[Tropmed-l] Case of fever and esplenomegaly

[chncosta at gmail.com]

Hi Igor,
Eosinophils?
I would insist with malaria and kala-azar, but would also check lymphoma, lupus-like diseases, tropical splenomegaly, brucellosis, acute Chagas disease, pbmycosis.
I would try PCR for Leishmania from the bone marrow aspirate, serology for malaria and Chagas. Any chance for a liver biopsy? Also check systemic inflammation: ESR and C-reactive protein.
Let's see what our fellows say.
Cheers,
Carlos.
 
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-----Original Message-----
From: Igor Thiago Borges de Queiroz e Silva <igorthiago em usp.br>
Sender: tropmed-l-bounces em lineu.icb.usp.br
Date: Tue, 03 Jul 2012 19:45:01 
To: <tropmed-l em lineu.icb.usp.br>
Subject: [Tropmed-l] Case of fever and esplenomegaly

Hi, everybody.
I would like some help in a case here in Sao Paulo:

"Patient, 60 years, male, married, with no comorbidities, retired  
truck driver, coming from Manaus / AM, where he lives in urban area  
and has a place in the jungle.
He arrived at the referring hospital with fever, myalgia, headache and  
dysphagia for 4 days, when it came to travel. On examination, revealed  
hepatomegaly (2 cm) and splenomegaly (below the left costal margin).  
Normal cardiac and pulmonary auscultation. No palpable lymphadenopathy.
Reported contact with flood water, where had rats in peridomicile.  
Confirmed vaccination against yellow fever (2009). Social drinking,  
denied smoking or illicit drug use. One sexual partner (wife). He  
denied domestic animals, neither contact with birds or bats.
Laboratory revealed pancytopenia, normal renal function, elevated  
transaminase levels (300-400) and canalicular enzymes, total  
bilirrubins (3) with predominance of direct fraction (2). USG  
confirmed homogeneous hepatosplenomegaly.
Serology: Anti-HAV IgG+, HBsAg negative, anti-HCV negative, anti-HIV  
negative, schistosomiasis IgM and IgG negative, blood smear with  
negative plasmodium research, test for leishmaniasis (rK39) negative.  
Dengue IgM negative and IgG positive, IgM negative for leptospirosis  
(confirmed one week later). Bone marrow aspirate without significant  
changes (only karyolysis) and without the presence of parasites.  
Immunohistochemistry unchanged.
Evolves with persistence of fever, with the biggest increase of the  
spleen in relation to the liver, confirmed by computed tomography. He  
was transferred to ICU because of pneumonia and respiratory failure  
after 15 days of hospitalization. Today, even without definitive  
diagnosis after one month of research, he persists with fever!"

Any suggestions?

Hug´s

-- 
Igor Thiago Borges de Queiroz e Silva
Infectologista do Hospital Giselda Trigueiro - SESAP - Natal/RN
Infectologista do Hospital ABC Unidade Cirúrgica - São Bernardo do Campo/SP
Mestrando do Departamento de Doenças Infecciosas e Parasitárias - FMUSP
Laboratório de Soroepidemiologia e Imunobiologia (LIM38) - IMT/USP
igorthiago em usp.br





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