Helal presented with fever last 3 wks reporting frm Thoddooh island only a couple of days before.His complaints were Rt.flank pain,multiple jt.pain,headache,anorexia,extreme fatigue.He was running a temp of 38'C,BP 100/70,Tongue coated,Pallor plus, edema ,Icterus nil,constipated bowel,Dysuria features.He being an illegal immigrant without proper documents & low on cash ,could be investigated for his urinary complaints as per his suggestion which included Urine Routine & Microscopy.R/E urine suggested Blood +,Albumin +,Microscopy suggested RBC 15-20/hpf,Pus cells 30-40/hpf,Epithelial cast ++++,Mucus threads in abundance with Cocci +,Upon arrangement of funds a few blood Inv was ordered,TLC stood at 12,000/cmm,Platelets at 1,48,000/cmm,Widal Negative,CRP positive & Hb% as 12gm/dl.Last two days of Cipro,Pantoprazole,IVfluids,Paracetamol,Ondansentran Inj have stabilized him today with him reporting afebrile,BP 110/70 but fatigued....his job entails him to go back to Thoddooh 6hrs frm Male'but the low platelet count is deterring me frm allowing him to go back...I intend a rpt platelet & BUN ,Creatinine tomorrow....paucity of funds is a limiting factor for further Inv including a KUB scan.....your thoughts....
PLT count of 148,000 is safe. Absolutely no risk of bleeding until it falls below 20,000 or even lower, so I wouldn't worry.
However, male UTI in a young chap is uncommon, and the cocci on microscopy maybe simply contaminants due to improper collection. (In any case, you'd expect to see gram negative rods, rather than cocci).
Am worried about tuberculosis, which can transiently respond to ciprofloxacin. Do you have facilities to send three consecutive early morning urine samples for AFB? A chext X-ray may be useful because of similar reasons.
...tnx...yestday's Platelet count stood at 90000/cmm and past experience shows there will be further fall in a couple of days...hence necessitating his extended stay...to which he has agreed...CXR PA appeared NAD...yes will ask for the consecutive 3samples of urine...paucity of funds is a deterring factor...as told to earlier Widal test was +ve nd with Platelets goin down....the pattern is again the same,with alarming regularity in the clinic... as told to you earlier in last mail...though Widal definitely is not definitive....but on the flip side Thrombocytopenia in Typhoid will it be severe as to mimic DF....???
I can't figure this out. I have checked the haematological manifestations of typhoid and low PLT is not one of them.
So do all these patients have DF? However, flank pain suggests pyelonephritis, and the musculoskeletal pain of DF would be expected to be more widespread....unless some of them have HIV. HIV can cause thrombocytopenia and should be considered when there is regular contact with sex workers.
...yes, ur rt....will cross chk again...HIV is screened upon entry to the country...no documented living HIV case so far here...pl comment on the Sapon &Forhad case as I got another one Mazharul m/23,this eve. with pyuria ,nocturnal seminal discharge for a long period now & just like Forhad diminution in organ size & loss of libido, anxiety leading to Anorexia nd subsequent loss of wt....Male UTI ,I thought, outnumber females in my clinic a couple of case daily on an average....I remembered u while examining a case:Abul m/35,arriving only today frm a resort whr he works as Commiss2 in the kitchen,with complaints of B/L feet swelling 15 days with pain,nd Lt.Elbow jt pain of 2 days origin with severe neck strain,there is no history of fever,L/E reveals B/L Nonpitting type pedal edema dorsum of foot around ankles,recent Xray @Health outpost is Normal.His nature of job is standing long hrs in the kitchen dressing Fish & meat products...Vitals r normal..upon his agreement Inv has been sought: I asked for a CBC,ESR,ASOT,RA factor,S.Uric acid,CRP,S.Calcium,Phosphorus,RBS,S.AlkPhosphatase,S.Alb & Glob,CK,is there a need for a FP smear,which I missed...pl let me know wht else I missed in ordering an inv..?...Tnx...
