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

[ivo at ufc.br]

Dear Igor
As you have not yet found infectious disease as a cause for the case, I
suggest investigating a neoplasic cause. Because the patient's age, he had
FAN reagent and hemogram with pancytopenia. I suggest doing a bone biopsy,
bone scintillography with flux, evaluate the prostate and use other
methods that can clarify this diagnostic line.

Ivo Castelo Branco Coelho
Coordinador do Núcleo de Medicina Tropical da
Universidade Federal do Ceará
55 85 33668252, 94031559
ivo em ufc.br, ivocastelo em uol.com.br



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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