2/24/11
Stump the Chump
Discussant (Chump):
Harry Hollander, MD
Professor of Medicine, UCSF
Case 1
Case
•  KF is a 27 year old previously healthy
student at San Francisco State with a 3-4
day history of swollen left cervical lymph
nodes, fevers, chills and myalgias
•  8/28/2010—SF State health Center and
given amoxicillin
•  8/29/2010—Felt worse with N,V, higher
fevers and was given IM penicillin
1
2/24/11
Case
 9/1/2010 presents to UCSF ED
›  Moderately toxic appearing
›  132/62 120 22 39° C
›  No rash
›  HEENT—normal w/o tonsilar exudate
›  Neck—5X5 cm tender L mass
›  Abdomen—non-tender; no HSM
›  Lungs—clear
›  Heart– no murmur
›  Neurologic exam– normal
Case
•
•
•
•
•
WBC 5.1—80%P, 15% L, Plts 233K
Cr—0.7; UA < 5 WBC and < 3 RBC
LFTs– normal
Electrolytes– normal
CXR—normal
2
2/24/11
Large necrotic jugulodigastric LN measuring 3.5 cm with enlarged LNs extending down the
Internal jugular & posterior cervical chains into the supraclavicular area
Case
•  9/2/2010 (Day 2)
–  FNA Lymph node—reactive lymphoid tissue
•  Cultures
–  BC & Urine—negative
•  Started on Zosyn (Pip-Tazo)
–  Temps now 40.5°C
–  Repeat CBC—WBC 2.8, Plts 128K, Hct 28%
Case
•  9/3/2010 (Day 3)—ID consult called
•  Additional labs
–  Mono spot– negative
–  HIV—negative
–  CMV PCR– undetectable
–  Toxo—negative
–  ANA-- <1:40
3
2/24/11
Case
•  Additional ID history
–  From Portland
–  Has a cat at home—been home during the
summer but does not remember any
scratches/bites
–  Volunteered at a homeless shelter while on
summer break
–  Cousin with SLE
4
2/24/11
Case
•  OH YES, AND BY THE WAY
Case
•  Before I came back to school I stopped at
Lake Tahoe with some friends.
•  Mostly in the casinos but did go to the
beach
•  And, I thought this was interesting even
though I have no idea what it means but I
took a picture of this on my cell phone—is
it important
5
2/24/11
CASE
•  Started on doxycycline and streptomycin
•  For insurance reasons was transferred to
SFGH
•  And a diagnosis was made
Case--DDx
  EBV
  HIV
  CMV
  Toxo
  Plague
  Tularemia
  TB
  CSD
  Strep
  Staph
  Lymphoma
  SLE
  Castleman’s Disease
  Kawasaki’s
  Kikuchi Fujimoto’s
Disease
6
2/24/11
What is your most likely
diagnosis?
A.  Castleman’s Disease
B.  EBV
C.  HIV
D.  Kikuchi Fujimoto
E.  Lymphoma
F.  Plague
G. Toxoplasmosis
H.  Tularemia
Kikuchi Fujimoto Disease or Histiocytic
Necrotizing Lymphadenitis
  Benign cause of lymphadenopathy
  Female predominance
  Age range broad (11-80 yrs) but vast majority <30 yrs
  Cervical LN’s in 80-95% but almost all nodal areas
involved
  Fever in 30-50%
  Leukopenia (+/- atypical lymphocytes) in 50%
  Diagnosis by histopathology
  Course benign, self limited usually several weeks to a
month (can be several months)
  Recurrence, 5%
7
2/24/11
Case 2
Case History
•  CC: Left wrist pain
•  71 year-old man presents with 1 month of
swelling, redness, and pain at left wrist
•  No fever, chills, nightsweats, or weight loss
•  Denis any trauma
•  Steroid injection was done with some
improvement but pain then progressed
8
2/24/11
Case history continued
•  PMH
–
–
–
–
–
–
•  SH
HTN
Cataracts
B-thalasemia trait
Gum abscesses – ‘07-’08
Dacrocystitis – ‘09
Pyoderma gangrenosum – ‘10
•  Meds
–  Lisinopril/HCTZ
–  Multivitamin
–  Born in Hong Kong –
moved to US 40 yrs ago
–  Lived in midwest US for
15 years
–  Lives in Mississippi near
Memphis, TN (last 25 yrs)
–  College professor in
engineering
–  No animals
–  Sex with wife only
–  Denies IVDU
Physical exam
•  VS: 120#, 123/67, 77, 18, 99% RA
•  GEN: well appearing, NAD
HEENT: oropharynx clear; surgical pupils
•  LN: no LAD
•  CV: RRR no M
•  Chest: clear
•  Abdomen: soft, no organomegaly
•  Skin: healed ulcer on right shin
•  MSK: L lateral wrist: warm, swollen, minimal pain to
palp. Able to flex/extend w/o much pain
9
2/24/11
Labs
•  12>33<316
•  Cr and LFTs: wnl
•  ESR: 43; CRP: 31
MRI arm: hyperintense destructive process
centered within the distal ulna causing
circumferential endosteal scalloping
surrounded by a thick rind of periosteal reaction
10
2/24/11
Bone Biopsy
•  Pathology: neutrophilic infiltrate suggestive
of acute and chronic osteomyelitis
•  Culture: Proprionobacterium acnes in
enrichment broth only
11
2/24/11
Which specialist confirmed the
suspected diagnosis?
