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<div dir="ltr" align="left"><span class="939563212-19072012"><font size="4">Hi Carlos and Anthony,</font></span></div>
<div dir="ltr" align="left"><span class="939563212-19072012"><font size="4">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?).</font></span></div>
<div dir="ltr" align="left"><span class="939563212-19072012"><font size="4">best</font></span></div>
<div dir="ltr" align="left"><span class="939563212-19072012"><font size="4">jamie</font></span></div>
<div dir="ltr" align="left"><span class="939563212-19072012"><font size="4"></font></span> </div>
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<font size="2" face="Tahoma"><b>From:</b> Claudio Tadeu Daniel-Ribeiro [mailto:ctdr@uol.com.br]
<br>
<b>Sent:</b> Thursday, July 19, 2012 8:30 AM<br>
<b>To:</b> Carlos Costa; Anthony Bryceson<br>
<b>Cc:</b> Maguire, James Harvey,M.D.; tropmed-l@lineu.icb.usp.br<br>
<b>Subject:</b> Re: [Tropmed-l] Case of fever and esplenomegaly<br>
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<div>To go further with Malaria do a PCR for genre or both P falciparum and P vivax</div>
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<div style="FONT-FAMILY: Arial, sans-serif; COLOR: rgb(0,0,0); FONT-SIZE: 14px"><span style="FONT-FAMILY: Calibri; FONT-SIZE: medium" class="Apple-style-span"><font size="2"><b><span style="FONT-FAMILY: Calibri, sans-serif; FONT-SIZE: 14px; FONT-WEIGHT: normal" class="Apple-style-span"><b><font color="#000080" size="3">XVIII
INTERNATIONAL CONGRESS ON TROPICAL MEDICINE AND MALARIA </font></b></span></b></font></span></div>
<div style="FONT-FAMILY: Arial, sans-serif; COLOR: rgb(0,0,0); FONT-SIZE: 14px"><span style="FONT-FAMILY: Calibri; FONT-SIZE: small" class="Apple-style-span"><b><span style="FONT-FAMILY: Calibri, sans-serif; FONT-SIZE: 14px; FONT-WEIGHT: normal" class="Apple-style-span"><b><font color="#000080" size="3"><i>and
the </i></font></b></span></b></span><font class="Apple-style-span" color="#000080" face="Calibri,sans-serif"><b><i>XLVIII Congress of the Brazilian Society of Tropical Medicine</i></b></font></div>
<div style="FONT-FAMILY: Arial, sans-serif; COLOR: rgb(0,0,0); FONT-SIZE: 14px"><span style="FONT-FAMILY: Calibri; FONT-SIZE: small" class="Apple-style-span"><b><span style="FONT-FAMILY: Calibri, sans-serif; FONT-SIZE: 14px; FONT-WEIGHT: normal" class="Apple-style-span"><font class="Apple-style-span" color="#fe2615" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span">23
to 27 September, 2012</span></font></span></b></span></div>
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<span style="FONT-FAMILY: Arial; FONT-SIZE: medium" class="Apple-style-span"><span style="FONT-FAMILY: Arial, sans-serif; COLOR: rgb(0,0,0); FONT-SIZE: 14px" class="Apple-style-span">
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<div style="COLOR: rgb(0,0,0)"><span style="FONT-FAMILY: Calibri" class="Apple-style-span"><font size="+0"><span style="COLOR: rgb(0,0,0); FONT-SIZE: medium"><span style="FONT-FAMILY: Calibri, sans-serif" class="Apple-style-span"><span style="FONT-SIZE: 14px; FONT-WEIGHT: normal"><font size="+0"><span style="FONT-SIZE: 12px" class="Apple-style-span"><br>
</span></font><font style="FONT-WEIGHT: bold" size="3"><i>Jose Rodrigues Coura & Claudio Tadeu Daniel-Ribeiro<br>
</i></font></span><font style="FONT-SIZE: 14px; FONT-WEIGHT: normal" class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span">(President, and President of the Scientific Committee)<br>
<br>
Royal Tulip Rio de Janeiro (ex-Hotel Intercontinental)</span></font></span></span></font></span></div>
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International Federation of Tropical Medicine<br>
Sociedade Brasileira de Medicina Tropical<br>
Fundação Oswaldo Cruz<br>
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Tel & Fax</span></font><b><font class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span"> </span></font></b><font color="#ff0000"><font class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span">(+55
