In this section of our website an interesting Infectious Diseases/Clinical Microbiology case with several teaching points will appear occasionally. The language of this section will be English.
The chief complaint, history of present illness, medical history, physical examination, and diagnostic work up are presented in a succinct way on the first page leading to a question for the reader about diagnosis or management (the usual question is: ''What is your diagnosis?'')
Differential diagnosis, final diagnosis, treatment, teaching points, references, and acknowledgements are presented on the second page.
While the majority of cases in our website come from our group, occasionally cases from other institutions from Greece or abroad may appear.
A 28-year-old white man was admitted to our hospital because of chronic swelling and redness of the left sub-axillary area. No fever, pruritus, or sweating was reported. His past medical history was unremarkable. The patient reported that, after switching deodorant, he noticed a painful swelling in his left axilla 3 months prior to his admission to our hospital. He was treated by his family physician for postulated hidradenitis suppurativa with antibiotics and anti-inflammatory medications, which did not lead to any improvement. Because of the persistence of the lesion in the axilla, a fine needle aspiration was performed then, which showed "atypical degenerating cells suspicious for malignancy". This finding prompted referral to a major tertiary medical center. At that time there was a flare-up of symptoms in the left axilla in addition to the appearance of a new palpable, tender mass in his left supraclavicular area. This mass was chosen by the attending surgeon to be removed for testing. Culture of a part of the removed specimen grew Propionibacterium acnes. Microscopic examination showed fibrous adipose tissue with acute and chronic inflammation findings consistent with organizing abscess. No lymph node tissue was identifiable. Based on these findings the patient received treatment with levofloxacine 500 mg once a day and metronidazole 500 mg three times a day p.o., which, again, did not lead to any improvement.
Physical examination on admission showed temperature 37,5 degrees C and pulse rate 80/min. His body mass index (BMI) was 35,46 kg/m2 (weight: 128 kg, height: 190 cm). He had gynecomastia and inversion of the nipples. Examination of the chest and neck revealed inflammation of the skin surrounding the left nipple, extending up to the left axilla, and a scar in the left supraclavicular area related to previous biopsy (Figures 1-2). Small, palpable, and tender lymph nodes in the left axilla, left and right cervical areas and left and right inguinal areas were also found. All other systems were examined and found normal.
C-reactive protein level was increased at 2.99 mg/dl (normal less than 0.5 mg/dl). Erythrocyte sedimentation was increased as well at 39 mm/first hr. Complete blood count, blood glucose, aspartate aminotransferase (AST), alanine aminotransferase (ALT), glutamyl transpeptidase, bilirubin, lactate dehydrogenase (LDH), creatine phosphokinase (CPK), serum sodium, potassium, urea, and uric acid were all normal. Tests for cytomegalovirus (CMV), Epstein-Barr (EBV) and human immunodeficiency virus (HIV) were negative. Mantoux test was also negative.
In this teaching case we used the format of presentation of successive parts of the history, physical examination, and management accompanied by discussion (in bold characters) of a commentator.
A 64-year-old male presented to the Emergency Room of the local hospital in a rural area of Greece complaining of fever, shortness of breath, productive cough, and mild low back pain. He had no previous hospitalizations.
The patient's symptoms suggest a lower respiratory tract (LRT) infection as the most likely diagnosis. Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis are common etiologic agents in patients with community acquired LRT infections. In addition, atypical bacteria including Mycoplasma, Chlamydia, Legionella, and Rikketsiae species are the cause of a considerable proportion of lower respiratory tract infections that varies in different age groups. Also, several viruses including influenza, parainfluenza, and adenoviruses may cause LRT infection, especially during the winter session.
The patient was a farmer. His past medical history was significant for a work-related injury in the lower back 10 years ago. He consumed alcohol, about half a liter of wine per day, for 20 years. He did not smoke. He never traveled outside Greece.
The details of the medical history and the habits of the patient suggest additional possible pathogens for his LRT infection, mainly Klebsiella pneumoniae, given the history of alcoholism. Because of his occupation, leptospirosis should be considered in the differential diagnosis. In addition, brucellosis should be also considered given that the patient lives in a rural area in Greece where the infection is endemic. It should be noted that brucellosis may cause manifestations from the respiratory system.
