[Tropmed-l] RES: Case of fever and splenomegaly 2 - Fever of UnknownOrigin

Mon Jul 16 13:10:32 BRT 2012

Hello everyone
If we are thinking in infectious disease: I would like to know more details about the probable origin of infection: Is it a forest area? What do you know of epidemiologic informations about this area? So, I agree with the persistent parasitological search (molecular or not) for plasmodium and the screening for arbovirusis.  
By the way, if we are thinking in non infectious disease, I would like to know more details about mielogram (kariolisis???) and pancitopenia. Maybe neoplasis is a basis of this disease? Maybe you pay attention to thorax CT.
Its a really difficult case....

Good look for your patient 

Ana Yecê Pinto
Pesquisadora em Saúde Pública
Instituto Evandro Chagas-SVS-MS 
Belém/PA

-----Mensagem original-----
De: tropmed-l-bounces em lineu.icb.usp.br [mailto:tropmed-l-bounces em lineu.icb.usp.br] Em nome de Igor Thiago Borges de Queiroz e Silva
Enviada em: terça-feira, 10 de julho de 2012 22:31
Para: tropmed-l em lineu.icb.usp.br
Assunto: [Tropmed-l] Case of fever and splenomegaly 2 - Fever of UnknownOrigin

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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