Cases of the week Flashcards by Hamish Reed-Embleton

Several days sunbathing at a nearby beach in Colombia

Hookworm-related Cutaneous Larva Migrans due to Ancylostoma braziliense.

Ivermectin or albendazole

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72 yo with 3 day history of acute onset severe epigastric pain
raised bilirubin, amylase and eosinophils
-dye injected into the common bile duct; the arrow on the image demonstrates the relevant filling defect

Pancreatitis and acute biliary obstruction due to Ascaris lumbricoides.

In cases of biliary obstruction -> endoscopic removal of the adult worm
+albendazole if other worms

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79-year-old man is brought to the ER after having vomited twice over the previous 4 hours approximately 200 cc of blood clots, and experienced one episode of black stools.

Intermittent cough and wheezing over the course of the last year
Worms from vomit as pictured

Ascaris lumbricoides

Rx albendazole or mebendazole

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27 year old male presents with 10 day history of fever, cough, mild hemoptysis and production of very white sputum which tastes salty.

Echinococcus granulosus.
Surgery + post op albendazole

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47 year old female with 2 weeks of moderate constant right upper quadrant pain. No fever or systemic symptoms. Referred because of a dilated common bile duct noted on ultrasound
Raised eosinophils
ERCP as shown

infection and dilatation of the common bile duct due to Fasciola hepatica

rx triclabendazole

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44 year-old female presented to the outpatient clinic complaining of a 2-week history of 2 cm itchy migratory subcutaneous nodule initially arising over the epigastric region. She had earlier presented to another hospital with right upper quadrant pain.

Fasciola hepatica

Triclabendazole

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62-year-old female 16-day history of cutaneous lesions. Began with a 5cm serpiginous-erythematous lesion on the chest wall that was intensely pruritic.
Disappeared then new nodular lesion appeared on the left breast.
By by the time of presentation to the face where it was associated with significant edema.

Gnathostoma spinigerum

albendazole

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57 year-old female with 10-day history of highly pruritic rash which began as a painful violaceous nodule in the mid upper abdominal region with surrounding erythema and extreme warmth

Gnathostoma spinigerum

Albendazole

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Peruvian farmer with a two day history of a non painful ulcer, dyspnea, headache and shock
Rx?

Bacillus anthracis

ciprofloxacin + meropenem (penicillin) + linezolid (clindamycin) + antitoxins/Ig

Pleural effusion from necrotic lymph nodes

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Peruvian farmer with a two week history of painful lesions

Sporothrix schenckii ; itraconazole

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Painless lesion (12cm) that developed
over several months

Mycobacterium ulcerans

clarithromycin plus rifampicin

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Painless lesion that developed over a one week period in a Brazilian farmer

Leishmania braziliensis; pentavalent antimonials

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Painful lesion that developed over two days in a Peruvian male

Loxosceles sp

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Bolivian patient with a 6 month history of pleuritic chest pain and fever
Fistula with GRAIN

Actinomyces spp;
penicillin

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Painless lesions in a Chinese chef with concomitant
uveitis and hepatitis. Ulcers on hands

Treponema pallidum;
penicillin

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47-year-old male who presented to our hospital with partial motor seizures

Taenia solium
Neurocysticercosis with parenchymal, intraventricular and sub-arachnoid cysts

Western blot

Albendazole, praziquantel, dexamethasone and antiepileptic

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16-year-old female, presented with a 1-month history of decreased appetite, burning epigastric pain, nausea, and vomiting. Remembers gran having spastic paralysis

Strongyloides stercoralis hyperinfection syndrome.
HTLV-1 infection

Ivermectin

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41 year-old previously healthy male presented with a 2-year history of persistent cough and blood-tinged sputum
Repeated AFB negative
Sputum -

Paragonimus mexicanus - [westermani if not south america]
Praziquantel

Inf: ingestion of inadequately cooked crustaceans w metacercariae

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24 year-old male admitted with a 6-month history of watery diarrhea, nausea, vomiting, unspecified but significant weight loss, and disseminated desquamation of the skin with plaque like lesions scattered over the body.
HTLV- 1 positive

Disseminated hyperinfection with Strongyloides stercoralis and crusted (Norwegian) scabies (Sarcoptes sp) secondary to HTLV-1 infection

Ivermectin

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Name 3 complications of HTLV-1

Strongy hyperinfection
severe diarrhea from Cystoisospora belli
crusted scabies
tropical spastic paraparesis
adult T-cell leukemia/lymphoma (ATLL)
autoimmune disease including uveitis, Sjögrens, arthropathy, polymyositis, and thyroiditis.