The patient's condition deteriorated despite the administration of antimicrobial treatment (ceftriaxone 1 g every 12 hours i.v. and clarithromycin 500 mg every 12 hours p.o.) at the local hospital. He was transferred to a tertiary hospital in Athens, two days after his admission at the local hospital. He presented with temperature 38.5 oC, heart rate 108/min, and tachypnea (45 breaths/min). Physical examination on admission revealed crackles in the base of the left lung and the upper right lung. Routine laboratory testing showed white blood cell count 8,800/mm 3, neutrophils 88%, erythrocyte sedimentation rate 104 mm/1st hour, serum urea 57 mg/dl and creatinine 1.4mg/dl. Gram stain of a sputum specimen showed about 20 neutrophils per optic field. Chest x-rays on admission showed infiltrates in the left lower and the right upper lobe (figure 1). Arterial gas testing showed PaO2/FiO2=240, arterial pH = 7.48, and PCO2=28 mmHg.
The patient's worsening condition despite the use of appropriate antimicrobial treatment for community-acquired pneumonia suggests several possibilities. First, that the pathogen responsible for his pneumonia was indeed one of the most commonly implicated micro-organisms in LRT infections, namely Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, or an atypical pathogen that was however resistant to the administered agents. There is an increasing proportion of pneumococcal isolates with full resistance to penicillin in several countries during the last years. Although still a controversial issue, it seems that the majority of evidence supports that the outcome of patients who receive treatment with ceftriaxone for pneumonia due to Streptococcus pneumoniae with full resistance to penicillin is worse than with vancomycin or other agents with activity against this pathogen. Second, the pathogen may be one not included in the above list of microorganisms. Someone should also consider other etiologic agents such as staphylococci, streptococci other than Streptococcus pneumoniae, anaerobes, and Gram-negative bacteria other than Klebsiella pneumoniae. In addition, mycobacteria, mainly Mycobacterium tuberculosis, should be always considered in the differential diagnosis in patients with LRT infection. It should be also noted that antibacterial agents would not influence the natural history of a viral LRT infection, except if a secondary bacterial infection had already developed. Non-infectious causes of lung infiltrates should also be included in the differential diagnosis at this stage.
Because of deterioration of his condition, antimicrobial treatment with vancomycin 1 gr every 12 hours i.v. and ciprofloxacin 400 mg every 12 hours i.v. was started. Treatment with ceftriaxone continued, while clarithromycin was stopped. Despite the change of the regimen of antibiotics, the patient's condition continued to deteriorate and he was transferred to the intensive care unit (ICU), after a three-day hospitalization in the medical ward. On admission to the ICU, he was intubated due to severe respiratory failure (PaO2/FiO2 ratio 175, arterial pH 7.21, PaCO2=59 mm Hg). Laboratory testing showed white blood cell count =11,100/mm3 (polymorphonuclear cells = 89%), hemoglobin = 9.9 g/dl, hematocrit = 32%, platelets = 103,000/ mm3, serum urea 131 mg/dl, serum creatinine 1.7 mg/dl, C-reactive protein = 16.4 mg/dl, fibrinogen 935 mg/dl, and D-dimmer 544 μg/l. A CT-scan of the chest showed extensive infiltrates in both lungs with pneumoceles (figure 2).
What's your diagnosis? (Please click below for the response)
A 58-year-old man was admitted to the hospital complaining of a 3-day history of fever, malaise and a painful swelling of the right parotid gland. For 2 days before his admission, he had been taking amoxicillin and metronidazole, as the swelling was thought to be related to dental infection, by his general practitioner. His medical history was unremarkable. The patient did not suffer from any immune or endocrine disease and has not taken any other medication in the past. He did not mention any history of diarrhea, vomiting, abdominal pain, joint pain or joint swelling. He was living in Athens suburbs, working as a civil servant.
As the symptoms seemed to persist, the patient was referred to our Hospital's ENT department for evaluation. At physical examination, a firm mass was palpable at the right parotid, and the patient was admitted for further investigation. No evidence of palpable regional lymph nodes was noted and no other clinical findings could be revealed. The chest X-ray showed no abnormalities. His white blood count was 9,250/mm3 (69.7% neutrophils, 17.2% lymphocytes, and 6.8% monocytes), haematocrit 48.5%, haemoglobin level 16.1 g/dl, platelet count 267,000/mm3, C - reactive protein 8.3 mg/dl (normal values up to 0.5 mg/dl) and erythrocyte sedimentation rate 70 mmHg/1st hour. A CT scan of the face was performed (Figure).