....I got a link ...got to chk its authenticity....Typhoid & Thrombocytopenia.....Typhoid Fever Presenting as Acute Cerebellar Ataxia and Severe Thrombocytopenia
Cheong, B.M.K., (2008) Typhoid Fever Presenting as Acute Cerebellar Ataxia and Severe Thrombocytopenia. Medical Journal of Malaysia, 63 (1). pp. 77-78. ISSN 0300-5283
About the guy with the joint pains, I'd wait until I see the ESR and CRP before investigating further, as it could all be related to his nature of work. Long hours of work in unfavourable postures leading to elbow and neck pain and perhaps orthostatic oedema related to long periods of weightbearing (and low albumin?). Wouldn't take it further unless ESR, CRP raised.
...this is the abstract...."....Typhoid fever being a systemic infection can present in a multitude of ways, involving various systems. Here we describe a case of typhoid fever presenting with acute cerebellar ataxia and marked thrombocytopenia. This atypical presentation is not common in typhoid fever and can lead to misdiagnosis as well as a delay in the initiation of appropriate therapy. Prompt clinical improvement and the return of platelet counts to normal were noted after the patient was started on IV Ceftriaxone
The ECG shows notching on R waves in the inferior leads. When present in all three inferior leads and accompanied by partial RBBB, it is thought to be a sensitive and specific sign for secundum type ASD and correlates with the size and severity of left to right shunt. However, crochetage, as it's called because of resemblance to a crochet needle, can also be prsent less often in VSD and pulmonary stenosis.
....surprisingly male Urinary inf.are a common presentation....last Eve.Sapon m/26 presented with severe burning sensation Micturition with white clump like discharges,low grade fever,Low back pain.Routine Urine Inv.revealed RBC& Pus cells>100/hpf.Upon prodding he confessed to recent contact with a sex worker.The history is 1 wk old.Urine C/s is ordered & previous experience will make me anticipate,E.Coli & Klebsiella,Proteus & Enterobacter in tht descending order of freq. ranging frm 2+ to 4+....many cases of High color Urine in these young males will reveal UTI...its also a regular pattern here....if fund permits I will ask for STD panel & possibly do a KUB scan....
STDs should cause STD, not UTI in males, unless we are talking about urethritis, which can lead to dysuria, frequency discharge etc. Different bugs- chlamydia, mycoplasma, gonorrhoea, etc.
OTOH, females often develop cystitis after sexual contact because of their short urethra.
...yes,...urethritis,prostatocystitis r very common here....imported gonorhoea frm B'desh,Chlamydia inf r there....but Dysuria feature is quite common.....nocturnal seminal discharge is a common complaint here....
....Forhad m/22 is in melancholia for a long time now....his presenting complaint of 2yrs of duration @my clinic is not suitably addressed...he had been over the years observing loss of libido, ED & marked diminution in male organ size...under my care he learnt he had HTN 160/100,Deranged Lipid profile with TG >300mg/dl,S.Chol as 280mg/dl & has been taking regular t/t with a fair control now..however his presenting complaint still un addressed nd not much improvement...Forhad is a regular group of pts here having left home for an avg 5 to 10 yrs nd hard physical labour in the Constn.industry.Physical exam over these group of pts will invariably reveal stark diminution in organ size as tht of a 6yr old, lack of proper erection & PME, also these groups would report Nocturnal seminal discharge nd upon straining at defecation........this is a regular feature & considerable heart burn & melancholia amongst these group....they r not ecstatic about correction of their underlying HTN,DLP,Diabetes or Hyperuricemia which often presents as Gout , but melancholic du2 the child like organ size or lack of Sex Power as they put it....Male' is not a conservative capital,but on the contrary lot of internation meet ups nd collusions with the opp.sex happen....long hrs of hard wrk....makes possibly jack a dull boy....Stringent Drug control leads to lack of availability of Medicines which hitherto is available else whr....making my job tough.....
