[Tropmed-l] Case of fever and splenomegaly 2 - Fever of Unknown Origin

[gema ponce]

What about Mantoux and baciloscopy ?
fungi?: histoplasma criptococo?
Non infectious: Sarcoidosis?
 
Hope we all can help you and your patient 
 
 
Gema Ponce Revilla
 

> Date: Tue, 10 Jul 2012 22:31:13 -0300
> From: igorthiago em usp.br
> To: tropmed-l em lineu.icb.usp.br
> Subject: [Tropmed-l] Case of fever and splenomegaly 2 - Fever of Unknown Origin
> 
> Hi, everybody!
> I´m very pleased that this case has generated great discussion!
> I´m sorry for the delay in these informations. It took into account 
> many of yours remarks, hoping joins them to the fullest, and many 
> tests are still ongoing.
> Our patient remains febrile despite the previous use of ceftriaxone, 
> piperacillin / tazobactam, meropenem, vancomycin. Empirical treatment 
> with praziquantel, even without serologic status for schistosomiasis.
> Currently, makes use of polymyxin B (D5) for treatment of 
> Acinetobacter baumannii tracheobronchitis and amphotericin B (D13) and 
> doxycycline (D5), the last two being empirical.
> Last week, we began the use of prednisone (0.5 mg / kg / day), aiming 
> for the treatment of Still's disease.
> 
> Laboratorial tests:
> Anti- HIV negative, Anti-HCV negative, HbsAg negative
> EBV Serology ? IgM negative / IgG positive
> CMV Serology IgM negative / IgG positive
> Dengue Serology IgM negative / IgG negative
> Schistosomiasis (IFI) negative
> Chagas Disease (EIA) negative
> Leishmaniasis ? IFI negative and rK39 negative. ELISA in progress.
> Leptospirosis (IFI) ? IgM and IgG negative
> Widal reaction ? negative
> Thick blood smear for Plasmodium ? negative
> VDRL (anti- T. pallidum) negative
> Protein electrophoresis (Total protein = 5,5) ? albumin=37,5%, ?1= 
> 12%, ?2= 10,7%, ?=10,8%, ?=29%
> C3=102, C4=22, ANCA (c,p) negative, Anti-DNA negative, FAN postive 
> (cytoplasmic dense fine speckled) 1/160. Reumathoid factor = 9,6
> Ferritin = 3337
> Negative blood cultures ever
> VHS=35mm/h (<10mm/h)
> PCR=3,3 > 16,4 > 17,9 > 12,3 > 18,2
> TGO/P=33/35
> alkaline phosphatase = 575 (<390)
> GGT=605 (<85)
> BT= 2,7 / BI=2,1 > BT=1,7 / BI=0,3
> Artherial Lactate = 1,2 (0,4-2,0)
> Hb/Htc= 8,2/23,8 > 9,3/27,7 > 7,2/21,6
> Leuc= 2200 (Eo=0; 72 Segm) > 2300 (Eo=2%; 72Segm) > 2700 (Eo=3%; 71% Segm)
> Plq= 78000 > 52000 > 77000
> 
> Imaging studies:
> Transthoracic echocardiography without vegetations, and showing 
> moderate tricuspid valve insufficiency and mild mitral valve 
> insufficiency
> Endoscopy normal
> USG = homogenous splenomegaly + biliary gauge preserved
> CT Thorax = Ill-defined opacities in frosted glass and confluent 
> perihilar, predominantly in the right upper lobe, suggestive of 
> partial filling of the space aerial + Small / moderate right pleural 
> effusion posterior free
> CT abdomen = Liver shapes and dimensions preserved with radiodensity 
> homogeneous. Ectasia and hepatic vein of the splenic hilum. An 
> enlarged spleen (20x9x18), with regular contours and solid density of 
> the parenchyma. Prostate of dimensions increased with regular contours 
> and attenuation coefficients usual. Content in a small liquid volume 
> in the pleural spaces, with tenuous amorphous densification in the 
> lung bases.
> 
> 
> We are having some limitations in others tests such as mild laboratory 
> infrastructure or release of health insurance. But I will fight on it 
> to search of a definitive diagnosis. I count on the help of you.
> 
> More details later...
> 
> Sincerely.
> 
> 
> 
> -- 
> Igor Thiago Borges de Queiroz e Silva
> Infectologista do Hospital Giselda Trigueiro - SESAP - Natal/RN
> 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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