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Handle with care
e104 A 62 year old woman of Somalian origin presented with a two week history of fever, drenching night sweats and anorexia, and a two day history of a sore throat and swollen neck. She also complained of generalised arthralgia affecting her knees, back and shoulders which had begun following a trip to Somalia, five months previously. The initial clinical history was incomplete owing to language difficulties. On examination, she appeared uncomfortable and was febrile, temperature 38 C. Her neck was markedly swollen and painful to palpation although examination of her throat and oropharynx was unremarkable. There was pain on movement of the neck, upper limbs and lumbar spine. Cardiovascular, respiratory, abdominal and neurological examinations were unremarkable. Admission CRP was 400, WBC 11 (9.0 neutrophils) and Hb 10.9 (normochromic, normocytic). Renal and liver function normal. CXR unremarkable; lumbar spine XR showed degenerative change. A diagnostic test was performed and confirmed on culture. Answer and lessons learnt: The patient is resident in the UK but travels frequently to visit friends and relatives in northern Somalia. During her trips, she makes a point of drinking camels’ milk twice daily, a local delicacy believed to have great therapeutic value. Brucella serology was positive in this patient and Brucella melitensis was isolated from blood cultures on day 4 of admission. She made a good recovery on streptomycin, doxycycline and rifampicin. This case emphasises the importance of careful history taking. What had assumed to be part of a ‘generalised’ body ache was in fact a specific symptom of brucellosis. The diagnosis was considered upon direct questioning regarding the ingestion of unpasteurised milk. The incidence of infection of domestic camels with Brucella spp. varies according to farming intensity but can be up to 8% in this region. Brucella spp. can be demonstrated in the milk obtained from infected camels.
P 133 HANDLE WITH CARE Darling K, Davies F, Kidd M Dept of Infection, St Thomas’ Hospital, London A 39 year old health care worker presented with a three day history of fever, malaise and abdominal discomfort, and a one day history of a pustular, vesicular rash, one week after returning to the UK from Nigeria. There was no history of contact with anyone unwell or with a similar rash. On direct questioning, she had tested negatively for HIV seven months previously. On examination, she was febrile at 38.3 C, had conjunctival suffusion and was mildly obtunded. She had a florid, papular rash associated with deep, fleshy vesicles over her face, forearms, palms and soles, with relative sparing of her trunk and abdomen. Some lesions had the appearances of pustules. She had symmetrical, non-tender inguinal and axillary lymphadenopathy.
Abstracts A diagnostic test was performed. The differential diagnoses of the clinical findings are discussed and the immediate management steps including infection control are described. Answer and lessons learnt The appearances and distribution of the vesicles raised the concern of smallpox infection. The patient was isolated immediately. A scrape was taken from one of the lesions over the patient’s forearm and examined under electron microscopy in-house. A diagnosis of disseminated varicella zoster infection was made and confirmed on immunofluorescence and PCR. The patient tested positive for HIV, with a CD4 count of 24. She made a good recovery on intravenous aciclovir and was commenced on HAART. There are two learning points from this case. Firstly, in this age of potential bioterrorist attack, infection with smallpox should be considered in any patient who presents with fever and a centrifugal vesicular rash. Secondly, we demonstrate how atypical the presentation of familiar pathogens can be in advanced HIV infection.
