Clinical Reports

89. an hiv patient with microscopic haematuria

Mon, 6 Sep 2010 17:28:18 +0200

A 47 year-old Spanish man with long term HIV infection, well controlled with a protease inhibitor, tenofovir and FTC (emtricitabine) without complications, came for a routine check. He had been a heavy smoker in the past. He had never been to the tropics.

He was asymptomatic and the physical examination was unremarkable. Haematology and biochemistry tests were normal. The CD4 lymphocyte count was 35 % (870 cells/microL) and the HIV-1 viral load was undetectable. Microhaematuria with undeformed erythrocytes was detected, without any other abnormalities in the urine sediment.

A urinary ultrasound scan was performed and is shown in the image.

What is your diagnosis and what test would you advise to confirm it?

88. cutaneous lesions and seizures

Mon, 23 Aug 2010 19:08:45 +0200

An 18 year-old Ethiopian woman was referred having had several episodes of loss of consciousness with seizures. She had had similar episodes for 5 years.

Physical examination highlighted lesions on the face and forehead (images). Another lesion was present on the forearm (image).

What is your diagnosis?

Seizures and facial cutaneous lesions suggest the diagnosis of tuberous sclerosis. Her elder sister had similar facial lesions.

Tuberous sclerosis is an autosomal dominant hereditary disease with incomplete penetrance. It is one of the neurocutaneous syndromes. Mutations in two genes (TSC1 and TSC2) cause the disease. It occurs in different ethnic groups and has no gender predominance. It is estimated that 1 to 2 million people are affected.

It presents with angiofibromas, reddish rounded tumors often on the chin, cheeks and nose in a butterfly distribution (nasolabial folds) as in our case (image 1) and hypochromic lanceolate or ash leaf shaped macules (image 3).

Symptoms of tuberous sclerosis may present at birth or later.

Mental disorders, behavioural or psychotic disturbances, may be associated. The condition can also be complicated by giant cell intraventricular astrocytomas near the foramen of Monro, retinal and cardiac hamartomas, angiomyolipomas and pulmonary lymphangioleiomyomatosis.

Treatment is symptomatic. Phenobarbital is frequently used in Africa in the case of epilepsy.

87. pleuritic pain and fever

Mon, 9 Aug 2010 18:42:30 +0200

A 28 year-old man from the Dominican Republic presented with right pleuritic pain of 4 days’ duration, with fever, moderate dyspnoea and dry cough.

He had had dengue fever and hepatitis A in his childhood.

Physical examination was normal except for fever (38.5°C) and a basal oxygen saturation of 94%.

He had a haemoglobin of 10.6 g/dL, with normal erythrocyte volume, LDH of 693 IU/mL, ESR 77 mm/hr and CRP 18 mg/L, polyclonal hypergammaglobulinaemia and D dimer of 3414 ng/ml.

A chest X-ray was performed (see image) and thoracic CT angiography showed filling defects in the right posterior basal segment and left base with bilateral lung infarcts.

Anti nuclear, DNA, SM, Ro, La and RNP antibodies were negative. RPR and TPHA were negative. HIV-1 RNA viral load was 2,600,000 copies/mL, and CD4 lymphocytes were 297 cells/μL.

What is your diagnosis and what complementary tests would you recommend?

This is a case of bilateral pulmonary thromboembolism in a patient with antiphospholipid syndrome within a primary HIV infection.

IgG anti cardiolipin and beta2 glycoprotein1 antibodies were positive in two assessments three months apart. IgM antibodies were negative.

The presence of anti cardiolipin antibodies is common during the acute phase of several infectious diseases: HIV (49%), HBV (24%), HCV (20%), Q fever (80%), CMV, EBV, HZV, parvovirus B19 and HTLV-1. However, the presence of anti beta2 glycoprotein1 antibodies is rare.