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6 year old female with 20 days of fever, fatigue, irritability, loss of appetite, sore throat and mild cough
EKG showed sinus tachycardia with inverted T-waves in leads V1-V4.

Trypanosoma cruzi. Acute infection in a child with myocarditis.

benznidazole

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44-year old male from highlands and high jungle presented to the outpatient clinic with palpitations and dizziness.
An arrhythmia had been diagnosed 5 years earlier

Trypanosoma cruzi - Chagas cardiomyopathy
ELISA and IFA for T cruzi

benznidazole

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51 year-old male admitted with a 1-month history of fever and chills. 15 days after onset he noticed watery diarrhea for 5 days that resolved spontaneously.
10 days before admission he developed nausea and right upper quadrant pain.

Liver abscess due to Entamoeba histolytica

Metronidazole/tinidazole
+ paromomycin or iodoquinol

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8-month history of an indurated erythematous plaque affecting the nose and left maxillary region, rhinorrhea and headache.

Balamuthia mandrillaris CNS infection

Fluconazole, Albendazole and miltefosine
[Shit infection to have FAM]

Palliative care referral

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A 27-year-old male patient complains of 3 months of ulcerative lesions on the left forearm and nuchal region. The lesions began as small, pruritic, erythematous papules, both of which ulcerated over about two weeks He noticed the appearance of multiple new painless ulcers on his shoulders and back Biopsy dx? rx?

Disseminated cutaneous leishmaniasis L. braziliensis Pentavalent antimonials are the first line [High failure -> Ampho B] DSL: more than 10 lesions over more than 2 noncontiguous body parts

7-day-old infant boy referred for evaluation of bilateral enlargement of the lateral ventricles that had been noted on a week-36 fetal ultrasound performed on the mother. chorioretinitis, hydrocephalus, and intracranial calcification rubella, CMV and syphilis negative =? rx?

Congenital infection with Toxoplasma gondii pyrimethamine + sulfadiazine +folinic acid

25 weeks pregnant 22F fever, malaise, and pruritic skin lesions seven days earlier. The lesions began on her abdomen and spread over subsequent days to her chest, face, and then extremities. Several mouth lesions have now resolved. Three younger siblings living at home developed a similar febrile rash illness in the 2 weeks prior to illness onset. =? Most common complication in adults? rx?

Varicella zoster Varicella pneumonia Aciclovir VZIg only if exposed but no symptoms

10M 4-day history of fever and a vesicular rash starting on the trunk and spreading to involve the entire body. One day prior to admission he developed dyspnea and was brought to the hospital.

Varicella zoster acyclovir

34F 6-day history of fever, headaches, joint pain, and mucosal bleeding. Recent return from jungle Mild neutropenia/thrombocytopenia LFTs mildly derranged Gallbladder thickening Morbilliform rash =? rx?

Dengue - severe Supportive

38F 8 years of difficulty walking, parasthesias in both legs, and a feeling that her legs were hard and weak On exam - bilateral spastic paraparesis with ankle clonus Normal spinal MRI/LP dx? ix? rx?

Tropical spastic paraparesis (TSP) secondary to HTLV-1 infection. ELISA / western blot for HTLV-1 nil steriods maybe useful if used early in dz course https://link.springer.com/article/10.1007/s13311-017-0533-z

5M recurrent infection of the scalp, ears, neck, and less often axilla and groin since the age of 5 months. Episodes occur 3-4 times per year that respond rapidly to therapy with 2-3 weeks total of oral anti-staphylococcal antibiotics.

Infected dermatitis secondary to HTLV-1

38F 16-month history of multiple skin lesions. Initially, a single, painless, small (<1cm) furuncle-like lesion Biopsy - T cell lymphoma Grandmother is bed-bound with 'tight legs' Dx?

