice Time of admission: 03 of May 2011 Complains at admission: fatigue, mild nausea,
edema of the legs, icteric scleras Anamnesis morbi: 2 months before admission
patient has expereinced a few episodes of nasal bleeding and mild edema around her ankles in a evenings. She is working in a food store and thought that was related to long hours shifts.
A week before admission she had drunk around 150 ml of vodka and feel weak next day. She had lost appetite, gradually fatigue had been increasing, she noticed a dark urine, edema on her legs and been hospitalized.
Case 1: 23 y.o. women with jaundice Anamnesis vitae: when she was 6 y.o. her father was
diagnosed with liver cirrosis and soon died in his 45 y.o. At that time our patient was examined by pediatric-hepatologist and infection diseases specialist and moderate ALT level elevation was found. Serological markers of viral hepatitis including PCR for HBV and HCV was negative.
Since that time till 18 y.o. patient was constantly monitored for liver function (ALT, ultrasound examination, scintigrafia) and only moderate increase of ALT been observed throught these years. Her older brother is IDU and have been diagnosed with chronic HCV couple of years ago.
Since 18 y.o. patient didnt have a medical chek-up. 2 years ago she had moved to St-Petersburg from her hometown in south of Russia and rent a flat with her boyfriend.
Case 1: 23 y.o. women with jaundice Physical examination: 175 cm/62 kg, scleras and skin
were subicteric, moderate edema of the legs, moderate ascitis, liver was 5 cm below costal margin
Laboratory tests:
- CBC count HGB 11,3 g/dl, RBC 3,42, MCV 100,3, WBC 8,59, PLT 138
- HCV, HAV markers were negative.
- ALT 78 E/l, AST 163E/l, BL 73 mkmol/l (39/35), GGTP 250E/l, CREAT&UREA — N, Protrombin index 54%
- Proteinigramme: serum protein 60,7 g/l, alb 48,3%, gamma-globulin 25,2%
Ultrasound — cirrosis, ascitis, Endoscopy — varicosal esophagial viens stage 2
Case 1: 23 y.o. women with jaundice For 7 days on therapy her condition was gradually
worsened and she been showed to physician in charge in 8 pm (7 in-hospital days)
Patient looked very weak, wasnt able to sit down in bed and walk without assistance, her jundice was very intensive (in contrast to a morning notes of her doctor), moderate ascitis and leg edema was presented, her 24h urine volume was decreased to 300 ml and color of urine was dark-brown
Lab test from express lab showed: Bl 443 mkmol/l (284/158), HGB 5,5 g/dl, RBC 1,9, Protrombin index 50%
Patient was transfered to ICU
Case 1: 23 y.o. women with jaundice What is a diagnosis?
Case 1: 23 y.o. women with jaundice Autoimmune markers
was negative, circulating immune complexes increased 3 times
Ophtalmologist described an accumulation of a pigment on her corneal limbus (so called Kaizer-Fleishner ring)
Case 1: Wilson's disease
Case 1: Wilson's disease
Case 1: Wilson's disease
Ceruloplasmin: 110 mg/l (180-450) Serum Cu: 43 mkmol/l (12,6-24,4) Patient was treated with plaqenil and dialisis,
consulted with transplantologist but developed a liver/kidney insuficency, hemorragic syndrome, became comatousus and died with a signs of POIS after 18 days in ICU.
Case 2: 28 y.o. men with hemocolitis Admission date: 02 of Aug 2005 Complains at admission: fatigue, bloody diarhea,
false attemts, cachexia, fever 38 C. Anamnesis morbi: Patient was transfered to
hospital from psychiatric hospital were he was treated for shizophrenia from 27.07.05 till 02.08.11 (first time diagnosed in 2002). Spent 4 month in India — had a diarrhea and fever 39-40 C since April 2005 and had lost 23 kg (75to52 kg) .
He didnt take any drugs or vaccine for prevention of infections.
Had appendectomy in 14 y.o.
Case 2: 28 y.o. men with hemocolitis Physical examination: 182cm/53kg, scleras and
skin were pale, cachexia, his sigma was spastic and painful, liver was 8 cm below costal margin and slightly painful on palpation
Laboratory tests:
- CBC count HGB 10,48 g/dl, RBC 3,6, WBC 12,6, left shift, ESR 50 mm/hour
- HCV, HAV markers were negative.
- ALT 35 E/l, AST 60 E/l, BL 14 mkmol/l, CREAT&UREA — N,
- Coprogramme: WBC 35-40&RBC 1-2 per view Stool culture for bacterial pathogens: negative
Case 2: 28 y.o. men with hemocolitis What is a diagnosis?
