Course 1
Case 15
Kas 1-15E: Patient with fever and rash (exanthem)
Mother called and asked the general pediatrician to come and see her 6 years old daughter,
who has got fever, sore throat and rash.
History taken from the mother.
Family history:
Father 36y, treated for high blood pressure for 5y, mother 36y, has got pollinosis with springsummer seasonal complaints, otherwise healthy, sister 3y is healthy.
Personal history:
Perinatal data: child of 1st pregnancy, physiological, spontaneous in term delivery, head
presentation, 3350g/50cm, no resuscitation, Apgar score 9-10-10, physiological icterus,
breast-fed 4 months, hip joints with no dysplasia, vaccinated according schedule. No severe
illness before, only common colds. No severe injury, operation - nasal adenotomy in 3y of
age. No regular medication. No known alllergy. Fair social conditions, attends a kindergarten.
Current illness:
Yesterday since the morning the girl was tired, complained of abdominal pain and sore throat,
therefore did not go to the kindergarten. In the evening she got fever 39o C, was given
paracetamol 200 mg, fever transiently decreased to subfebrile. This morning she got again
38,5o C, worse sore throat, mother mentioned some rash on the lower abdomen. She called the
general pediatrician and asked her for a visit. Because the girl is in good general condition,
the doctor promised to come and see her in the afternoon (after office hours). By that time she
recommended to keep the child in bed rest and give again paracetamol for fever.
Physical examination (only significant or pathological findings are listed):
T 38oC, girl conscious, responds adequatelly, complains of sore throat and mild headache
during fever, does not want to eat, only drinks. On the skin of the anterior and lateral parts of
the abdomen and axillae there is tiny maculopapular exanthem of red colour, confluent,
slightly itching, with blanching under pressure or scratching. Face erythem with circumoral
pallor, heavily reddened throat mucosa, reddened and swollen palatal tonsills, white tongue.
Moderate bilateral submandibular lymphadenopathy, slightly painful. Eupnoic, normal lung
and heart sounds, HR 100/min, reg., BP 90/60. No pathology on the abdomen. Meningeal
signs negative.
Questions:
1. What is the likely diagnosis?
2. What is the cause of the disease?
3. What does evolve the exanthem in this disease?
4. What laboratory tests can specify the diagnosis?
5. Is there a causative treatment for this disease?
6. Can the patient suffer from the same disease more than once?
Course 1
Case 15
Case study: Patient with fever and rash (exanthem)
Mother called the general pediatrician to come and see her 5 years old son, who has got fever
and rash.
History taken from the mother.
Family history:
Father 30y, has got polyvalent drug allergy, mother 24y, healthy, no brothers or sisters.
Personal history:
Perinatal data: child of 1st pregnancy, physiological, spontaneous cranial delivery in 37th
gestational week, 2950g/49cm, no resuscitation, Apgar score 7-9-9, few days in incubator,
physiological icterus, breast-feeded 2m, hip joints with no dysplasia, vaccination according
schedule, psychomotoric development normal. Previous illnesses: pneumonia in 4y of age,
when not hospitalized, given peroral antibiotics, otherwise not frequently ill. Common small
injuries, operation – right inguinal herniotomy in 3y of age. No regular medication. No known
alllergy. Fair social conditions, attends a kindergarten.
Current illness:
Two days ago the mother noticed several „spots“ on the son´s forehead, she thought, he was
bitten by mosquitos, as he was well, with no signs of disease. Yesterday more spots occured
on the abdomen and back and the boy had got fever 37,7o C. Today he has got even more
spots and fever 38o C and does not want to eat. Mother called the general pediatrician and
asked if she has to take the son to the office. The doctor promised to come and see the boy in
the afternoon (after office hours) and by that time recommended to keep the child in bed rest
and give paracetamol for fever.
Physical examination (only significant or pathological findings are listed):
T 38,2oC, boy conscious, cooperates well, responds adequatelly, does not appear to be ill,
does not want to eat because of pain on the tongue. Well hydrated. On the skin of the face,
chest, abdomen and back there are macules, papules, vesicles and pustules up to 5mm size,
itching. Throat with no inflammation, several aphtous lesions on the tongue and soft palate.