86. a musician with cutaneous abscesses

Mon, 26 Jul 2010 19:27:48 +0200

A 72 year-old professional musician from North America was admitted with high fever, malaise and multiple painful skin lesions (see image).

He had suffered similar symptoms before, having had then distal necrosis of two fingers.

A cardiac ultrasound was normal.

What do you think is the cause of the illness and what treatment would you recommend?

This patient was an active intravenous drug user and the cutaneous abscesses were produced through venepunctures in poor hygienic conditions.

Methicillin sensitive Staphylococcus aureus was isolated from the abscesses. Surgical drainage and intravenous cloxacillin cured the infection.

Older age does not exclude intravenous drug abuse.

85. a peruvian woman with a seizure

Mon, 12 Jul 2010 16:13:01 +0200

A 28 year-old Peruvian woman was transferred to the emergency department with a generalised seizure of 2 minutes’ duration. She had a history of repeated middle ear infections.

Physical examination after the seizure was normal, including the neurological examination.

A cerebral MRI was performed and is shown in the image.

What is your diagnosis and what treatment would you recommend?

A hypodense, ring enhanced lesion with surrounding oedema suggestive of a brain abscess is present in the MRI. The differential diagnosis could include a brain tumour or neurocysticercosis. However such clear ring enhancement makes the diagnosis of cysticercosis very unlikely.

The history of repeated middle ear infections is a strong indication of brain abscess.

A diagnostic and therapeutic aspiration was performed with drainage of purulent material, and Streptococcus anginosus (milleri) isolated.

Streptococci (aerobic, anaerobic or microaerophilic) are responsible for 70 % of all brain abscesses, either as single agents or in combination with other bacteria. In all cases infectious endocarditis should be excluded.

Surgical drainage and intravenous penicillin G is the treatment of choice for this infection.

84. fever in a young moroccan

Wed, 30 Jun 2010 16:33:32 +0200

A 24 year-old Moroccan man residing in Spain, previously healthy and without any history of epidemiological interest, substance misuse or sexual risk, presented with fever.

During the last year he had felt febrile, predominantly in the evenings, with malaise and 4 kg weight loss. He recalled having had oral ulcers and had recently suffered a limited episode of haemoptysis.

Physical examination revealed slight cutaneous pallor, a left parasternal pansystolic murmur, 3 cm of hepatomegaly and minimal splenic enlargement.

Blood tests showed a thalassemia minor with Hb12.2 g/dl, WBC 10,770/mm3 with normal differential and platelets 287,000/mm3. ESR was 21 mm/hr. Protein electrophoresis was normal. Auto-antibodies were negative. HIV and hepatitis B and C antibodies were negative.

A chest X ray was performed (see image).

What abnormalities do you see and what is your diagnosis?

The chest X ray shows bilateral aneurysmal dilatations of the pulmonary arteries.

This lesion is characteristic of Behçet’s disease with cardiopulmonary involvement. The disease is a vasculitis that predominantly affects young men, having a higher prevalence in the Far and Middle East and in North Africa.

The presence of oral ulcers, uveitis, genital ulcers, pathergy, and erythema nodosum are common symptoms.

Cardiopulmonary involvement occurs in 1 to 7.7 % of cases, with large pulmonary aneurysms, as in the present case, and formation of mural thrombi in the right ventricle or within the aneurysmal vessels.

The mean survival after an episode of haemoptysis is 10 months.

Treatment includes immunosuppressive therapy.

83. An infant with cutaneous lesions

Mon, 31 May 2010 23:19:55 +0200

An infant of a few months was brought to a rural hospital in South America with a generalised rash. His mother reported that he had been irritable and prone to crying for a few weeks. He had had no fever or any other symptoms.

Physical examination showed a generalised papular rash, predominantly on the trunk and limbs as shown in image 1. The family lived in a poor rural area in the south of Paraguay.

What is your diagnosis? What treatment would you recommend? What test is shown in image 2?

