[Tropmed-l] Case of fever and esplenomegaly

Thu Jul 19 19:45:41 BRT 2012

Hi Carlos and Anthony,
Sorry for the delay--was out of town. Hope all is well with both of you--would be great to catch up some time. I have little to add to the very complete evaluation to date and Anthony's (as always) insights and recommendations. Agree with concerns for an infiltrative or granulomatous process-in addition to infections and sarcoid would wonder about lymphoma:  flow cytometry and if liver biopsy not possible or nondiagnostic, bone marrow biopsy (I believe that he had an aspirate but not biopsy?).
best
jamie

________________________________
From: Claudio Tadeu Daniel-Ribeiro [mailto:ctdr at uol.com.br]
Sent: Thursday, July 19, 2012 8:30 AM
To: Carlos Costa; Anthony Bryceson
Cc: Maguire, James Harvey,M.D.; tropmed-l at lineu.icb.usp.br
Subject: Re: [Tropmed-l] Case of fever and esplenomegaly

To go further with Malaria do a PCR for genre or both P falciparum and P vivax

-------------------------------------------------------------------------------------------------------------------------------------------------
XVIII INTERNATIONAL CONGRESS ON TROPICAL MEDICINE AND MALARIA
and the XLVIII Congress of the Brazilian Society of Tropical Medicine
23 to 27 September,  2012

Jose Rodrigues Coura & Claudio Tadeu Daniel-Ribeiro
(President, and President of the Scientific Committee)

Royal Tulip Rio de Janeiro (ex-Hotel Intercontinental)

International Federation of Tropical Medicine
Sociedade Brasileira de Medicina Tropical
Fundação Oswaldo Cruz

Tel & Fax (+55 21) 3865-8145
Mail to : ictmm2012 at mleventos.com.br<mailto:ictmm2012 at mleventos.com.br>
http://ictmm2012.ioc.fiocruz.br<http://ictmm2012.ioc.fiocruz.br/>
------------------------------------------------------------------------------------------------------------------------------------------------

From: SBMT - Carlos H Nery Costa <chncosta at gmail.com<mailto:chncosta at gmail.com>>
Date: Mon, 16 Jul 2012 16:48:26 -0300
To: Anthony Bryceson <a.bryceson at doctors.org.uk<mailto:a.bryceson at doctors.org.uk>>
Cc: "Maguire, James Harvey, M.D." <JMAGUIRE at partners.org<mailto:JMAGUIRE at partners.org>>, <tropmed-l at lineu.icb.usp.br<mailto:tropmed-l at lineu.icb.usp.br>>
Subject: Re: [Tropmed-l] Case of fever and esplenomegaly

Igor,

Have you tried serology or empirical therapy for malaria?

Carlos.

2012/7/16 Anthony Bryceson <a.bryceson at doctors.org.uk<mailto:a.bryceson at doctors.org.uk>>
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<mailto:igorthiago at usp.br>>
Date: 2012/7/3
Subject: [Tropmed-l] Case of fever and esplenomegaly
To: tropmed-l at lineu.icb.usp.br<mailto: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<mailto:igorthiago at usp.br>

_______________________________________________
TropMed-L mailing list
TropMed-L at lineu.icb.usp.br<mailto:TropMed-L at lineu.icb.usp.br>
http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/tropmed-l

--
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
Rua Artur de Vasconcelos 151-Sul
64001-450 Teresina-PI
Brazil
Telephones: +55 86 3222-4377<tel:%2B55%2086%203222-4377> (W),
+55 86 3221-3062<tel:%2B55%2086%203221-3062> (W),
+55 86 3237-1075<tel:%2B55%2086%203237-1075> (R).

Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas pelo sigilo legal, por direitos autorais e destinadas exclusivamente à pessoa ou organização para a qual a mensagem foi destinada.
Warning: This message is meant only for the intended recipient of the transmission.  It is forbidden any unauthorized use, alteration, reproduction and distribution. If you are not the correct recipient, please notify us immediately by return e-mail and delete this message from your system.

--
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
Rua Artur de Vasconcelos 151-Sul
64001-450 Teresina-PI
Brazil
Telephones: +55 86 3222-4377 (W),
+55 86 3221-3062 (W),
+55 86 3237-1075 (R).

Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas pelo sigilo legal, por direitos autorais e destinadas exclusivamente à pessoa ou organização para a qual a mensagem foi destinada.
Warning: This message is meant only for the intended recipient of the transmission.  It is forbidden any unauthorized use, alteration, reproduction and distribution. If you are not the correct recipient, please notify us immediately by return e-mail and delete this message from your system.

_______________________________________________ TropMed-L mailing list TropMed-L at lineu.icb.usp.br<mailto:TropMed-L at lineu.icb.usp.br> http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/tropmed-l

The information in this e-mail is intended only for the person to whom it is
addressed. If you believe this e-mail was sent to you in error and the e-mail
contains patient information, please contact the Partners Compliance HelpLine at
http://www.partners.org/complianceline . If the e-mail was sent to you in error
but does not contain patient information, please contact the sender and properly
dispose of the e-mail.
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://lineu.icb.usp.br/pipermail/tropmed-l/attachments/20120719/61fd53d9/attachment-0001.htm>