Tiny bilateral submandibular lymph nodes, slightly painful. Eupnoic, normal lung and heart
sounds, HR 100/min, reg., BP 90/60. No pathology on the abdomen. Meningeal signs
negative, normal movements.
Questions:
1. What is the likely diagnosis?
2. What is the cause of the disease?
3. What does evolve the exanthem in this disease?
4. Is it necessary to confirm the diagnosis by laboratory tests?
5. Does exist any way of prevention of this illness?
6. Can the patient suffer from the same disease more than once?
Course 1
Case 15
Case study: Patient with fever, diarrhoea and vomiting
A 2 years old boy has been brought by his parents to the hospital for fever, vomiting and
diarrhoea.
History taken from the parents.
Family history:
Unimportant, he has got no brothers and sisters.
Epidemiological data:
The parents are not aware of any dietary mistake or boy´s contact with diarrhoea.
Personal history:
Perinatal data: child of 1st pregnancy, physiological course, spontaneous in term delivery,
head presentation, 2800g/48cm, no resuscitation. Phototherapy for neonatal icterus, hip joints
with no dysplasia. Breast-fed 4months, afterwards changed to artificial nutrition, currently
toddler food, vitamin D supplementation. Vaccinated according schedule. No severe illness
before, once mesotitis, twice respiratory infection. No severe injury, no operation. No known
alllergy.
Current illness:
On Wednesday morning the boy refused eating, at noon his temperature was 39.6o C and he
vomited, later he has got watery stools. He was examined by family paediatrician who
recommended a diet and paracetamol for fever. Next day he has got fever up to 39o C, he
vomited again and watery stools with mucus occured every half an hour. He has not urinated
since the morning, refused drinking and therefore he was sent to the hospital.
Physical examination (only significant or pathological findings are listed):
Boy is peevish, crying, does not want to be examined. Body weight 12 kg, height 88 cm, T
37,8oC. Skin with no icterus, no exanthem, no petechiae. Sunken eyes. Nose and ears – no
pathological finding. Throat slightly reddened, oral cavity and tongue mucosa dry. Lymph
nodes of normal size. Eupnoic, normal lung and heart sounds, HR 120/min, reg. Abdomen
soft, no sensitivity on palpation, no peritoneal signs. Liver 1 cm below costal margin, no
spleenomegaly. Meningeal signs negative.
Laboratory results:
Blood count: Leu 13.000, Ery 4,7, Hb 156, Hkt 0,48, Throm 336.000
Serum: urea 8,2mmol/l, creatinine 53 umol/l, Na 157 mmol/L, K 3,2 mmol/l, Cl 130 mmol/l,
AMS 2,7 ukat/l, CRP 10 mg/l
Astrup: pH 7,325, BE –13,2 mmol/l
Urinalysis: protein +, acetone +, negative glucose, bilirubin, urobilinogen
Stool culture negative.
Questions and tasks:
1.
2.
3.
4.
5.
6.
7.
What is the diagnosis?
What is the presumptive etiology?
What examination will detect the etiological agent?
How does the disease spread?
What possible complication do clinical and laboratory findings speak for?
What will be the first step in treatment of this patient?
Would you recommend antibiotics for this disease?
Course 1
Case 15
Case study: Patient with diarrhoea
A 45 years old lady comes to the hospital because of fever, diarrhoea and vomiting
Family history:
Mother has got cholecystolithiasis, father diabetes mellitus type II, children are healthy.
Personal history:
Common diseases of childhood, she was treated repeatedly for urinary tract infections. In
recent years she has got frequent back pain, probably of vertebral origin, she occasionally
uses ibuprofen and diclofenac. Allergy: hay fever, major problems in the spring.
Social history: married, lives together with her family in an apartment building.
Occupation: clerk
Epidemiological data:
On Friday evening she visited a restaurant in the centre of Prague along with her husband and
friends. She had got “tatarský biftek” (raw beef meat with raw egg yolk).
Current illness:
On Saturday (following day) afternoon at about 4 PM she got fever 38o C and she vomited.