A.  Gastroenterologist
B.  Orthopedic surgeon
C.  Rheumatologist
D.  Endocrinologist
E.  Oncologist
History continued
•  P acnes felt to be contaminant
•  Based on the multiple recent sterile,
neutrophil rich processes…
–  Gum abscesses
–  Dacrocystitis
–  Pyoderma gangrenosum
–  Sterile osteomyelitis
•  Concern was raised for non-infectious
process
Rheumatology consult
•  Elicited further history of pustular facial
rash in 2007-2008
•  Son with ankylosing spondylitis and HLAB27+
•  Felt that the clinical presentation was
consistent with SAPHO syndrome
•  Patient HLA-B27+
•  Rx: Entanercept, wrist improved
12
2/24/11
SAPHO syndrome
•  Synovitis
•  Acne
•  Pustulosis
•  Hyperostosis
•  Osteitis
•  Immune mediated
syndrome
•  Predominated by
multiple, sterile,
neutrophil rich
infiltrates in bone, skin,
and joints
•  Association with HLAB27+
Case 3
Case History
•  57 y/o Native American man
– Called back to the ED for positive blood
cultures
•  3 days ago seen in ED for AMS and
hyperglycemia which resolved with IV
hydration
– Two blood cultures were drawn
– Patient discharged
13
2/24/11
Case History cont.
•  Now both blood cultures are positive
– BC #1: Klebsiella pneumoniae, E. coli,
Yeast, GBS, 2 types viridans strep, CNS
and “additional organisms”
– BC #2: E coli, 2 types strep, CNS,
“additional organisms.”
•  Further questioning reveals subjective
fevers and night sweats for ~3-4 months
Other History
•
•
•
•
•
•
•
•
Homeless
Chronic alcoholism
Insulin-dependent diabetes for 20 years
Hx of CVA 10 years ago
Seizure disorder
s/p cholecystectomy in 1996
GSW to right knee 1/08
Numerous recent admissions, ED visits
14
2/24/11
Recent Admissions
•  6 mo PTA: DKA + MRSA bacteremia
– BC drawn on day 1, 2 and 4 of admission all
positive for MRSA
– Day 3: vancomycin started 6/1/08
– Day 7: patient signs out AMA
– Returns 3 weeks later: repeat BC all
negative
Recent Admissions (cont.)
•  2 months PTA: DKA and AMS
– 1 of 2 BCs postive for CNS, E. coli, viridans
strep, Candida tropicalis, corynebacteria
– Briefly treated with fluconazole and
vancomycin, D/C’d by ID fellow who
considered positive BC contaminated
– F/u BCs negative
Recent Admissions (cont.)
•  1 mo PTA: DKA and foot pain
– Blood cultures negative
– Treated for presumed cellulitis and
discharged in good condition
•  1 week PTA: seen in ED for AMS
– Blood cultures negative
15
2/24/11
Summary of Blood Culture Results
•  6 months ago
–  7/8 positive for MRSA over a 4 day span
–  Patients signs out AMA after 5 days of vanco
–  2/2 f/u cultures 3 weeks later: negative
•  2 months ago
–  1 of 2 positive for CNS, Candida tropicalis,
cornyebacteria
–  2/2 three days later: negative
•  1 month PTA: 2/2 negative
•  1 week PTA: 2/2 negative
Exam
•  T=35.9 BP 140/80 P 90 RR 16 96% RA
•  Gen: drowsy, slurring speech
•  HEENT: multiple facial ecchymoses, PERRLA
•  CV: RRR, nl S1/S2 No m/r/g
•  Pulm: LCTA bilaterally. No wheezes
•  ABD: Diffuse mild TTP. No HSM
•  Skin: erythematous rash in groin region
•  Neuro: A&Ox3. CN2-12 intact.