Adult T-cell leukemia/lymphoma (ATLL), smoldering type. HTLV-1 infection.

70F 6 months of erythroderma, pruritic desquamating plaques, and crusted lesions A/B - desquamating annular lesions on forearms, legs, trunk c/d - Crusted lesions on feet, legs, and ear E - blood film dx?

HTLV-1 with: -Adult T-cell leukemia/lymphoma (ATLL) -Tinea corporis -crusted Sarcoptes scabei. Ivermectin Zidovudine (AZT) with IFN-α,

39 HIV+ not taking antiretrovirals several painless violaceous skin lesions on the trunk and extremities and also dry cough without constitutional symptoms. dx?

Kaposis sarcoma (pulmonary)

fever and arthritis, with onset 10 days into a jungle trip. onset of a diffuse erythematous rash and diffuse polyarthralgia involving the hands, wrists and heel. Unable to walk due to arthralgia PCR and IgM ELISA for dengue, chikungunya, spotted fever negative dx? ix? rx?

Mayaro Fever with polyarthritis. IgM ELISA for Mayaro virus Supportive South America, some Caribbean islands mosquitos (Haemagogus sp > Aedes sp)

41M 5-day history of fever to 38°C, headache, muscular pain in the lower extremities, nausea and vomiting. One day prior to admission his family noted jaundice, altered mental status, and reduced urine output. Recent return from jungle in Africa Platelets 188,000. PT 71.3 (N <13). Glucose 77. BUN 67 mg/dl. Creatinine 8.3 mg/dl. Albumin 3.3 (N>3.5). Bilirubin 8.0 (4.7 direct; 3.3 indirect). AST 13,300 (N <40). ALT 11,253 (N<40). Conjuntival and mucosal haemorrhage Dx? Why not dengue? Why not rift valley? Why not lepto? Why not Crimean-Congo Hemorrhagic Fever?

Yellow fever ELISA for IgM Dengue - Hepatitis occurs only occasionally and is mild. Renal involvement does not occur with dengue Rift Valley fever - predominates in livestock raising areas of Africa, which do not overlap much with the forested and forest fringe areas where yellow fever occurs. Lepto - hemorrhagic manifestations are not usually as severe. hepatonecrosis is not a hallmark of leptospirosis – there may be dramatic hyperbilirubinemia but hepatic transaminases are no more than 5 times normal levels. Crimean-Congo Hemorrhagic Fever - associated with multi-organ failure due to a “cytokine storm” and may have both renal and hepatic failure later in the course of the illness whereas in yellow fever the hepatic necrosis and renal failure is manifest from the outset

Baby - when mum 10 weeks pregnant: Had a pruriginous generalized rash associated with malaise and subjective fever, which resolved within a week without any treatment. microcephaly, retrognathia, and valgus deviation of lower extremities with a left club foot

Congenital Zika virus infection RT-PCR zika

A silver stain demonstrated very thin filamentous bacteria If grains yellow/white? Red?

Actinomycetoma - Nocardia TMP/SMX + Aminoglycoside or Rifampicin or Dapsone Nocardia, Streptomyces (white/yellow grains) Actinomadura (red grains).

16-month old child from highlands with onset of a single non-tender but pruritic lesion on the ear lobe 2 months earlier. Over the next weeks similar lesions developed on the face and limbs dx? rx?

Bartonella bacilliformis - Verruga Peruana Azithromycin

46F acute onset of decreasing visual acuity in the left eye to almost complete visual loss in 3 weeks Married, monogamous, middle-class, with one child and two cats dx? rx?

Bartonella hensellae with neuroretinitis “stellate maculopathy" Doxy/azithro + rifampin

72 yo male first presented 3 months earlier with 6 weeks of fever, night sweats and some mild lumbar pain Dx? Key Ix? How can you be sure on this Xray?