Since Sunday morning she suffered from severe cramps in abdomen, with frequent watery
stools, at the beginning of yellow-brown, later green colour, containing mucus and blood. The
fever reached 39o C. In the afternoon the patient collapsed and therefore her husband brought
her to the internal medicine office of the nearest hospital, from where she was recommended
to the infectious diseases department.
Physical examination (only significant or pathological findings are listed):
T 38,6oC, patient conscious, orientated, markedly tired, pale, slightly sweatened. Eutrophic.
Skin anicteric, no exanthem. Eyes, ears and nose with no secretion. Throat with no
inflammation, dry oral cavity mucosa, brownish tongue surface. No submandibular
lymphadenopathy. Eupnoic, 12 breaths/min, normal lung and heart sounds, HR 104/min, reg.,
BP 80/50. Abdomen soft, with diffuse tenderness on palpation, with no resistence, no
hepatomegaly and splenomegaly. Meningeal signes negative.
Laboratory results:
ESR: 12/20
Blood count: Leu 14.000, Ery 4,8, Hb 144, Hkt 0,452, Throm 234.000
Serum: urea 29,3 mmol/l, creatinine 168 umol/l, Na 129 mmol/l, K 3,6 mmol/l, Cl 95
mmol/L, AMS 2,4 ukat/l, CRP 150 mg/l
Urinalysis: protein +, acetone +, negative glucose, blood, bilirubin, urobilinogen
Questions and tasks:
1.
2.
3.
4.
5.
6.
What is the diagnosis?
What is the presumptive etiology?
What kind of examination will detect the causative agent of the disease?
What possible complication does the clinical finding in this patient speak for?
Do the laboratory findings confirm this suspicion?
What are the mainstays of the treatment?
Course 1
Case 15
Case study: Patient with fever after returning from tropics
A 23 year old man has got repeated attacks of fever after his arrival from South Africa.
Family history:
Unimportant.
Personal history:
Common diseases of childhood, no severe illness before, he has never been hospitalized. No
known allergy.
Abusus : alcohol occasionally, non smoker, no drug abuse.
Social history: single, lives together with his parents. Occupation: technical university
student.
Epidemiological data:
The patient bought a “last moment “ trip to South Africa 7 days before the departure, he had
not got enough time to get information on health risks in this part of the world. This was his
first trip to tropics. He spent 4 days in Johannesburg, then 7 days on the safari in Kruger Park.
He had got mild diarrhoea with watery stools with no blood and mucus and no fever. He kept
a little diet and diarrhoea disappeared spontaneously within 2 days. He had got no other health
problems. Several times he was bitten by mosquitos, did not use any repellent.
Current illness:
One week after arrival from the Kruger Park the patient got fever 40o C and terrible headache.
The fever dropped 2 - 3 hours later with profuse sweating. Next day he felt better, however on
the third day in the afternoon he got a new attack of fever with similar course. On the fourth
day was afebrile and on the fifth day got again a peak of fever. Therefore he came to see a
doctor on the following day.
Physical examination (only significant or pathological findings are listed):
T 36,9oC, patient conscious, orientated, well hydrated. Skin anicteric, no exanthem. Throat
with no inflammation, dry oral cavity mucosa. No submandibular lymphadenopathy. Eupnoic,
normal lung and heart sounds, HR 88/min, reg., BP 120/80. Abdomen soft, with no pain on
palpation, with no resistence, no hepatomegaly or splenomegaly, tapottement negative
bilaterally. Meningeal signes negative.
Laboratory results:
Blood count: Leu 8.200, Ery 4,82, Hb 147, Hkt 0,405, Throm 80.000
Serum: urea 3,2 mmol/l, creatinine 75 umol/l, bilirubin 17 mmol/l, AST 0,42 ukat/l, ALT 0,38
ukat/l, CRP 6 mg/l
Urinalysis: negative
Questions and tasks:
1.
2.
3.
4.
5.
6.
Which severe infections are necessary to be confirmed or excluded in this patient?
Which of them is the most likely in this patient?
What is the etiological agent of the disease?
