| QUIZ: Dream Holiday *solved* |
 |
 |
 |
| Sunday, 13 December 2009 00:41 |
|
30-years old woman without relevant history. She saved money with her husband, and finally they went on their dream holiday - to Africa She has spent the next two days in her room suffering from arthralgia and overall weakness. In the evening, erosion occurred in her oral cavity. Her husband noticed pallor of her skin. On the day of departure she developed: swelling around her eyes and both ankles, high fever and seizures. Woman was admitted to a local hospital. What affliction could she suffer from?
The case is here since Sunday, so I think that I should develop give more details about it... The patient was admitted to the hospital and diagnosed. In an air-conditioning, shaded and mid-temperate room she felt better, but on the 2nd day, new symptom emerged: erythematous rash. Lesions were mainly on her shoulders, abdomen and legs. Additionally: doctor took the history very accurately and the patient recalled, that she had swelling around her eyes and painful knees already since beginning of summer (4 weeks ago), but that didn't bother her very much so she ignored it. Only during her holidays she started to feel really bad. |
Comments
I'd do a physical examination with careful examination of oedemas (are they dough-like), erosion (are they clean, do they excrete pus) and a check up of peripheral lymph nodes for petechiae.
Lab tests: morphology with smear, ESR, CRP, toxicology, urine - general test + creatinine with urea, liver panel. That's it for now, I suspect some sort of hemorrhagic fever
She did swim and sunbathed on the beach, drank only mineral bottled water, tried local food, although under supervision of a guidebook with instructions on what's safe to eat and what's not. Her husband was with her at all times, eating, drinking and bathing in the same place as she, he's healthy
--> Any insect bites
Mosquitoes
--> Other symptoms? Dyspnoea? Pain? Loss of consciousness?
Apart from what i wrote, nothing. I think it's still a lot
--> Erosion (clean? with pus?)
clean, without infection
--> Peripheral lymph nodes
normal size, petechiae are present, mainly in the limbs, in places prone to injuries
--> Is the patient treated for any chronic diseases?
no
Tests:
morphology: thromobopenia 30000 + normocytic anemia
creatinin: 1.00
toxycology: negative
urine: proteinuria
liver: AspAT and AlaT slightly elevated
ESR: slightly elevated
Dough-like oedemas
Leshmaniasis - the changes would not appear that quickly, besides eozynophilia would be present as well, and morphology excluded that. First and foremost the other symptoms don't fit the picture: proteinuria! thrombopenia? Alright those can appear in leshmaniasis, but if we examine the spleen we'll find out that it's not enlarged so we can suspect something else.
Other exotic diseases: Since the time spent in Africa is short we can exclude in that way many diseases. What is noteworthy to ask a tourist which is going to or coming back from such exotic regions?
Low platelets, elevated liver enzymes, anemia are all parts of the HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelets) HELLP is one of the hypertensive states of pregnancy, along with preeclampsia. Symptoms of preeclampsia include high blood pressure (i suspect a systolic pressure to be at least 180) and proteinuria.
Because of the shivers we can diagnose eclampsia.
We can ask if she had any pain in the upper abdomen, it's also a common symptom of preeclampsia
A very good question, they both underwent prophylaxis against malaria
--->the most relevant question, when did she have her last period, what kind of anti conception does she use (if any)
She gets her period regularly, goes to a gynecologist on regular basis, doesn't have children nor does she plans to get any. She uses anti conception in forms of condoms and vaginal globules, no hormonal anti conception
---->Because of the shivers we can diagnose eclampsia.
Pregnancy test negative + further affirmation by the gynecologist
Don't leave it like that :-)
The disease is important and it's not one of those exceptionally rare tropical diseases
Most of you had contact with patients suffering from this affliction
The patient was admitted to the hospital and diagnosed. In an air-conditioning, shaded and mid-temperate room she felt better, but on the 2nd day, new symptom emerged: erythematous rash. Lesions were mainly on her shoulders, abdomen and legs.
Additionally: doctor took the history very accurately and the patient recalled, that she had swelling around her eyes and painful knees already since beginning of summer (4 weeks ago), but that didn't bother her very much so she ignored it. Only during her holidays she started to feel really bad.
Diabeł- The Stevens-Johnson is a interesting idea but in our case that's not it. The erosion is present only on the mucous membrane of the oral cavity and there are no blisters. If I remember correctly erythema multiforme doesn't explain the proteinuria
It's correct, the patient has SLE.
Diagnosed on the basis of following criteria:
-proteinuria
-erosion in oral cavity
-arthralgia
-hematologic disorders (thrombopenia, anemia)
We have 4 out of 11 symptoms, so we can make a diagnosis. We could also have hypersensitivit y to light, and the antibodies tests will definitively diagnose SLE.
One more thing, elevated aminotrasferase s also require an explanation, but it's an entirely different matter.
Cheers
RSS feed for comments to this post