CR
DR MOHSEN KHAYAT
• A 28-year-old man comes to your office
complaining of a 5-day history of nausea,
vomiting, diffuse abdominal pain, fever to
38.4, and muscle aches. He has lost his
appetite, but he is able to tolerate liquids and
has no diarrhea. He has no significant medical
history or family history, and he has not
traveled outside the Kingdom.
• He denies illicit drug use, or drinks alcohol. He
takes no medications routinely, but he has
been taking acetaminophen, approximately 30
tablets per day for 2 days for fever and body
aches since this illness began.
• On examination, his temperature is 100.8°F,
heart rate 98 bpm, and blood pressure 120/74
mm Hg. He appears jaundiced, his chest is
clear to auscultation, and his heart rhythm is
regular without murmurs. His liver percusses
12 cm, and is smooth and slightly tender to
palpation. He has no abdominal distention or
peripheral edema.
• Laboratory values are significant for a normal
complete blood count, creatinine 1.1 mg/dL,
alanine aminotransferase (ALT) 3440 IU/L,
aspartate aminotransferase (AST) 2705 IU/L,
total bilirubin 24.5 mg/dL, direct bilirubin 18.2
mg/dL, alkaline phosphatase 349 IU/L, serum
albumin 3.0 g/dL, and prothrombin time 14
seconds.
• ➤ What is the diffretial diagnosis of this
condition?
• ➤ What is the most important immediate
diagnostic test?
• ➤ What is the important serological test
• ➤ How can you treat this condition
Case 2
• A 41-year-old Saudi male goes on a holiday in
The Far East. He takes no malaria prophylaxis.
On return to the Saudi she develops high fever
and self-medicates at home with Fevadol®.
• On presentation to hospital, she had a fever of
40 °C and looked markedly unwell, with a
pulse of 130 bpm and BP 90/50 mmHg. He
was commenced on IV ceftriaxone and
quinine in casualty.
• Despite this, she deteriorated rapidly, and
after 2 hours is found to have a GCS of 3. His
blood film is reported as showing trophozoites
and schizonts of Plasmodium falciparum with
a parasitaemia of 20%.
• What is your DD (causes of coma in this
patient)
• Which is most important as the next step in
the management of this patient?
• What is the manifestatation of cerebral
malaria
• How can you treat cerebral malaria
• What are the precautions taken for malaria
prophelaxis
Case 3
• A 61-year-old man is seen because of a fever.
He was well until 2 months before, when he
noted the onset of fatigue, fever, chills, and
weight loss. Temperatures as high as 40°C
have occurred in a cyclic manner (every 2 to 3
days), but resolve with acetaminophen.
• He denies headaches, arthralgias, visual
disturbances, abdominal pain, and diarrhea.
His medical history is remarkable for asthma,
environmental allergies for which he is
undergoing immunotherapy, and a hiatal
hernia. His family history is unremarkable.
• The patient does not consume alcohol or
smoke cigarettes. He is a retired fireman and
has not traveled or had exposure to ill
contacts. He has no pets or other animal
exposures. There are none of the usually
recognized risk factors for HIV infection. He is
taking no medications
• On physical examination, the patient is found
to be a tired-appearing, elderly man. His blood
pressure is 146/85 mm Hg; pulse, 106 beats
per minute; respirations, 20 per minute; and
temperature, 38.3°C .The head, eyes, ears,
nose, and throat examination is remarkable
for the finding of dry mucous membranes; his
oropharynx is clear and the tympanic
membranes are normal.
• There is no lymphadenopathy except for a
small, 1.5cm, non tender lymph node in the
right inguinal area. The heart sounds are
unremarkable except for a regular tachycardia.
The lungs are clear to auscultation and
percussion. Abdominal examination reveals
normal
bowel
sounds,
and
no
hepatosplenomegaly or masses are palpated.
• Prostate and rectal findings are normal and a
test for occult blood is negative. His skin
appears jaundiced. The neurologic findings are
normal.
• A chest radiograph is normal. A CT scan of the
abdomen reveals enlarged portacaval lymph
nodes. The serum electrolyte values are
normal, and the following laboratory data are
reported: white blood cell count, 4,000/mm3;
hemoglobin, 11.4 g/dL; and platelet count,
134,000/mm3. The differential count reveals
high eosinophils.
• The albumin content is 3.1 mg/dL; total
bilirubin,
2.8
mg/dL;
alanine
aminotransferase, 31 IU/L; AST, 35 IU/L;
alkaline phosphatase, 242 IU/L; and lactate
dehydrogenase, 567 IU/L. All blood cultures
are negative. The erythrocyte sedimentation
rate is 110 mm per hour.
• A PPD of Mycobacterium tuberculosis skin test
is negative, as is the serum antinuclear
antibody test.
• A bone marrow biopsy specimen shows mild
chronic
inflammation
and
extensive
granulomatosis.A needle biopsy specimen of
the liver reveals sinusoidal dilatation, triaditis,
bile stasis, and focal periportal fibrosis with
granulomas and dilatation of the portal
venous channels.
• The patient is begun empirically on a regimen
of isoniazid, ethambutol, and rifampin for a
presumptive diagnosis of extrapulmonary
tuberculosis, but there is little attendant
improvement in his clinical status.
• What is the likely diffretial diagnosis in this
patient?
• What diagnostic test should be performed
next?
• What is meant by theraputic trial ,any role in
diagnosis of FUO