Internal medicine cases

Dr. Hayam Hebah.

CASE 1:

• 55 year old male presents to clinic with fever , myalgia and generalised malaise for several weeks.

• There is history of abdominal pain, weight loss and lack of energy . Prior to the assessment she had left foot drop.

• O/E: B.P: 160/90, Pulse 104/min, temp: 38.3°C , no LL edema, tender proximal muscles

• left peroneal nerve damage .• Skin shows the following picture:

• What is the lesion?• What is the DD?• What is missing in examination?• WHAT ARE REQUIRED INVERSTIGATIONS?

livedo reticularis• Primary• Secondary:• Vasculitis autoimmune conditions:

– Livedoid vasculitis - Polyarteritis nodosa ,Systemic lupus erythematosus[, Dermatomyositis, Rheumatoid arthritis ,Lymphoma Pancreatitis[

– Tuberculosis• Drug-related:

– Amantadine ,Bromocriptine • Obstruction of capillaries:

– Cryoglobulinaemia - Antiphospholipid syndrome ,Hypercalcaemia – Haematological disorders of polycythaemia rubra vera or thrombocytosis

(excessive red cells or platelets)– Infections (syphilis, tuberculosis, Lyme disease)– Associated with acute renal failure due to cholesterol emboli status after

cardiac catheterization– Arteriosclerosis (cholesterol emboli)

• CBC: WBCs 14,000/mL• RBCs: 4.5 ; Hb: 10.2• ESR: 105 mm/h• Occult blood in stool: positive• ANCA and ANA showed negative results• HBsAg is positive• DD?• FURTHER INVESTIGATIONS?

• Few days later the patient start to develop oliguria and hematuria with worsening of BP reaching 180/110 .

• Investigations:• Urine---RBCs:10-15/HPF, Prot +• S.creatinine----2.5 mg/dl• Abd u/s---

• What is the diagnosis?• What is the mechanism of renal injury in this

condition?A. Nephrotic syndromeB. Diffuse GNC. GranulomaD. Necrotizing vasculitis of vesselsE. Small vessel involvement.

• How to confirm diagnosis?• Angiography• Muscle or sural nerve biopsy

Polyarteritis nodosa

• Any 3 of the following 10 findings is sufficient for the diagnosis of PAN (sensitivity 82%, specificity 86%):

• Mononeuritis multiplex• Myalgias with muscle tenderness• Livedo reticularis• Testicular pain or tenderness• Renal impairment (elevated BUN and creatinine levels)• Weight loss of 4 kg or more• Diastolic blood pressure greater than 90 mm Hg• Hepatitis B positive• Arteriography showing small and large aneurysms and focal

constrictions between dilated segments• Biopsy of small- or medium-sized arteries containing white blood

cell infiltrate• Peripheral eosinophilia (common and an important clue to PAN)

CASE 2:

• A 17 year old Pakistani male was admitted with high-grade fever associated with chills and rigors (40.5–41 °C) for 2 weeks prior to admission. During a course of oral antibiotics he had taken for 5 days, his symptoms had subsided, however the fever recurred on discontinuation of therapy.

• On examination, the patient, a lean, thin individual, appeared toxic and dehydrated. He was tachypneic, tachycardiac and febrile at 38 °C, with an occasional spike up to 40 °C. He was started on symptomatic treatment.

• Biochemical tests on admission showed :• a low white blood cell (WBC) count, with

neutrophilic predominance. • His malaria work-up was negative.• Direct bilirubin of 0.5.• Gamma-GT of 178• alkaline phosphatase 205.• lactate dehydrogenase of 2380.

• A screening ultrasound done showed para-aortic, retro-peritoneal and mesenteric lymphadenopathy, especially in the right iliac fossa and the aorto-caval regions.

• Q:D.D INCLUDES which of the following?1. Tuberculosis 2. malignancy.3. Typhoid fever4. Inflammatory bowel disease5. malaria

• However, 2 days later, the blood culture reports showed that the patient had actually been suffering from enteric fever, with the causative organism Salmonella paratyphi(S. paratyphi) A being sensitive to ampicillin, chloramphenicol, ceftriaxone, co-trimoxazole, and cefixime, and resistant to ciprofloxacin.

Typhoid fever

• The diagnosis is primarily a clinical one, but a definitive diagnosis requires isolation from blood, bone marrow, stool or urine cultures and the diagnosis of typhoid fever is not a simple one, due to its non- specific clinical features and lack of an immediate confirmatory test.

• Initially the drugs of choice for enteric fever were ampicillin, chloramphenicol and co-trimoxazole, however when resistance developed to these drugs ,ciprofloxacin was shown to be very effective.

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