What is your diagnosis?
A 67-year-old female patient was admitted to our unit due to fever and shortness of breath.
Her past medical history was significant for breast cancer, which was treated with mastectomy in November 2003. She received chemotherapy from December 2003 until April 2004 (every 21 days). Then she underwent 30 cycles of radiation treatment.
The patient finished the last radiation treatment in June 2004. In September 2004 she developed difficulty in breathing and mild fever (up to 37.50C), which was felt to be due to radiation pneumonitis. She was given steroid treatment (methylprednisolone 16 mg every 12 hours for 1 week, with gradual decrease of the dose and discontinuation within one month). She felt improved with this treatment. However, 3 months later she developed similar symptoms for which she received methylprednisolone again (16 mg every 8 hours, with gradual decrease of the dose and discontinuation within 3 months), which led again to improvement of her symptoms.
However, in February 2005 the patient complained again of shortness of breath and mild fever. Physical examination on admission showed a temperature of 37.70C. There were bilateral rales in the middle and lower lung fields (more in the right lung). C-reactive protein and erythrocyte sedimentation rate were elevated.White blood cell count was also elevated. A chest X-ray showed an infiltrate mainly in the right middle and lower lobes (Figure 1).
A 36-year-old woman was admitted to the hospital because of fever and abdominal pain of one-week duration. Fever was up to 39 degrees Celsius and was accompanied by chills. The pain was located in the right lower quadrant of the abdomen. She did not complain for other symptoms.
The patient was married to a shipman and had five healthy children, three of whom were delivered by cesarean section. Her past medical history included recurrent cellulitis-like episodes after a glass related injury, which was located in her left forearm.
Physical examination showed elevated temperature (38,8 degrees Celsius). The pulse rate was 90/min and the blood pressure 120/70 mmHg. There were three areas (2X2 cm), on her left forearm, with atrophy and hyperpigmentation. Inflammation was obvious on the right lower quadrant of the abdominal wall, where swelling, tenderness, heat and redness were found in an area of 25X15 cm. Liver, spleen and peripheral lymph nodes were not palpable. The rest of the physical examination did not show any abnormal findings.
Laboratory work-up revealed: Ht=36%, Hb=12,9 g/dl, WBC=9980/mm3 (neutrophils=75%, lymphocytes=18%, monocytes=6%, eosinophils=1%), platelets=210,000/mm3, erythrocyte sedimentation rate (ESR) = 57mm/first hour. The level of C-reactive protein was normal. The biochemical (glucose, renal and liver function, electrolytes, lipid profile, uric acid, amylase, lactate dehydrogenase, creatine kinase, and proteins) and immunological tests of the serum (rheumatoid factor test, antinuclear antibodies, antimitochondrial antibodies, anti-smooth muscle antibodies, cytoplasmic and perinuclear anti-neutrophil cytoplasmic antibodies, serum angioconverting enzyme and complement), were normal, except of the slight elevation of IgM, slight reduction of IgA and low value of C4. Urinalysis did not show abnormal findings. Chest X-rays, ECG, U/S of the abdomen and C/T of the thorax, upper and lower abdomen were normal.
A 68-year-old male was admitted to our hospital due to fever and abdominal pain in the left lower quadrant that started 2 days prior to admission.
His past medical history was significant for coronary artery by-pass surgery 15 years earlier, perforation of the stomach 20 years earlier, and atrial fibrillation. His medication included acenocoumarol, isosorbide mononitrate, ramipril, furosemide, and carvedilol. The patient had dental work done 7 days prior to admission. He reported that he had stopped taking some of his medications, including acenocoumarol, prior to the visit to the dentist. However, two days prior to his admission he re-started taking acenocoumarol.
