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Case of the month
Case of the Month Submitted by Eduardo P. Rubin de Celis, MD Prepared by Lawrence M. Tierney, MD Each month, we will present a challenging Case of the Month for The Green Journal readers, who must use their clinical acumen to arrive at the correct answer. We will also post the case each month on the Journal’s web site (http://www.elsevier.com/ locate/ajmselect). Several possible answers may be consistent with the case presentation; use your best judgment. Please send your answer (one per respondent) and indicate the case to which you are responding to The Green Journal at [email protected] or via FAX to (415) 447-2799. Only those answers with a complete mailing address will be considered.
A
64-year-old white man presented for evaluation of a 15 kg weight loss with nausea and vomiting during the preceding 6 months. Two months earlier he had several episodes of passing 3 to 4 loose stools daily. This was ascribed to amiodarone, which had been prescribed for atrial fibrillation and which was discontinued. Six years previously he had undergone mitral valve replacement. His only medication was warfarin. He did not smoke tobacco or drink alcohol. He denied fever, abdominal pain, or melena. On physical examination, he appeared emaciated and pale. He had a temperature of 37.8⬚C, a blood pressure of 130/80 mm Hg, a pulse of 90 beats per minute, and a respiratory rate of 15 per minute. There was no hyperpigmentation or edema. A 2 cm rubbery non-tender right axillary lymph node was palpated. The liver edge was felt 4 cm below the costal margin; it was smooth and slightly tender. The spleen was not felt. There was no occult blood in the stool. The remainder of the physical examination, including a detailed neurological examination, was normal. Laboratory evaluation revealed a hemoglobin of 9.1 g/dL, with a mean corpuscular volume of 85 fL. The leukocyte count was 5,600 per L; the differential was 73% neutrophils, 16% lymphocytes, 6% monocytes, and 3% esosinophils. The erythrocyte sedimentation rate was 60 mm/h. Serum electrolyte and creatinine levels were normal. The serum aspartate aminotransferase level was 23 U/L, the alanine aminotransferase level was 30 U/L, the lactate dehydrogenase level was 288 U/L, the amylase level was 214 U/L, and the albumin was 3.5 g/dL. An abdominal ultrasound examination showed extensive retroperitoneal lymphadenopathy; an upper endoscopy showed chronic gastritis, with an abnormal duodenal mucosa that resembled lymphangiectasia. During the hospitalization, the patient acutely developed a swollen and painful left wrist.
䉷2000 by Excerpta Medica, Inc. All rights reserved.
The correct answer will appear in the April issue of the Journal. The first five persons who submit correct answers will receive a free one-year subscription to the Journal. Colleagues of Dr. Rubin de Celis at the Hospital A. Marcide are not eligible for this month’s case. We will offer special recognition to the clinicians with the most correct answers at the end of the year. If you would like to contribute a case, please submit a brief synopsis (⬍250 words) to the editorial office. An individual may win only once per calendar year. Am J Med. 2000;108:337. 䉷2000 by Excerpta Medica, Inc.
What is the most likely diagnosis?
ANSWER TO THE FEBRUARY CASE OF THE MONTH Last month’s patient with headache, right-sided neck pain, and fever after returning from Thailand had scrub typhus. Her fever resolved after 24 hours of oral minocycline (200 mg daily). Analysis of serum obtained at admission was positive for Rickettsia tsutsugamashi by immunofluorescence (Gilliam, IgG 1:160 and IgM 1:320; Kato, IgG 1:80 and IgM 1:80; Karp, IgG 1:40 and IgM 1:80). Two weeks after treatment, R. tsutsugamashi titers had increased markedly (Gilliam, IgG 1:1,280 and IgM 1:1,280; Kato, IgG 1:640 and IgM 1:640; Karp, IgG 1:320 and IgM 1:320). Scrub typhus is transmitted by a mite that is principally a rodent parasite on mice in endemic areas, including Thailand. The mite lives on plants, but completes its maturation cycle by biting mammals. The site of the bite develops a black eschar. The incubation period is 1 to 3 weeks long. Three-day treatment with doxycycline is adequate (Song J-H et al. “Short-course doxycycline treatment versus conventional tetracycline therapy for scrub typhus.” Clin Infect Dis. 1996;21:506). Correct answers to the December case (herpes simplex virus encephalitis) were supplied by Ajit Singh (Pune, India), P. Dileep Kumar (Richmond Heights, Ohio), Nicholas A. Tritos (Boston, Massachusetts), and JeanJacques Mourad (Paris, France). Several readers suggested use of a more definitive diagnostic test: DNA polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) for evidence of the virus (Lakeman FD et al. “Application of PCR to CSF from brain-biopsied patients and correlation with disease.” J Infect Dis. 1995;171:857).
