Clinical cases from infection diseases hospital, part 3

Clinical cases from infection diseases hospital

Part 3Pavlov State Medical University,

St-Petersburg, Russia

Dr. Andrey Dyachkov

E-mail: [email protected]

Botkin's hospital was found in 1882

Clinical case — Just do it!

Case 5: 46 y.o. women with erythema Time of admission: 23 of January 2012 Complains at admission: a long history of slightly

painful erythema at a left region of a small of the back, which had started to spread up to the left scapula 3 days ago.

Anamnesis morbi: at 9 of June 2011 patient visited her friend' summer cottage situated in a suburb of St-Petersburg, Russia. She was swimming in a outdoor swimming pool (picture) when suddenly she felt a sharp pain in the left side of the small of her back.

She belives that that was a bite of some insect and didn't pay much attention to that but can recall a strange feelings at this site for a next couple of months which was unusual for regular insect bite — she felt a consolidation or a kind of a nodule at a site of a bite, which was around 1-1,5 cm in diameter.

At the end of October 2011 a skin at this site become painful, hyperemic and edematous, she also felt a numbness in her left arm and pain in a left part of her chest.

She decided to start amoxiclav and antihistamine pills and made appointment to visit surgeon next day

Case 5: 46 y.o. women with erythema


Case 5: 46 y.o. women with erythema Epidemiological data: patient visited Kazakhstan

(country in Central Asia) in May 2011, but didnt remember any significant health problem there

Anamnesis morbi: patient have obesity, moderate arterial hypertension and myoma

She is working for private company and live in a city' appartment with a good sanitary conditions

Patient friends who invite here to swim in a pool have a dog which live in a kennel outside house

Patient have 2 cats which are not allowed to go outside house and have regular veterinary check-up

What is a diagnosis?

Surgeon diagnosed erysipelas and adviced patient to continue amoxiclav for 5 days

Since there was no improovment patient visited another surgen who said he have doubts about erysipelas and advice to make ultrasound examination and to change treatment.

Ultrasound of the affected area revealed nothing significant. Compress with antiseptic and physiotherapy were prescribed for 10 days with positive effect.

After disapperaing of the edema and redness patient was still able to feel a small nodule in a skin but surface of a skin wasnt affected so surgeon didnt pay attention to it.

10 days later all symtoms were coming back. Patient visited same surgeon who reffered her to consultation with dermatologist.


What is a diagnosis?

Patient was examined by professor of dermatology who diagnosed erythema migrants (Lyme disease) and prescribed serological testing

Serology for JgM/JgG to Borrelia burgdorferi come negative which was explained by doctor as a effect of previous antibiotic treatment (amoxiclav), patient was prescribed doxycycline 0,1 bid for 28 days and local ichthyol applications.

After 7 days on treatment sympoms went away and patient finished prescribed course of doxycycline at 26 of December 2010.

02 of January 2011 edema and redness started again


Left part of the small of the back. Picture was taken at 03 of Jan 2012

Patients visited her dermatologist only at 12 of January 2012. By that time edema and redness became less prominent without any interventions.

A dermatologist had an consilium were collegue of professor suggest that it might be «something» inside. Patient was very scarred and decided to visit infection disease specialist.

She was examined in outpatient clinic in Botkin's infection disease hospital at 16 of January 2012.

Ultrasound — a 4 cm subcutaneous consolidation were revieled with 3 fluid inclusions (1 cm each) inside it.

Blood count: WBC 11,6; moderate bound shift to the left; Eos 3% (N less then 5%); ESR 26 mm/hour

Blood JgE 156 IU/ml (N 20-100 IU/ml)


At 20 of January 2012 erythema suddenly started to spread from a small of the back to a left scapula.

This was accompaning by moderate pain, itching, and formation of vesiculas along the spread of erythema

A picture made at 22 of January with mobile phone camera


Patient was admitted to infection disease hospital. Apperance of patients back at first day in hospital. You can see a scrubs along erythema — at this sites patients had vesiculas (note existence of vesiculas and absence of scrubs on previous slide)


What is a diagnosis?Case 5: 46 y.o. women with erythema

Apperance of patients left inguinal zone










10 cm long germ was found in subdermal tissue in a wound

Germ was examinned in a city parasitological laboratory and was found to be a Dirofilaria repens.

After healing of a wound patient was discharged from a hospital.

Since patient had visited Kazachstan a month before symptoms started we cant exclude a possability that this case was imported from there. No local cases of D. repens were reported previously in St-Petersburg and it suburbs.


Case 5: Dirofilariosis - Dirofilariosis is a filarial nematode of dogs and other carnivores (cat, wolves et cetera)- 2 main types are D. repens and D. immitis- Mature filaria (macrofilaria) shed microfilaria into animal blood- Microfilaria could cause damage of pulmonary vessels and heart in animals - Microfilaria is transmitted by mosquitos which can feed on both animals and humans (Aedes, Culex и Anopheles). - Although humans may become infected as aberrant hosts, the worms fail to reach adulthood while residing in a human body (there is some report when microfilaria was found in human blood as well)- During 1995-2000 372 new cases were diagnosed in 25 countries around the world, at the end of 2003 - 782 in 37 countries.

Case 5: Dirofilariosis • A first mention of dirofilariosis in literature could be found in a paper of portugees doctor Amato Licitano (1511-1585): In 1566 he removed a worm from a eye of 3 y.o. girl.

• Dr. Licitano is famous for discovery of the circulation of the blood, and through dissections of the Azygos vein, he was the first to observe and speculate about the venous valves found there.

• A monument in his hometown Castelo Branco, Portugal

Case 5: Dirofilaria repens

- In humans D. repens in most cases are found subcutaneously.- Ophtalmological manifestations are most common. - South and Western Europe, Central Asia, Shri-Lanka are endemic. More cases from south and central part of Russia recently (around 200-300 cases totally)

Case 5: Dirofilaria repens

Ophtalmological maifestation of dirofilaria repens are the most commonly diagnosed

(around 50% of all cases)

Case 5: Dirofilaria repensAccording to study conducted in Russia when medical notes of 114 patients with dirofilariosis were examined there were no cases when helmintosis were suspected during first visit. Patients visited different specialsts (surgeon, general practicioner, neurologist) and in some cases a followed diagnosis were made:

- Ateroma of the soft tissues of the forehead- Postvacinal reaction- Neurofibroma of the soft tissues of left shin- Cancer of the chest wall - Reactive lymphoadenopathy- Idiopathic dilatation of the blood vessels of the right eye

Case 5: Dirofilaria immitis (heartworm)

- In humans D. immitis in most cases are found in pulmonary vessels- USA, Japan and Australia are endemic but cases been reported from Middle East, South America, South Europe and South Asia

Case 5: Dirofilaria immitis

Pulmonary maifestation of D. immitis in humans are the most commonly

diagnosed

In animals diagnosis in made based of microscopic examination for microfilaria in the blood

In humans microfilaria were found in just few cases so diagnosis is mostly made based on clinical picture

Migrating erythema with a mild allergic symptoms (not necessarely) are typical clinical findings in D. repens infection

Serological blood tests are commercially avaliable Main component of treatment in humans is surgical

removal of a worm In animals microfilarialcidial drugs are prescribed

Case 5: Dirofilariosis

•

More cases - http://www.slideshare.net/drandreyst-p/clinical-cases-from-infection-diseases-hospital

Health & Medicine

Clinical cases from infection diseases hospital, part 3