The diagnosis is scabies, an infestation caused by the mite Sarcoptes scabiei var. hominis. It is a common ectoparasite infection transmitted by direct skin contact and sometimes through fomites (sheets, towels, clothes). The incubation period is 1-3 weeks. Larvae reach the adult stage in 3 weeks then can re-initiate the cycle.

Nocturnal pruritis is the main symptom, generally affecting several members of the family (or closed community). Itching may be absent in very young infants.

Pathognomomic skin lesions are scabetic burrows and papules. The burrow is a linear skin elevation of a few millimetres dug by the female mite, which can advance 5 mm per day. At the end of the burrow is a 2-3 mm papule or vesicle where the parasite is located.

Treatment should be offered to the patient and his/her close contacts, even if they are asymptomatic. A thin layer of scabicide solution should be applied to the skin, with special emphasis on the interdigital spaces, wrists, elbows, armpits, breasts, buttocks, umbilical area and genitalia. In children under 2 years and immunocompromised patients the scalp should also be included. Nails should be trimmed and treatment applied under the ends.

Scabies can be treated with permethrin, lindane or sulphur.

Permethrin can be used in children over 2 months. Its use in pregnant women and neonates also appears safe.

Lindane (gamma-hexachlorocyclohexane) 1% lotion or cream remains a useful alternative in spite of possible toxicity and resistance. It should be applied for 6 to 12 hours then washed off. It should not be used in children under 10 years, during pregnancy or breast-feeding, or in those with skin or neurological disorders.

Sulphur is an old, cheap and widely-used treatment. A 6-10% preparation should be applied for 3 consecutive nights and washed off after 24 hours.

The clothes should be washed and/or dried at high temperatures (60C). Alternatively they can be kept on a sealed bag for 9-10 days. (The parasite is unable to survive outside the skin for longer than 4 days).

The diagnosis of scabies can be confirmed by visualization of the parasite, its ova or its faeces. A drop of oil is placed onto a scabetic papule which is then scraped with a sharp instrument and examined on a slide under the microscope (Muller test).

If you want to see more scabies photos click here.

82.Eosinophilia in a Senegalese woman

Mon, 17 May 2010 18:09:35 +0200

A 34 year-old Senegalese woman was referred during pregnancy with positive serology for hepatitis B virus infection (HBsAg positive, anti-HBc positive, anti-HBe positive, HBeAg negative and anti-HBs negative).

After delivery the hepatitis B virus DNA serum load was 3,200 IU/mL and the peripheral blood eosinophil count was 10 % (1,200 cells/mm3).

Stool tests for the detection of ova and parasites were performed as part of the investigation of eosinophilia. Ova were not detected. The Harada Mori technique for the detection of larvae revealed the microorganism shown in the image. It measured 500-600 microm.

What is your diagnosis and what treatment would you recommend?

This is a helminth larva. It is possible to detect two types of larvae in stools: Strongyloides stercoralis and hookworm (Ancylostoma duodenalis and Necator americanus). The filariform larvae of Strongyloides are 500-600 m long, but hookworm larvae are about 400 m. From its size this is probably a Strongyloides larva.

Hookworm ova can be detected in stool samples. However in S. stercoralis infection only larvae are seen.

In the Harada Mori technique, faecal material is placed onto filter paper, the end of which is soaked in water in a test tube. This test allows identification of larvae. It is a cumbersome but useful procedure. Rarely, larvae can be detected in concentrated stool samples. Other techniques can be used for identification of larvae in stool samples such as charcoal methods and inoculation of agar plates.

S. stercoralis is a unique parasite as it can reproduce within the human gut; this explains its persistence for many years. It is a common cause of eosinophilia in migrants from Latin America and sub-Saharan Africa.

Albendazole (400 mg bid for 3 days) or ivermectin (200 g/kg/day for 3 days) is the treatment of choice.

If you want to know more about this infection click here.