P 134 FULMINANT HEPATIC FAILURE DUE TO ACUTE HEPATITIS SECONDARY TO PLASMODIUM FALCIPARUM MALARIA Albur MS, McKendrick MW Dept of Infectious Diseases & Tropical Medicine, Royal Hallamshire Hospital Sheffield According to the WHO, severe hepatic dysfunction and encephalopathy are unusual in malaria although deranged liver function tests are common. However a literature review has recently shown evidence suggesting a correlation of severity (both morbidity and mortality) of P. falciparum malaria and the degree of abnormalities in liver function tests. In this case report we discuss a returning traveler with severe P. falciparum malaria who presented with jaundice, coagulopathy, encephalopathy, foetor hepaticus, acidosis, hypoglycemia to casualty with a 40% parasitic index. Unfortunately he died despite an aggressive management in the intensive therapy unit. Case summary A 47 year old Caucasian man, welder by occupation, presented to A&E two weeks after returning from holiday in Gambia. He gave a history of feeling generally unwell with jaundice, fever, lethargy and anorexia. He had not taken any anti-malarial prophylaxis or any vaccines before his trip. He had reported to friends that he had been bitten by a monkey in Gambia. On admission he looked unwell and deeply jaundiced with foetor hepaticus and generalised ecchymosis. Vital signs revealed Temperature 34C; BP 155/86; Pulse 98 bpm; Peripheral circulatory shut down with CRT >6 seconds and SpO2 95% on high flow oxygen. Abdominal examination revealed mild distension with sluggish bowel sounds and no organomegaly. Neurologically
P 133 HANDLE WITH CARE Darling K, Davies F, Kidd M Dept of Infection, St Thomas’ Hospital, London A 39 year old health care worker presented with a three day history of fever, malaise and abdominal discomfort, and a one day history of a pustular, vesicular rash, one week after returning to the UK from Nigeria. There was no history of contact with anyone unwell or with a similar rash. On direct questioning, she had tested negatively for HIV seven months previously. On examination, she was febrile at 38.3 C, had conjunctival suffusion and was mildly obtunded. She had a florid, papular rash associated with deep, fleshy vesicles over her face, forearms, palms and soles, with relative sparing of her trunk and abdomen. Some lesions had the appearances of pustules. She had symmetrical, non-tender inguinal and axillary lymphadenopathy.
Abstracts A diagnostic test was performed. The differential diagnoses of the clinical findings are discussed and the immediate management steps including infection control are described. Answer and lessons learnt The appearances and distribution of the vesicles raised the concern of smallpox infection. The patient was isolated immediately. A scrape was taken from one of the lesions over the patient’s forearm and examined under electron microscopy in-house. A diagnosis of disseminated varicella zoster infection was made and confirmed on immunofluorescence and PCR. The patient tested positive for HIV, with a CD4 count of 24. She made a good recovery on intravenous aciclovir and was commenced on HAART. There are two learning points from this case. Firstly, in this age of potential bioterrorist attack, infection with smallpox should be considered in any patient who presents with fever and a centrifugal vesicular rash. Secondly, we demonstrate how atypical the presentation of familiar pathogens can be in advanced HIV infection.
P 134 FULMINANT HEPATIC FAILURE DUE TO ACUTE HEPATITIS SECONDARY TO PLASMODIUM FALCIPARUM MALARIA Albur MS, McKendrick MW Dept of Infectious Diseases & Tropical Medicine, Royal Hallamshire Hospital Sheffield According to the WHO, severe hepatic dysfunction and encephalopathy are unusual in malaria although deranged liver function tests are common. However a literature review has recently shown evidence suggesting a correlation of severity (both morbidity and mortality) of P. falciparum malaria and the degree of abnormalities in liver function tests. In this case report we discuss a returning traveler with severe P. falciparum malaria who presented with jaundice, coagulopathy, encephalopathy, foetor hepaticus, acidosis, hypoglycemia to casualty with a 40% parasitic index. Unfortunately he died despite an aggressive management in the intensive therapy unit. Case summary A 47 year old Caucasian man, welder by occupation, presented to A&E two weeks after returning from holiday in Gambia. He gave a history of feeling generally unwell with jaundice, fever, lethargy and anorexia. He had not taken any anti-malarial prophylaxis or any vaccines before his trip. He had reported to friends that he had been bitten by a monkey in Gambia. On admission he looked unwell and deeply jaundiced with foetor hepaticus and generalised ecchymosis. Vital signs revealed Temperature 34C; BP 155/86; Pulse 98 bpm; Peripheral circulatory shut down with CRT >6 seconds and SpO2 95% on high flow oxygen. Abdominal examination revealed mild distension with sluggish bowel sounds and no organomegaly. Neurologically