What kind of examination will prove the diagnosis?
Are there any precautions to prevent the disease?
Is there possible person-to-person transmission?
Course 1
Case 15
Case study: Patient with fever and meningeal syndrome
A 16-years-old boy was brought by an ambulance car to the admission office of infectious
diseases department because of fever, vomiting, headache and disturbed consciousness.
History was gained from the father of the patient:
Family history:
Father 48y, was treated for duodenal ulcer, mother 45y, has got cervical spine troublescervicobrachial syndrome, sister 18y is healthy.
Personal history:
Perinatal data with no pathology, vaccinated according schedule. No severe illness before,
only common colds. Operations: appendectomy in 10y of age, with no complications. Sport
injury – fracture of the left forarm, fractures of the 3rd and 4th fingers of the right hand. No
regular medication, sometimes vitamines. No known alllergy.
Social history:
Lives with parents and sisterin an appartement, student of the 1st year of high school.
Physically active – ice-hockey training 4times a week. No alcohol, no smoking, no drugs.
Epidemiological data
No known source of infection, no travel abroad in the last year.
Current illness:
About 3 days of sore throat, with no fever, was training ice-hockey normally. Yesterday was
at school, feeling well, in the afternoon headache ant backache started, had fever 38,5oC,
thereby did not go for training. During the last night he vomited several times, complained of
severe headache, had fever 39oC, which slightly decreased with paracetamol tablet. Small red
spots occured on the skin of hands and chin. Since this morning the boy is very sleepy, father
could not wake him and worry, that the boy is confused. Thereby he called emergency
service, who took him to the hospital.
Physical examination (only significant or pathological findings are listed):
T 39,2oC, patient somnolent, is possible to wake him up, can answer his name correctly, to all
the other questions answers only „hurts“. Neck stiffness 3 fingers, Lassegue + 60degree bilat.,
other signs not examined. Petechiae on the face and upper extremities, some also on the lower
extr. Skin turgor normal. Eyes – isocoric pupillae, normal response to light. Throat slightly
inflammed, tonsils reddened with no exsudate, dry tongue mucosa. No submandibular
lymphadenopathy. Eupnoic, normal lung and heart sounds, HR 90/min, reg., BP 100/60,
oxygen saturation O2 97%. No pathology on the abdomen.
Laboratory results:
ESR: 20/40
Blood count: Leu 20.000, Ery 5,02, Hb 166, Hkt 0,50, throm 140.000
Serum: glycemia 6,6, urea 7,0, creatinine 67, Na 140, K 4,2, Cl 101, CRP 250
Coagulation: Quick 19,2s, INR 1,5, APTT 67s, R 2,1, D-dimers 1000, antitrombin III 80%
CSF: turbid, PMNs 8200/3, lymphocytes 0, protein 4,5g/l, glucose 0,8mmol/l
Questions:
1. What is the likely diagnosis?
2. What is the cause of the disease?
3. What is the cause of fever?
4. Why is the patient uncouscious?
5. What other testing of CSF is necessary?
6. What other material and for what testing is necessary to sample?
7. What the hemocoagulation tests results arise suspicion for?
8. How the disease would progress if not treated?
Course 1
Case 15
Case study: Patient with fever and meningeal syndrome
A 60-years-old woman was brought by an ambulance car to the admission office of infectious
diseases department because of fever, headache and disturbed consciousness.
History was gained from the husband of the patient:
Family history:
Father died 70y old due to acute myocardial infarction, previously suffered from ischaemic
heart disease and diabetes type II, mother died 80y due to colonic carcinoma, sister 55y is
healthy, 2 sons 30 and 34y are healthy.
Personal history:
No severe illness in childhood. Ten years ago was treated for duodenal ulcer, after therapy
without complaints. Three years ago hyperglycemia and hypertension was diagnosed, is on
diabetic diet and betablocker. Operations: 10y ago hysterectomy for myoma, 5y ago achillar
tendon sutura for injury rupture. Regular medication: betaxolol. No known alllergy.
Social history:
Lives with husband, elementary school teacher before, now retired. Alcohol sporadically and
little, no smoking, 2 coffees per day.