16
2/24/11
Labs
11.0
4.1
35.3
65% N
247
139
103
8
4.3
25
0.4
AST/ALT 25/15
Alk Phos 218
404
UA: 1+ ketones, 3+ glucose, 1+ protein 0 WBCs
CXR: negative
Hospital Course
•  Day 1
–  More blood cultures: 1/2 + Propionibacterium sp.
–  Fluconazole administered
•  Day 2
–  Night sweats but no new events
–  Fluconazole stopped
–  2/2 repeat BC: negative
•  Day 3
–  Temp to 39C
–  Ceftriaxone begun empirically
–  1/2 BCs eventually positive for K. pneumoniae
17
2/24/11
Abdominal CT
•  Focal 2.8 X 2.1 cm low attenuation
collection within the omentum of the right
lower quadrant with enhancing thickening
rim.
•  Findings may represent abscess or
omental implant.
•  The differential may include epiploic
appendagitis or omental infarct
At exploratory laparotomy the lesion
was found to be a complication of
which of the following?
A.  Diverticulitis of the R colon with abscess
B.  Omental tuberculoma
C.  Epiploic appendagitis
D.  Prior cholecystectomy
E.  Microperforated appendiceal abscess
18
2/24/11
Dropped Gallstones
•  Complicates as many as a third of all
laparoscopic cholecystectomies
•  Dropped stones should be recognized as a
potential cause of intra-abdominal abscess in
any cholecystectomy patient months or even
years after the surgery
•  Dropped stones produce an intra-abdominal
abscess in 0.6% to 2.9% of cases of dropped
stones
Case 4
19
2/24/11
Case History
•  69-year old woman from Berne presents
new onset maculopapular rash
•  Recently diagnosed with SLE vs. overlap
syndrome w/ dermatomyositis
–  Had symmetrical polyarthralgias, synovitis of
large joints, polyserositis, myositis, and
microvascular disturbances
–  Rx: Prednisone, azathioprine, chloroquine
Case History cont.
PMH
•  Hypertensive cardiomyopathy
•  Malnutrition
•  Hypercholesteremia
•  Panic attacks
Physical exam
•
•
•
•
•
•
•
VS: Afebilre, BP 160/95 mmHg, P = 110
GEN: chronically ill appearing
Chest: normal
Abdomen: no tenderness
LAD: none
Neuro: normal
Skin: Confluent, maculopapular rash on
upper trunk, arms and thighs
•  .
20
2/24/11
Case History continued
•  Rx: methylprednisolone 125 mg /day with
Improvement of rash by day 2
•  HD #4: Acute onset headaches and fever
•  Neurologic exam: Somnolent, slurred
speech, difficulty swallowing, right-sided
hemiparesis and Babinski sign, mild
meningismus
Labs
•  CBC: 11>32<228
•  CRP: 61 mg/l (normal <5)
•  Cr and LFTs: wnl
•  CSF values (performed after CT scan)
–  WBC: 41 (95% PMN)
–  Protein: 125 (< 44)
–  Glucose: 35 (glucose CSF/serum =0.36)
–  Lactate: 2.80 (1.20-2.10)
21
2/24/11
MRI on 4th hospital day
22
2/24/11
Etiology of Brain Abscess?
A.
B.
C.
D.
E.
F.
Cryptococccus sp
Fusarium sp
Zygomyces
Listeria sp
Mycobacterium sp
Nocardia sp
Subsequent course
•  Rx: ceftriaxone, amoxicillin, metronidazole
•  Blood cultures: Listeria monocytogenes
•  CSF cultures: negative
•  Antibiotics: amoxicillin + gentamicin
•  Neurosurgeons elected not to drain lesion
•  Failure to improve on antibiotics x 7 days
•  Repeat MRI
MRI on 11th hospital day
Initial
Day 7 of Rx
23
2/24/11
Case history continued
•  Drainage of abscess in thalamus
–  Large amounts of pus
–  Culture negative
•  Improvement of mental status but
persistence of focal neurologic deficits
Listeria monocytogenes
•  Food borne illness:
–  soft cheeses, food from delicatessen counters
•  Predisposing conditions:
–  Immunosuppression
–  Pregnancy
•  Clinical manifestations
–  Febrile gastroenteritis
–  Sepsis in pregnancy and neonates
–  CNS infection: meningoencephalitis,
romboencephalitis, brain abscess
24