0002-9343/00/$–see front matter 337 PII S0002-9343(00)xxx-x
A
64-year-old white man presented for evaluation of a 15 kg weight loss with nausea and vomiting during the preceding 6 months. Two months earlier he had several episodes of passing 3 to 4 loose stools daily. This was ascribed to amiodarone, which had been prescribed for atrial fibrillation and which was discontinued. Six years previously he had undergone mitral valve replacement. His only medication was warfarin. He did not smoke tobacco or drink alcohol. He denied fever, abdominal pain, or melena. On physical examination, he appeared emaciated and pale. He had a temperature of 37.8⬚C, a blood pressure of 130/80 mm Hg, a pulse of 90 beats per minute, and a respiratory rate of 15 per minute. There was no hyperpigmentation or edema. A 2 cm rubbery non-tender right axillary lymph node was palpated. The liver edge was felt 4 cm below the costal margin; it was smooth and slightly tender. The spleen was not felt. There was no occult blood in the stool. The remainder of the physical examination, including a detailed neurological examination, was normal. Laboratory evaluation revealed a hemoglobin of 9.1 g/dL, with a mean corpuscular volume of 85 fL. The leukocyte count was 5,600 per L; the differential was 73% neutrophils, 16% lymphocytes, 6% monocytes, and 3% esosinophils. The erythrocyte sedimentation rate was 60 mm/h. Serum electrolyte and creatinine levels were normal. The serum aspartate aminotransferase level was 23 U/L, the alanine aminotransferase level was 30 U/L, the lactate dehydrogenase level was 288 U/L, the amylase level was 214 U/L, and the albumin was 3.5 g/dL. An abdominal ultrasound examination showed extensive retroperitoneal lymphadenopathy; an upper endoscopy showed chronic gastritis, with an abnormal duodenal mucosa that resembled lymphangiectasia. During the hospitalization, the patient acutely developed a swollen and painful left wrist.
䉷2000 by Excerpta Medica, Inc. All rights reserved.
The correct answer will appear in the April issue of the Journal. The first five persons who submit correct answers will receive a free one-year subscription to the Journal. Colleagues of Dr. Rubin de Celis at the Hospital A. Marcide are not eligible for this month’s case. We will offer special recognition to the clinicians with the most correct answers at the end of the year. If you would like to contribute a case, please submit a brief synopsis (⬍250 words) to the editorial office. An individual may win only once per calendar year. Am J Med. 2000;108:337. 䉷2000 by Excerpta Medica, Inc.
What is the most likely diagnosis?
ANSWER TO THE FEBRUARY CASE OF THE MONTH Last month’s patient with headache, right-sided neck pain, and fever after returning from Thailand had scrub typhus. Her fever resolved after 24 hours of oral minocycline (200 mg daily). Analysis of serum obtained at admission was positive for Rickettsia tsutsugamashi by immunofluorescence (Gilliam, IgG 1:160 and IgM 1:320; Kato, IgG 1:80 and IgM 1:80; Karp, IgG 1:40 and IgM 1:80). Two weeks after treatment, R. tsutsugamashi titers had increased markedly (Gilliam, IgG 1:1,280 and IgM 1:1,280; Kato, IgG 1:640 and IgM 1:640; Karp, IgG 1:320 and IgM 1:320). Scrub typhus is transmitted by a mite that is principally a rodent parasite on mice in endemic areas, including Thailand. The mite lives on plants, but completes its maturation cycle by biting mammals. The site of the bite develops a black eschar. The incubation period is 1 to 3 weeks long. Three-day treatment with doxycycline is adequate (Song J-H et al. “Short-course doxycycline treatment versus conventional tetracycline therapy for scrub typhus.” Clin Infect Dis. 1996;21:506). Correct answers to the December case (herpes simplex virus encephalitis) were supplied by Ajit Singh (Pune, India), P. Dileep Kumar (Richmond Heights, Ohio), Nicholas A. Tritos (Boston, Massachusetts), and JeanJacques Mourad (Paris, France). Several readers suggested use of a more definitive diagnostic test: DNA polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) for evidence of the virus (Lakeman FD et al. “Application of PCR to CSF from brain-biopsied patients and correlation with disease.” J Infect Dis. 1995;171:857).
0002-9343/00/$–see front matter 337 PII S0002-9343(00)xxx-x