Epidemiological data:
No known source of infection, no travel abroad in the last year, a dog at home.
Current illness:
Two weeks ago pain in the right ear started, with no fever, 3 days later was examined by
otorinolaryngologist and received ear drops. She used the drops a week, but the earache
persisted. Two days ago she got fever 38oC, also yesterday, and a headache. Last night she
vomited twice. Since this morning she stays at bed, refused to stand up because of terrible
headache, did not vomit, has got fever 39oC. In the afternoon, when the husband came back
after a walk with dog, he found his wife uncouscious – could not wake her up, she did not
respond. He called emergency service, who took the ill to the hospital.
Physical examination (only significant or pathological findings are listed):
T 39oC, patient soporous, no response to speech, restless on painful stimuli, moaning
(Glasgow Coma Scale score 8-9). Severe neck stiffness, Lassegue + 60degree bilat., other
signs not examined. Skin with no icterus, no rash, no purpura, turgor normal. Eyes – isocoric
pupillae, normal response to light. In the right ear dried purulent fluid with a little blood.
Throat not possible to examine carefully, dry tongue mucosa. No palpable thyreopathy,
carotid arteries palpable bilat. Normal lung and heart sounds, HR 90/min, reg., BP 145/100,
oxygen saturation O2 91% on room air, snoring. No pathology on the abdomen.
Laboratory results:
ESR: 50/80
Blood count: Leu 25.000, Ery 3,98, Hb 133, Hkt 0,40, throm 240.000
Serum: glycemia 9,5, urea 9,0, creatinine 105, Na 140, K 4,0, Cl 105, CRP 360
Coagulation: Quick 16,3s, INR 1,2, APTT 41s, R 1,15
CSF: turbid, PMNs 10.200/3, lymphocytes 0, erythrocytes 300/3, protein 6,5g/l, glucose
0,5mmol/l, chlorine 116mmol/l
Questions:
1. What is the likely diagnosis?
2. What is the agent and the source of the disease?
3. What other testing of CSF is necessary?
4. What other material and for what testing is necessary to sample?
5. Why is the patient comatous?
6. What are the mainstays of treatment?
Course 1
Case 15
Case study: Patient with fever and meningeal syndrome
A 32-years-old man was sent by the general practitioner to the admission office of infectious
diseases department because of fever and headache.
Family history:
Father 62y, has got an ischaemic heart disease and suffered once from acute myocardial
infarction, mother 59y, has got a chronic nephritis, on regular check-ups. No brother or sister.
Son 4y is healthy.
Personal history:
Common childhood illnesses, check-ups for functional heart murmur, which disappeared
before adult age. No severe illness before, only common colds. Operations and injuries: 5y
ago tibial fracture at skiing, treated with osteosynthesis, 2y later metal device extracted. No
regular medication. No known alllergy.
Social history:
Lives with wife and son, is a carpenter. Alcohol – 2 beers per day, occasionally other alcohol,
no smoking, sometimes coffee.
Epidemiological data
No known contact with infection. No travel abroad in the last year. Frequently goes to a
weekend-house in Orlík (Vltava recreational area), walks in the forest, sometimes has got a
tick bite, this summer 3times, last tick bite a months ago, with no erythema, he always
removed the tick promptly. A dog at home, who also often has got ticks. Regular vaccination
in childhood according the schedule.
Current illness:
Ten days ago he had got feeling of cold – temperatue 37,5o C, myalgia, mild headache, he did
not work for 2 days and he became well, he was without complaints for 4 days. Then a new
headache started and worsens, he cannot work, outside he minds the sunlight a lot, he had got
again fever 38oC. Since yesterday he feels dizzy when standing, vomited several times, fever
reached 39oC. He neither can sleep nor read, feels nauzea while reading. Today he went to his
general practitioner, who sent him to the hospital. The wife brought him by car.