Brucella melitensis. B. melitensis agglutination titre of 1:400 Rose-Bengal test Doxy + rifampin + gent 1) lumbar location; 2) pathognomonic bridging osteophytes between adjacent vertebrae (seen here at 2 levels) simultaneous with the presence of both osteoblastic lesions and loss of bony mass in the same vertebrae; 3) loss of disk space; 4) loss of definition of bone at top of the affected vertebrae.

60F undermined ulcerative skin lesion over the right buttocks

Buruli ulcer - Mycobacterium ulcerans. Rifampin + clarithromycin

65M - erythematous painful nodules in his thorax, abdominal skin and upper limbs. Some nodules pustulated. On exam - bilateral paresthesiae on his hands, posterior and anteromedial aspects of forearms, and feet. dx? Rx?

Mycobacterium leprae. Type 2 leprosy reaction (erythema nodosum leprosum). Lepromatous leprosy Steroids + thalidomide Leprosy Rx - Dapsone, rifampin, clofazimine for 12 months

25M 2 year lesions which began as papular lesions and have progressed to form nodules. normal cranial nerves, sensation normal to pin-prick. AFB on skin smears Dx? Rx?

Lepromatous leprosy Dapsone, rifampin, clofazimine for 12 months

62-year-old male with a 2 year evolution of skin lesions He has thickening of the left ulnar, a branch of the left radial (wrist level), both common peroneal and right posterior tibial nerves. There is some loss of motor strength in both ulnar nerves and very mild loss of motor strength in the left radial nerve -

Borderline leprosy - ill-defined peripheral margin but a punched out center

61 yo male with 7-days of fever, watery diarrhea and severe generalized muscle pain most prominent in the lower limbs starting on the fourth day of illness. Two days later the muscle pain was severe enough to prevent walking. Jaundice was noticed on the fifth day. Bilirubin ++++ with transaminases + dx? rx?

Leptospira interrogans Ceftriaxone

17M 2 week history of unilateral right inguinal swelling which was tender, red, and painful. Did not notice any ulcer dx? rx?

LGV serovars (L1, L2, L3) of Chlamydia trachomatis Doxycycline [Primary LGV presents as a small painless papule (or ulcer) at the site of initial infection which may be penis, labia, vagina, or cervix. t heals spontaneously in a few days and is only noticed by the patient in 3 to 53 percent of cases.]

39M 4 years of diffuse nodular subcutaneous lesions CXR 18m ago - UL cavity and alveolar infiltrate - > TB Rx -Extensive nodular subcutaneous lesions and subcutaneous masses on the scalp, thorax and on the limbs -Left knee arthritis with extensive effusion -memory loss, blurred vision An aspirate of a right forearm abscess grew a weakly acid-fast organism Gene Xpert negative all samples

Disseminated nocardiosis TMP/SMX , Cef plus Amikacin - TMP/SMX - for brain abscess

8M daily high spiking fevers, this time accompanied by significant muscle pain and tenderness localized to small areas of both calves and both deltoids. -Right deltoid and both calves all visibly swollen with focal areas of about 10 cm extremely painful to light palpation

Staph aureus - Tropical Pyomyositis.

10-month old female born with red vesicular skin lesions from knee to toe which spread over the next several weeks to involve the feet (including the soles), hands (including the palms), and oral mucosa. dx? ix?

Congenital syphilis. RPR Benzylpenicillin

54F 2-month history of progressive decrease of visual acuity accompanied by mild conjunctival erythema, epiphora, and pruritus in the right eye. Similar symptoms developed shortly after in the left eye. On exam - Right eye (OD): non-reactive to light. Left eye (OS): reactive to light and accommodation. opacification with presence of a vitreous condensation (Black arrows) of “snowbank” appearance; TB/HIV negative dx? rx?

Treponema pallidum - ocular IV pen

25 yo male presented to the outpatient clinic complaining of multiple skin lesions for 1 month. The lesions started as small papules on the face that were unresponsive to oral acyclovir. The lesions disseminated to involve the entire body HIV ELISA positive, HTLV-1 negative, RPR negative. Spirochetes on Warthin-Starry (silver based)

Treponema pallidum Benzylpenicillin RPR initially negative secondary to prozone effect

52 yo with minor puncture wound of the foot eight days earlier. 4 days prior to admission he noted the onset of muscular back pain. 1 day later onset of painful spasm in the muscles of mastication Dx rx?

