PUO in a Civil Servant29.pptVIP

PUO in a Civil Servant Chris Conlon Infectious Diseases Unit Oxford Previously fit and well Civil servant: social services Presenting complaints: Fever Shortness of breath Detailed symptoms: Decreasing exercise tolerance ( 4 weeks ) Increasing shortness of breath ( 1 week ) Fevers Rigors Sweats Past history Sickle cell trait Polycystic kidneys ( a brother on dialysis ) Stopped smoking a year ago Alcohol: 10 units / week No regular medication Social history Born in Guyana but lived in UK for 20 years Separated from husband; one child Lives alone Travel history Visited Guyana 18 months previously Visited sister in Dallas a year ago Initial presentation to local hospital Diagnosed as community acquired pneumonia Received cefuroxime for 2 days Switched to piperacillin and clarithromycin Transferred to Oxford on day 5 Initial investigations Biochemistry Albumin 32 g/l AST 202 iu/l gGT 105 iu/l Alk phos 202 iu/l Creat 102 mm/l Haematology Hb 7.4 g/dl WBC 3.8 x 109/l Polys 2.8 Lymphs 0.8 Eosins 0.3 Monos 0.1 Platelets 89 x 109/l Clinical examination unremarkable Hectic fever chart Chest radiograph: ? Interstitial changes Question 1 What investigation would you like most? 1. broncho-alveolar lavage (BAL) 2. liver biopsy 3. bone marrow biopsy 4. HIV antibody test 5. stool microscopy 6. other Question 2 Would you like to start empiric therapy? 1. Yes 2. No Question 3 If you said yes, what would you start? 1. high dose co-trimoxazole (Septrin) 2. meropenem and gentamicin 3. amphotericin B (any form) 4. fluconazole 5. anti-tuberculous therapy 6. other Blood cultures were negative at 2 days A blood film was examined….. Question 4 What is the diagnosis likely to be? 1. malaria 2. babesiosis 3. histoplasmosis 4. cryptococcosis 5. leishmaniasis 6. coccidioidomycosis Histoplasma capsulatum was grown from: Blood Bone marrow Sputum Diagnosis of Histoplasmosis AIDS non-immunocomp Histology 41 – 63 40 - 61 Serology 67 – 70 85 - 100 ID 58 – 6