[Tropmed-l] Case of fever and esplenomegaly

[tomas orduna]

Hello Igor ! What a difficult case !!!
You did near all the tests we can think at the beginning with such a case.
I remember a case of a young girl with Leishmaniasis visceral with rK 39 negative and Bone marrow without parasites that have a biopsy positive of duodenum. Only to add cases that are in the extremes of Gauss curve !
What about hematological diseases such primary lymphoma of the spleen or something related ?. 
He is so old to think in diseases like Gaucher, isn't him ?
I supposed you have repeated some tests like blood smears looking for plasmodium or trypanosomes 
I don't know how to link this case with mycoses but ... just in case think about them !
Please tell us about the patient if you have some results
Best regards 


Dr. Tomás A. Orduna

Jefe de Servicio 
Patologías Regionales y Medicina Tropical (CEMPRA-MT)
Hospital de Infecciosas F. J. Muñiz
Uspallata 2272 (C.P. 1282)
Buenos Aires - Argentina
T.E.:(54-11) 4305-3161
T.E.:Conmutador:(+54-11) 4305-0357/1944 (int.231)
Fax: (+54-11) 4304-2386
torduna at intramed.net


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-----Mensaje original-----
De: tropmed-l-bounces at lineu.icb.usp.br [mailto:tropmed-l-bounces at lineu.icb.usp.br] En nombre de Igor Thiago Borges de Queiroz e Silva
Enviado el: martes, 03 de julio de 2012 07:45 p.m.
Para: tropmed-l at lineu.icb.usp.br
Asunto: [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 at usp.br





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