81. itching in pregnancy

Mon, 3 May 2010 18:01:48 +0200

A 26 year-old woman from the outskirts of Bata (semirural zone) in Equatorial Guinea, previously healthy and in her 21st week of pregnancy, was referred from the antenatal clinic complaining of generalised pruritus for weeks-months, without any other symptoms. The patient reported that the intensity of pruritus varied daily without any particular pattern.

On physical examination she was apyrexial, BP 100/50, and she had some abdominal cutaneous lesions (see image). Examination was otherwise unremarkable. The antenatal check was normal.

Given this information, what is you differential diagnosis and what diagnostic procedure would you recommend?

Causes of itching specific to pregnancy should be considered including anicteric cholestasis of pregnancy and “prurigo of pregnancy” generally associated with atopy or plaque-type skin lesions. Typically gestational pruritus appears during the second half of pregnancy, mainly during the third trimester, disappearing after delivery. Therefore other causes should be examined.

In Equatorial Guinea, infectious diseases are responsible for most longstanding pruritus in healthy subjects. Scabies may produce papular urticaria. In this case the cutaneous lesions observed are old scratch marks, some pigmented, and striae gravidarum. Onchocerca volvulus, Loa loa and Mansonella perstans may cause pruritus. A midday blood film showed an elongated structure of approximately 300 μm (x40) winding among the red blood cells. The size of the microfilaria and the time of detection pointed towards the diagnosis of Loa loa. A Giemsa stain showing the presence of the sheath confirmed the diagnosis.

The patient did not recall having had Calabar swellings or any other inflammatory lesions.

Manifestations of Loa loa vary within the host depending on the duration of exposure and the immune response to the presence of filarial antigens. For this reason clinical symptoms differ in native and expatriate patients. Those native to endemic areas have a diminished immune response, higher microfilarial burden, minimal clinical symptoms and lower eosinophil levels, whereas expatriates present with full-blown clinical disease due to hyperreactivity, high eosinophil counts and raised immunoglobulins.

It is advisable to rule out Onchocerca volvulus co-infection before treatment in order to minimize the risk of adverse effects (Mazzotti reaction).
Albendazole is the preferred drug and prednisone should be given prior to administration. DEC is another option, with the prior administration of ivermectin.
All these drugs are contraindicated in pregnancy and breast-feeding. The patient was treated symptomatically with topical antihistamine.

If you want to know more about loiasis click here (Spanish).

If you want to see more pictures about loiasis click here.

80. Cerebral lesion

Mon, 19 Apr 2010 16:38:31 +0200

An Ecuadorian women who had been living in Spain for the last five years gave birth to her second child without complications. Eight days later she attended the emergency ward complaining of left hemiparesis and a short loss of consciousness.

Physical examination showed motor paresis of the left hand with increased left brachial and patellar reflexes.

Blood counts and biochemistry were normal.

Cranial CT scan showed a hypodense spherical lesion of 22 mm in diameter (image 1) surrounded by digitiform oedema in the right frontal lobe. There was ring enhancement of the lesion with the administration of contrast (image 2) and nodular irregularity of the antero-medial margin. There were no haemorrhagic or ischaemic foci.

The patient was admitted to the neurosurgical ward with the suspected diagnosis of cystic glioblastoma, metastasic lesion or cerebral abscess.

What is your diagnosis?

The patient was treated surgically and a cystic calcified lesion was extracted. Pathological study showed a membranous structure with a villous external surface covered by an eosinophilic zone attached to an intermediate zone containing lymphoid elements (image 3). No strobila or scolex were detected.

The definitive diagnosis was neurocysticercosis, a disease resulting from infestation of the central nervous system with the larval form of the intestinal worm Taenia solium (cysticercus). This disease is cosmopolitan, and endemic in poor countries where pork is commonly eaten.

If you want to know more about the condition (in Spanish) click here.

If you want to see more photographs of this condition click here.