His temperature was 37.8 degrees Celsius. His blood pressure was 130/80 mmHg and his pulse rate was 120/min. Physical examination showed left lower quadrant abdominal tenderness and decreased bowel sounds. Routine laboratory testing showed: ALP 223 U/L, SGOT 41 U/L, γ-GT 239 U/L, total bilirubin 2.3 mg/dL, INR 2.33, prothrombin time 28.4 sec, partial thromboplastin time 49.2 sec, white blood cell count 15.70 K/μl, neutrophills 83.5%, red blood cell count 3.77 M/μl, hematocrit 39.3%, C- reactive protein 26.57 mg/dL (normal values up to 0.5 mg/dL), urea 34 mg/dL, creatinine 1.2 mg/dL.
A CT scan of the abdomen showed an area of hypodensity of the spleen with a size of 9.5x3 cm (Figure). Ascites was also noted.
A 56-year-old female from Greece with a history of Takayasu's disease (diagnosed in 1992) was admitted in late November 2002 to our unit because of fever, which started in April 2002. She was diagnosed at another hospital to have aortofemoral graft infection in June 2002. Only one of several blood cultures, performed at the previous hospital, grew a strain of Staphylococcus epidermidis. She received prolonged courses of antibiotics including vancomycin, linezolid, and rifampin. In addition, β-lactam antibiotics with coverage against Gram negative organisms had been given, because of the possibility that the isolated microorganism (Staphylococcus epidermidis) was a contaminant. Her fever relapsed and she was admitted to our unit for management.
Her past medical and surgical history was rich: rheumatic fever (1959), premature labour and eclampsia (1970), extrauterine pregnancy (1972), caesarean section (1982), small intestine ileus due to adhesions (1982), bilateral aortocarotid bypass and aortofemoral bypass (1992), which were both attributed to Takayasu's arteritis . Also, erythema nodosum (1992), appendectomy (1992), jaundice due to hepatitis B virus infection (seronegative at time of presentation), operations for femoral artery aneurysms (1994, 1995, 1997, 2001), cholecystectomy (1995), and coronary main stem bypass using the internal mammary artery (1999).
Physical examination on admission showed temperature 37.5 degrees Celsius. There were scars from previous operations. A bruit was audible over the left carotid and her femoral arteries. Right radial artery was not palpable. Laboratory testing on admission showed erythrocyte sedimentation rate (ESR) 60 mm/ 1st hour (normal<10) and C-reactive protein (CRP) 3mg/dl (normal<0.5). An electrocardiogram showed T wave inversion in leads V1 and V2. A magnetic resonance imaging (MRI) of the area of the aortofemoral graft was suggestive of active inflammation of the graft and of the surrounding area as well as adhesions of the third (retroperitoneal) part of the duodenum with the abdominal aorta.
She was treated with iv trimethoprim/sulphomethoxazole (80/400 mg) every 12h, iv chloramphenicol 1gr every 6h, iv quinupristin/dalfopristin 500 mg every 8h, sc enoxaparin 60 mg every day, ranitidine 150 mg every 12h, acetylsalicylic acid 100 mg once daily, atorvastatin 20 mg once daily, isosorbide mononitrate 60 mg once daily, and metoprolol 50 mg every 12h. Laboratory indices of inflammation initially improved and fever stopped. However, her aortofemoral graft infection seemed to be resistant to medical treatment.
What is the appropriate management?
A 56-year-old female patient seeked medical advice because of mild fever and a face lesion of two-week duration. Her past medical history was significant for diabetes mellitus (managed with insulin), mild chronic renal insufficiency and breast cancer for which she underwent total right mastectomy 10 years ago. The patient also received radiation and chemotherapy at that time. She recently received again chemotherapy due to hepatic and bone metastases (the last chemotherapy regimen was one month ago). Physical examination showed a temperature of 37 degrees Celsius and a large, vegetating lesion on the nose with areas of honey-coloured and black areas (Figure 1). Routine laboratory testing showed: hematocrit 39.6%, hemoglobin 13 g/dL, white blood cell count 6.91 K per cubic mm, neutrophills 93.6%, glucose 622 mg/dL, creatinine 1.9 mg/dL, blood urea 96 mg/dL, and total bilirubin 1.36 mg/dL.
A 73-year-old male patient was admitted to our hospital because of fever and pain of the left tibia.
His past medical history was significant for diabetes mellitus (managed with oral antidiabetic agents) and lung cancer for which he underwent resection of the left upper lobe one year ago. The patient also received chemotherapy that was completed 1 month ago.