Physical examination (only significant or pathological findings are listed):
T 39oC, patient conscious, Glasgow Coma Scale score 15, well orientated, but responds with
some latency. Neck stiffness 2-3 fingers, spine sign ++, Lassegue + 70 degree bilat., fingers
tremor, mild ataxia, titubation in Romberg III position. No paresis. Skin – no icterus, no rash,
no bleding, skin turgor normal. Eyes – isocoric pupillae, normal response to light, mild
conjunctival hyperemia. Throat slightly inflammed, tonsils with no exsudate. Eupnoic, normal
lung and heart sounds, HR 100/min, reg., BP 110/60. No pathology on the abdomen.
Laboratory results:
ESR: 20/35
Blood count: Leu 7.500, Ery 4,95, Hb 150, Hkt 0,46, throm 295.000
Serum: glycemia 5,5, urea 4,5, creatinine 75, Na 141, K 4,3, Cl 107, CRP 18
CSF: clear, PMNs 20/3, lymphocytes 256/3, erythrocytes 0/3, protein 1,0g/l, glucose
3,9mmol/l, chlorine 118mmol/l
Questions:
1. What is the likely diagnosis?
2. What is the possible cause of the disease?
3. What is the most likely etiology with regard to epidemiological data ?
4. What test can detect the etiology?
5. What are the mainstays of treatment?
6. Could the illness be prevented?
7. Is there possible interhuman transmission of this illness?
Course 1
Case 15
Case study: Patient with fever, cough and dyspnea
A 52-years-old man came to his general practitioner because of fever lasting 1 day.
Family history:
Father died 67y for myocardial infarction, mother is 79y, last 20y has been treated for
rheumatic disease not well specified, 3y ago diabetes mellitus was diagnosed, put on diet. His
brother 55y has got arterial hypertension and some allergy. Has got two sons 29 and 31y old
who are healthy.
Personal history:
At 20y of age at a car accident he suffered from chest contusion and partial spleen rupture,
underwent splenectomy. Since that time he does not any sport, is obese (98 kg/176 cm). At
45y cholecystectomy, at 48y diabetes mellitus type II and arterial hypertension was
diagnosed. Regular medication: Vasocardin (metoprolol, Glucobene (glibenclamid).
No known alllergy.
Social history:
Lives with his wife, sons have got their own families. Occupation: factory worker. Abusus:
smoker 10-20cig per day, alcohol – 2 beers per day, occasionally more with friends in the
pub.
Current illness:
Yesterday he was fishing and got cold. In the evening he did not feel well, at night he got
chills. This morning he got fever 39,2oC, malaise, breathing troubles and cough, he lost his
apetite. He did not go to work, took 2 tablets of paracetamol and felt better, but breathing
troubles remained and cough worsened. In the afternoon fever peaked again to 40,5°C, he
took again paracetamol and went to his G.P., accompanied wis his wife, as he was too weak to
walk alone.
Physical examination:
T 38,6oC, breath 28/min, HR 108/min, BP 150/100. Patient obese, conscious, orientated,
malaised, dyspneic, with non-productive cough. Eyes, ears, nose with no pathology. Skin with
no icterus, no rash, no purpura, turgor normal. Mild cyanosis of lips, throat slightly inflamed,
dry tongue mucosa with white surface. No submandibular or neck lymphadenopathy. Breath
sounds decreased on the right lower side, with little crepitation. Heart sounds normal, regular.
Abdomen soft, not well palpable due to obesity, scare after splenectomy years ago, liver 2cm
below the costal margin, lumbar area with no pain. Extremities with no pathology. Mild neck
stiffness 1-2cm, spine sign +.
Laboratory results:
ESR: 32/68
Blood count: leucocytes 27.600/mm3 , erythrocytes 4,70/mm3, hemoglobin 151 g/l,
thrombocytes 210.000
Serum: glycemia 15,8mmol/l, urea 12,4mmol/l, creatinine 98 μmol/l, ALT 0,55 μkat/l
Urinalysis: protein +, otherwise negative
Questions and tasks:
1.
2.
3.
4.
5.
What kind of pneumonia is concerned?
Which predisposing factors could give rise to the disease?
Which other examinations are necessary?
What is the most likely etiological agent?
How can we detect the etiology (what material, what examination)?
6. Why serology cannot help to detect the etiology in this case?