21) 3865-8145<br>
</span></font></font><font class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span">Mail to : </span></font><font color="#000080" size="2"><a href="mailto:ictmm2012@mleventos.com.br"><font class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span">ictmm2012@mleventos.com.br</span></font></a><font class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span"><br>
</span></font><font class="Apple-style-span" size="3"><span style="FONT-SIZE: 12px" class="Apple-style-span"><a href="http://ictmm2012.ioc.fiocruz.br/" eudora="autourl">http://ictmm2012.ioc.fiocruz.br</a></span></font></font></span></b></font></span></div>
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<span style="FONT-WEIGHT: bold">From: </span>SBMT - Carlos H Nery Costa <<a href="mailto:chncosta@gmail.com">chncosta@gmail.com</a>><br>
<span style="FONT-WEIGHT: bold">Date: </span>Mon, 16 Jul 2012 16:48:26 -0300<br>
<span style="FONT-WEIGHT: bold">To: </span>Anthony Bryceson <<a href="mailto:a.bryceson@doctors.org.uk">a.bryceson@doctors.org.uk</a>><br>
<span style="FONT-WEIGHT: bold">Cc: </span>"Maguire, James Harvey, M.D." <<a href="mailto:JMAGUIRE@partners.org">JMAGUIRE@partners.org</a>>, <<a href="mailto:tropmed-l@lineu.icb.usp.br">tropmed-l@lineu.icb.usp.br</a>><br>
<span style="FONT-WEIGHT: bold">Subject: </span>Re: [Tropmed-l] Case of fever and esplenomegaly<br>
</div>
<div><br>
</div>
<font color="#000000"><font size="+0"><font face="verdana,sans-serif">Igor,<br>
<br>
Have you tried serology or empirical therapy for malaria?<br>
<br>
Carlos.<br>
</font></font></font><br>
<div class="gmail_quote">2012/7/16 Anthony Bryceson <span dir="ltr"><<a href="mailto:a.bryceson@doctors.org.uk" target="_blank">a.bryceson@doctors.org.uk</a>></span><br>
<blockquote style="BORDER-LEFT: #ccc 1px solid; MARGIN: 0px 0px 0px 0.8ex; PADDING-LEFT: 1ex" class="gmail_quote">
<div style="WORD-WRAP: break-word">Dear Carlos
<div>Thanks. i don't know Brasil as well as I should.</div>
<div>What lurks in the jungle by Manaus? What infections do truck drivers get in Brazil?</div>
<div>What are the values of his blood count?</div>
<div>What does cardiac examination show?</div>
<div>Is the chest x-ray normal?</div>
<div><br>
</div>
<div>a 60 year old married male, fever, hepatosplenomegaly, various negative investigations; pneumonia ?why.</div>
<div><font size="4"></font><br>
</div>
<div>I would think especially of the granulomatous diseases (infections, sarcoidosis etc). You need blood cultures, and tissue for histology and culture. </div>
<div><br>
</div>
<div>I would suggest the following:</div>
<div>Look at least twice more for malaria, and if you have it in Brasil, babesia.</div>
<div>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.</div>
<div><br>
</div>
<div>Blood cultures - I am not sure that you have excluded typhoid, coxiella, brucella, endocarditis, (warn the laboratory about extended cultures for brucellosis.</div>
<div><br>
</div>
<div>Liver biopsy for histology and culture for fungus, TB, leishmania, toxoplasma, </div>
<div><br>
</div>
<div>I shall be very interested in Jamie's opinion, particularly of the non-infectious possibilities.</div>
<div><br>
</div>
<div>Keep me in the loop; best wishes</div>
<div><span class="HOEnZb"><font color="#888888">
<div><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Helvetica; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px">
<div><span style="FONT-SIZE: 16px">Anthony</span></div>
</span></div>
</font></span>
<div>
<div class="h5"><br>
<div>
<div>On 16 Jul 2012, at 10:13, Carlos Costa wrote:</div>
<br>
<blockquote type="cite"><font color="#000000"><font size="+0"><font face="verdana,sans-serif">Dear Jim and Anthony,</font></font></font>
<div><font color="#000000"><font size="+0"><font face="verdana,sans-serif"><br>
</font></font></font></div>
<div><font color="#000000"><font size="+0"><font face="verdana,sans-serif">What are your ideas about this case?</font></font></font></div>
<div><font color="#000000"><font size="+0"><font face="verdana,sans-serif"><br>
