[Tropmed-l] Case of fever and esplenomegaly

[Anthony Bryceson]

Dear Carlos
Thanks. i don't know Brasil as well as I should.
What lurks in the jungle by Manaus? What infections do truck drivers get in Brazil?
What are the values of his blood count?
What does cardiac examination show?
Is the chest x-ray normal?

a 60 year old married male, fever, hepatosplenomegaly, various negative investigations; pneumonia ?why.

I would think especially of the granulomatous diseases (infections, sarcoidosis etc). You need blood cultures, and tissue for histology and culture. 

I would suggest the following:
Look at least twice more for malaria, and if you have it in Brasil, babesia.
Repeat the serology done so far, and add Serology for histoplasmosis and other Brazilian fungi that present llike this, toxoplasma, coxiella, brucella; you should use paired samples after one month of fever.

Blood cultures - I am not sure that you have excluded typhoid, coxiella,  brucella,  endocarditis, (warn the laboratory about extended cultures for brucellosis.

Liver biopsy for histology and culture for fungus, TB, leishmania, toxoplasma, 

I shall be very interested in Jamie's opinion, particularly of the non-infectious possibilities.

Keep me in the loop; best wishes
Anthony

On 16 Jul 2012, at 10:13, Carlos Costa wrote:

> Dear Jim and Anthony,
> 
> What are your ideas about this case?
> 
> Cheers,
> 
> Carlos.
> 
> ---------- Forwarded message ----------
> From: Igor Thiago Borges de Queiroz e Silva <igorthiago at usp.br>
> Date: 2012/7/3
> Subject: [Tropmed-l] Case of fever and esplenomegaly
> To: tropmed-l at lineu.icb.usp.br
> 
> 
> 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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> 
> -- 
> Carlos H. N. Costa, MD, DSc.
> Sociedade Brasileira de Medicina Tropical 
> (Brazilian Society of Tropical Medicine)
> President
> 
> Universidade Federal do Piauí
> Instituto de Doenças Tropicais Natan Portella
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> 
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