Case 2: 28 y.o. men with hemocolitis Rectoromanoscopy:
ulcer in rectum, contact bleeding, edema of the mucous
Ultrasound showed a cavity with fluid in left lobe of the liver 14 cm in diametr
CT scan: cavity in a left liver lobe 9,2*15 cm (abscess?), small hydrotorax in both diaphragmal sinuses
Case 2: Amoebiasis
Case 2: Amoebiasis
Case 2: Amoebiasis
Case 2: Amoebiasis
Our patient was on metronidazol, chlorochuine and doxicyclin for 3 weeks and had a surgical treatment for dreinage of liver abscess after that (300 ml of white purulent liquid was evacuated). Patient was discarged in normal condition after spending 2 months in hospital.
Case 3: 80 y.o. women with headache Time of admission; 24 of Jul 2011 Complains at admission: fever 38 C, night sweets,
constant diffuse headache, sometimes acute sharp pain in occipital zone, neck stifness
Anamnesis morbi: 1,5 months ago patient developed a heavy night sweets, fever up to 39 C, which was poorly reactive to antipyretics and headache wich was more prominent on her occipital zones where sometimes during a day it was stinging
One week after outset of the disease she had to call a ambulance service at home because of severe headache and joint stifness. She had a shot of meloxicam after which all symptoms was gone till next morning.
Case 3: 80 y.o. women with headache Anamnesis morbi: Patient visited outpatient
clinic where Xray of neck was perfomed with neurologist examination after that. Patient was prescribed oral nonsteroid antiinflamatory drus for osteochondrosis with no effect.
She has also received a 7 day course of cyprofloxacin for what they doctors thought was urinary infection. This course also was ineffective.
Patients was referred to infection disease hospital with a diagnosis of meningitis on 35 day after disease outset.
Case 3: 80 y.o. women with headache Anamnesis vitae: Patient sufffer arterial
hypertension stage 2, coronary heart disease (refuse to have a myocardial infarction or stroke before), podagra, varicose vein disease of legs, systemic osteoporosis
Physical examination: 156 cm/48kg, scleras and skin were clean and slightly pale, rotation of the head in to both sides was slightly painful, neck stifness symptoms was positive, Kerniga's symptom negative, no focal neurological symptoms were found.
Case 3: 80 y.o. women with headache Consultations: Patient was examined by neurologist
and ophtalmologist who didnt find any acute changes and describe diffuse osteochodrosis and angiopathy of the retina respectively. LP was postponed.
Laboratory tests: - CBC count HGB 11,2 g/dl, RBC 3.8, WBC 12,8,
ESR 66 mm/hour
- Potassium 4,8 mmol/l, Sodium 144,7 mmol/l - ALT 45 E/l, AST 34 E/l, BL 17 mkmol/l,
CREAT&UREA — N - Proteinogramme: serum protein 67,1 g/l, alb
45,9%, gamma-globulin 17,7%
Case 3: 80 y.o. women with headache Patient recieved I.V. ceftriaxone 1g bid, 500 ml of
I.V. Infusion, vitamins amd antipyretics with no effect.
On this therapy all symptoms had been persisting and 7 days after hospitalization she developed a double vision on her right eye.
Case 3: 80 y.o. women with headache What is a diagnosis?
• Palpation of her temporal arteries revialed a numerous small solid nodules on them
Case 3: 80 y.o. women with headache
Case 3: Horton's disease • The symptoms of
Temporal (Giant Cell) Arteritis
• Severe headaches
• Pain and tenderness in one or both temples
• Jaw pain, especially when chewing
• Double vision
• Vision loss
• Pain and stiffness in the neck and arms
• Unintended weight loss
Case 3: Horton's disease
• The symptoms of PMR include:
• Aching pain and stiffness in the neck, shoulders, hips and thighs
• Fatigue
• General muscle
weakness
• Unintended weight loss
About half of people who have GCA also have Polymyalgia rheumatica (PMR).
Case 3: Horton's disease
Patient was treated with per oral prednizolone 8 tabl daily (5 mg/tabl) with which fever and headache disapeared on 3rd day but double vision persisted. Patient was transfered to city's reumatology center.
The diagnostic criteria of the American College of Rheumatology
Three of the following criteria to allow the diagnosis :* Age greater than or equal to 50 years* Headache of recent onset localized,* Indurated temporal artery or reduction/abolition of the temporal pulse,* Sedimentation rate (VS) exceeding 50 mm in first hour* Positive arterial biopsy showing infiltration by mononuclear or granulomatous inflammation with or without giant cells.
Their sensitivity is 93.5% and specificity 91.2%.
Case 4: ??????????????
• The symptoms of PMR include:
• Aching pain and stiffness in the neck, shoulders, hips and thighs
• Fatigue
• General muscle
weakness
• Unintended weight loss
•
About half of people who have GCA also have Polymyalgia rheumatica (PMR).
•