Clostridium tetani [Disease is caused by a toxin, tetanospasmin] Likely ICU Benzos Antitoxin surgical debridement and metronidazole

26F 6 month history of a left posterior calf lesion which began as a red hard indurated and erythematous papule. 2 weeks later it spontaneously drained purulent material and began to ulcerate Mantoux test was highly positive at 15 mm biopsy - mild vasculitis with fibrinoid necrosis and inflammation of vessel walls. Within the adipose tissue lobules there was a lobar panniculitis with inflammatory infiltration consisting of necrosis and granulomatous (non-caseating) reaction 4-drug anti-TB therapy and within 15 days the lesions were healing with good granulation tissue and within 1 month the ulcer was completely healed over Dx?

Erythema induratum - One of the tuburculids Diagnosis of Erythema induratum is made by a combination of: -clinical presentation -markedly positive TB skin test -response to anti-TB therapy -characteristic histologic findings (see above).

21 year-old male with decreased vision in both eyes for 3 months. Redness and pain present mostly in the left eye. Multi-focal choroidal lesions in right eye [Image A] and a localized exudative choroidal detachment in the left eye [Image B] PPD was positive at 18 mm. Other tests performed on serum included a negative VDRL, negative toxoplasma IgG, negative brucella agglutinins.

Ocular tuberculosis due to Mycobacterium tuberculosis. RIPE

22M 1-month of mild lumbar pain that increased with physical activity, with progressive onset of paresthesias over the next two months and difficulty in walking. No fevers A CT scan of the spine showed lytic lesions and disk-space narrowing at L4-5 and L5-S1 levels; no new bone formation was observed =? Rx? If acute onset and high fevers what would you suspect?

Spinal TB (potts) RIPE - 12 months Salmonella or staphylococcal infection

46 year old female with an extensive plaque-like lesion over the face. Biopsy - granulomatous (non-caseating) reaction with some giant cells throughout the dermis but without epithelial hyperplasia. PPD 18mm

Cutaneous tuberculosis. Lupus vulgaris form. [slowly enlarging plaque with a slightly elevated verrucous border and central atrophy] RIPE

19F 3 weeks illness - initially fever followed by watery diarrhea that had started on the third day of illness and lasted for two days. Now acute peritonitic distended abdomen Widal test was positive

Typhoid with intestinal perf Salmonella typhi / paratyphi [complications usually after 2-3 weeks] Ceftriaxone (may need meropenem in Pakistan)

22M 24-day history of fever up to 40°C, particularly at night, headache and insomnia. Eats food from street vendors, including ceviche, salads, and drinks with ice Anaemic with gram negative bacteria in blood cultures Colonoscopy - multiple ulcers lesion dx? rx?

Salmonella typhi/ paratyphi Ceftriaxone DDx intestinal tuberculosis or Yersinia infection. Entameba histolytica and Balantidium coli infection cause ulcers and perforation but would only be found in the colon

2M 2-week history of dry cough. The mother states that over the 2 weeks, the cough became paroxysmal with most of the events lasting up to a maximum of 5 minutes -inspiratory stridor during the episodes of cough Lymphocytes >10,000 =? rx?

Bordetella pertussis. [Gram-negative coccobacillus] Azithromycin Ddx - RSV, mycoplasma, adenoviruses and Chlamydia trachomatis

60M 8 year history of a painless chronic skin lesion -progressed slowly over the years to become a verrucous plaque with some black dots on the surface

Chromoblastomycosis Itraconazole

Lesion on face - biopsy dematiaceous (pigmented) hyphae fungi inflammatory responses mainly in the sinuses, lungs, and brain

Phaeohyphomycosis

47-year-old male, HIV positive, presents with a 6-month history of abdominal pain, watery diarrhea, fever and weight loss. Anaemic and neutropenic Colonoscopy - multiple colonic ulcers were observed scattered over the entire colon and ileum Bilat infiltrates on CXR Biopsy: Dx? Rx? 2 Key DDx of wasting syndrome?