Physical examination showed a red area of the left tibia (Figure). His temperature was 37.40C. Routine laboratory testing showed: C-reactice protein 30.50 mg/dL (normal value (0-0.50 mg/dL), creatinine 1.7 mg/dL (0.8-1.3 mg/dL), urea 61 mg/dL (15-50 mg/dL), hematocrit 28.1% (41.0-53.0%), white blood cell count 9.19 K/μl (4.50-11.00 K/μl).
An ultrasound of the lower extremities arteries and veins was performed which showed a generalized atherosclerotic disease, including a total obstruction of the left superficial femoral artery.
What is your diagnosis? What should be done?
A 59-year-old female presented with superficial hypogastric pain and low grade fever of one week duration. The patient had a history of ovarian cancer for which she underwent two abdominal operations as well as chemotherapy two years earlier. Six months prior to her visit she had been operated for hypogastric abdominal hernia with abdominal wall reconstruction using mesh support. Physical examination on admission showed erythema in the hypogastric area extending around the middle line (Figure). Routine laboratory testing, including erythrocyte sedimentation rate (ESR) did not show abnormal findings.
A 78-year-old male was presented to his local orthopedic surgeon for low back pain. The patient had no neurologic deficits, and with the presumptive diagnosis of degenerative spondylosis, he has been treated with non-steroidal anti-inflammatory medications and physiotherapy for 3 months.
The past medical history included hypertension, chronic obstructive pulmonary disease, atrial fibrillation and congestive heart failure. He was receiving b-blockers, loop diuretics, and digoxin for his cardiovascular problems and inhaled corticosteroids and ipratropium for his chronic obstructive pulmonary disease.
Three months later, the patient had worsening of his back pain. Plain radiographs, computed tomography and magnetic resonance imaging of the lumbar spine were obtained, which showed osteoarthritis of the lower lumbar facet joints. Facet joints injection was done using methyl-prednisolone acetate and bupivacaine hydrochloride 0.5%. The patient had temporary relief of his symptoms for 2 days followed by deterioration of his low back pain and acute onset of low-grade fever. Laboratory investigation revealed increased white blood cell count (16.010/μl), erythrocyte sedimentation rate (83 mm/1st hour), and C-reactive protein (185 mg/l). Spine infection was suspected and ciprofloxacin was administered (500 mg per os, twice a day) for four weeks. However, this treatment led to minimal improvement of the clinical symptoms.
The patient was referred to us for further evaluation and treatment. At the time of his admission, his main signs and symptoms included low back pain and tenderness, and increased body temperature (37.8o). Magnetic resonance imaging of the lumbar spine showed end plate erosions of L3, L4, L5 vertebral bodies (Figure 1) and signal abnormalities at the L2-L3 and L3-L4 intervertebral discs (Figure 2).
What is the appropriate management?
A 24-year-old man presented to our office because of fever and redness of his left lower extremity. The patient had been bitten at his left foot by an insect two days prior to his presentation. He could not recognize the kind of the insect. The patient used a local anti-allergic ointment at the site of the insect bite. He developed fever accompanied by rigors two days after the insect bite. Concomitantly, the patient started feeling a burning sensation on his left lower limb. Physical examination at presentation showed temperature of 38,7° C. The rest of the vital signs and of the physical examination were normal except for findings rom the left lower extremity. He had an extensive area with redness, increased local temperature, and tenderness extending from the foot to the upper part of the thigh (Figure 1). On the lateral surface of the left ankle there was a small area of necrosis, at the site of the insect bite (Figure 2). In addition, there were palpable and tender lymph nodes of maximum 2 cm of diameter in the left inguinal area. Routine laboratory tests on admission were normal except for the white blood cells count [12,750 cells/μl (neutrophils 81,5%, lymphocytes 11,9%)]. The rest of hematological and biochemical tests were normal.
What is the most likely diagnosis?
A. Thrombophlebitis of the major saphenous vein
D. Allergic reaction
-Διευθυντής 'Αλφα Ινστιτούτου Βιοϊατρικών Επιστημών (ΑΙΒΕ)
-Διευθυντής Δ' Παθολογικού Τμήματος, Ερρίκος Ντυνάν Hospital Center
-Αναπληρωτής Καθηγητής Παθολογίας, Πανεπιστήμιο Tufts, Μασαχουσέτη, Βοστώνη, ΗΠΑ
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