</font></font></font></div>
<div><font color="#000000"><font size="+0"><font face="verdana,sans-serif">Cheers,</font></font></font></div>
<div><font color="#000000"><font size="+0"><font face="verdana,sans-serif"><br>
</font></font></font></div>
<div><font color="#000000"><font size="+0"><font face="verdana,sans-serif">Carlos.<br>
</font></font></font><br>
<div class="gmail_quote">---------- Forwarded message ----------<br>
From: <b class="gmail_sendername">Igor Thiago Borges de Queiroz e Silva</b> <span dir="ltr">
<<a href="mailto:igorthiago@usp.br" target="_blank">igorthiago@usp.br</a>></span><br>
Date: 2012/7/3<br>
Subject: [Tropmed-l] Case of fever and esplenomegaly<br>
To: <a href="mailto:tropmed-l@lineu.icb.usp.br" target="_blank">tropmed-l@lineu.icb.usp.br</a><br>
<br>
<br>
Hi, everybody.<br>
I would like some help in a case here in Sao Paulo:<br>
<br>
"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.<br>
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.<br>
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.<br>
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.<br>
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.<br>
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!"<br>
<br>
Any suggestions?<br>
<br>
Hug´s<br>
<br>
-- <br>
Igor Thiago Borges de Queiroz e Silva<br>
Infectologista do Hospital Giselda Trigueiro - SESAP - Natal/RN<br>
Infectologista do Hospital ABC Unidade Cirúrgica - São Bernardo do Campo/SP<br>
Mestrando do Departamento de Doenças Infecciosas e Parasitárias - FMUSP<br>
Laboratório de Soroepidemiologia e Imunobiologia (LIM38) - IMT/USP<br>
<a href="mailto:igorthiago@usp.br" target="_blank">igorthiago@usp.br</a><br>
<br>
<br>
<br>
<br>
<br>
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<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Carlos H. N. Costa, MD, DSc.</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Sociedade Brasileira de Medicina Tropical </span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif"></span><span style="FONT-FAMILY: verdana, sans-serif">(Brazilian Society of Tropical Medicine)</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">President</span></div>
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</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Universidade Federal do Piauí</span></div>
<div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Instituto de Doenças Tropicais Natan Portella</span></div>
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<div style="TEXT-ALIGN: center; DISPLAY: inline !important"><a href="tel:%2B55%2086%203237-1075" target="_blank" value="+558632371075">+55 86 3237-1075</a> (R). </div>
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<br>
<br clear="all">
<br>
-- <br>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Carlos H. N. Costa, MD, DSc.</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Sociedade Brasileira de Medicina Tropical </span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif"></span><span style="FONT-FAMILY: verdana, sans-serif">(Brazilian Society of Tropical Medicine)</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">President</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif"><br>
</span></div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Universidade Federal do Piauí</span></div>
<div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">Instituto de Doenças Tropicais Natan Portella</span></div>
<div style="TEXT-ALIGN: left"><font face="verdana,sans-serif">Rua Artur de Vasconcelos 151-Sul</font></div>
<div>
<div style="TEXT-ALIGN: left"><span style="FONT-FAMILY: verdana, sans-serif">64001-450 Teresina-PI</span></div>
<font face="verdana,sans-serif">
<div style="TEXT-ALIGN: left">Brazil</div>
<div style="TEXT-ALIGN: left">Telephones: +55 86 3222-4377 (W),
<div style="TEXT-ALIGN: center; DISPLAY: inline !important">
<div style="TEXT-ALIGN: center; DISPLAY: inline !important">+55 86 3221-3062 (W), </div>
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