Disseminated Histoplasma capsulatum Ampho B -> itra TB, MAC (Another biopsy pic)

50M 10 weeks of fever, night sweats and weight loss. 8 weeks before admission, he presented to a local physician with mild diffuse abdominal pain, and watery diarrhea. A month prior to admission, he starts noticing dyspnea, which steadily progresses

Progressive disseminated histoplasmosis Ampho b

29M 17-year history of an indolent proliferative lesion on the left ear. Initially the lesion was a pruritic papule, then multiple papules but has increased greatly in the past years. Biopsy + KOH - 9 µm cells with blastoconidia sometimes appearing in chains. DX? Rx?

Lobomycosis due to Lacazia loboi Surgical excision [posaconazole or clofazimine + itra have rare case reports]

3-year history of cough, occasional hemoptysis, and worsening dysphonia Works in jungle.

Paracoccidioides braziliensis, chronic multifocal form [chronic form of paracoccidioidomycosis most often involves pulmonary disease with oral mucosal involvement]

12F 3-month history of malaise, fever, diarrhea and generalized lymphadenopathy. Hepatosplenomegaly Biopsy - dx? rx?

Paracoccidioidomycosis, juvenile form Ampho B -> itraconazole [Juvenile form - Skin, lymph node and visceral involvement]

51M from jungle 3-year history of mildly painful ulcerative lesions on the lower lip and oral mucosa involving gums with haemorrhagic spots. Mild cough dx? rx?

Paracoccidioides brasiliensis infection (chronic form) with mucosal involvement. [Gums with haemorrhagic spots] itraconazole

63 yo male with 3 week history of a painless skin lesion over the left ankle beginning with a nodule which ulcerated after a few days and progressed by the end of the first week to include ascending mildly painful linear nodules up the leg to the knee Dx? Rx? DDx of sporotrichoid lesions?

Sporotrichosis Itraconazole SLAN Sporothrix schnekii Leishmaniasis Atypical mycobacteria Nocardia

Snakebite on hand On exam - skin was darkened and blistering (Image A). The right arm was swollen up to the axilla, with petechiae and ecchymoses (Image B).

envenoming by desert lance-headed pit viper (Bothrops pictus or B. roedingeri) [These are the only venomous species found in the Lima area.]

Snake bite -> Pale appearing. Afebrile. Hemodynamically stable. Oliguric for previous 12 hours. Extensive bruising over body dx?

Envenomation with DIC due to Viper bite (Bothrops atrox) Antivenom

61F 5-day history of acute pain and discoloration of the left arm. While carrying a piece of wood she suddenly felt a sharp stabbing pain -> erythematous lesion and swelling. =? rx?

South American brown recluse spider - Loxosceles laeta Polyclonal equine IV antiserum if within 24hrs

42F 2 days - necrotic skin lesion and hematuria. While she was getting dressed, she felt a sudden stabbing pain on her right inner thigh dx? Patients with evidence of hemolysis or hemoglobinuria require ?

Loxosceles laeta “red, white and blue” sign Evidence of hemolysis or hemoglobinuria -> IV hydration and urinary alkalinization to prevent renal failure.

43M laryngectomy south america complain of worms in stoma Removal of >30 larvae Why often so many? DDx?

Cochliomyia hominivorax [Screwworm myiasis] - the odor of the lesions attracts other gravid female flies, which leads to a single wound containing hundreds of larvae -Cochliomyia larvae typically have a smooth external aspect, with dorsal tracheal trunks and are pigmented C1 -Dermatobia hominis larvae are hairy, pear-shaped, with transverse bands of hooks and a respiratory spiracle in the broad end [Image C2].

51F 6-day history of a tender, expanding, erythematous lesion on her left forearm.

Furuncular myiasis due to Dermatobia hominis [breathing hole = botfly]

60M Recent wound from motorbike accident -> feeling of something moving inside the wound.

Cochliomyia hominivorax (the new world screwworm).

49M 2-day history of a rapid onset intensely pruritic lesion on the left arm that began during the evening during a visit to the jungle.

Paederus irritans, known in Perú as latigazo (whiplash). -Blister beetle dermatitis

Cases of the week Flashcards

(77 cards)