.....the dramatic diminution in organ size is evident upon physical exam....hard labour, away frm home syndrome,anxiety r all causative agents I guess,propounding a theory of Disuse atrophy....lack of Libido,ED all could be Psychosomatic ...but significant diminution in organ size...?& this cuts across all age barriers except the v old....
.....Mazharul the B/L swollen feet nd ankle jt pain pt has ASOT >200, & CRP positive with all other inv asked for in normal range....the non pitting edema how its to be tackled now..?...will it wane all by itself?...will a Hydrocortisone Iv inj aggravate the Edema?...will past history of un accounted DF,Chikingunya an incriminating factor here..?..for in remote Islands Fever is not Dx nd symptomatically treated...!!!!
No Shonkus, he has acute rheumatic fever! He has arthritis and carditis, the latter manifesting as swollen legs associated with heart failure. Apart from those 2 major criteria, he has at least one minor criterion in the form of raised CRP and supportive evidence of strep infection in raised ASO titre.
I'd listen to his chest to document any murmurs, get an ECG and an Echo, but would start him on Penicillin-V 500 mg TDS for 10 days without delay along with NSAIDs (not steroids, which can damage inflamed myocardium). Best NSAID for RF is still aspirin but you'll need big doses- 4 g daily in divided doses along with lansoproazole or omeprazole.
Subsequently, if echo confirms valvular regurgitation or stenosis and reduced ventricular function, I'd maintain him on lifelong prophylaxis with Benzathine penicillin (Penicillin-G), 1.2 million units IM every 4 weeks. If he is in AF, he'll need warfarin.
If he is penicillin allergic, choice is between azithromycin, clarithromycin and clindamycin.
......Superb....!!!....yes with raised ASO T nd Bangladesh having a Rheumatic fever & Rheumatic heart diseases fame( epidemiology) with all pts making a bee line to CMC Vellore & Devi Shetty's(famous Cardiothoracic Surgeon) Narayana Hrudayalaya @Bangalore for surgery.....gud news is I hv already put him on Lasilactone & Ecosprin,pending ECG & Echo;primafacie the heart sounds were normal,but definitely will strain max to auscultate again...Penicillin V tabs r available,will order tomorrow asap nd Inj.Penidure can easily be obtained frm B'desh easily...Tnx....also will attempt a reply to your Arthralgia case with POTS tomorrow...!!!
....sorry for late reversal....ASD : crochetage sign it is.....!!!...tnx...
ReplyDeleteHelal presented with fever last 3 wks reporting frm Thoddooh island only a couple of days before.His complaints were Rt.flank pain,multiple jt.pain,headache,anorexia,extreme fatigue.He was running a temp of 38'C,BP 100/70,Tongue coated,Pallor plus, edema ,Icterus nil,constipated bowel,Dysuria features.He being an illegal immigrant without proper documents & low on cash ,could be investigated for his urinary complaints as per his suggestion which included Urine Routine & Microscopy.R/E urine suggested Blood +,Albumin +,Microscopy suggested RBC 15-20/hpf,Pus cells 30-40/hpf,Epithelial cast ++++,Mucus threads in abundance with Cocci +,Upon arrangement of funds a few blood Inv was ordered,TLC stood at 12,000/cmm,Platelets at 1,48,000/cmm,Widal Negative,CRP positive & Hb% as 12gm/dl.Last two days of Cipro,Pantoprazole,IVfluids,Paracetamol,Ondansentran Inj have stabilized him today with him reporting afebrile,BP 110/70 but fatigued....his job entails him to go back to Thoddooh 6hrs frm Male'but the low platelet count is deterring me frm allowing him to go back...I intend a rpt platelet & BUN ,Creatinine tomorrow....paucity of funds is a limiting factor for further Inv including a KUB scan.....your thoughts....
ReplyDelete....corrigendum: read Widal +ve....Helal
DeletePLT count of 148,000 is safe. Absolutely no risk of bleeding until it falls below 20,000 or even lower, so I wouldn't worry.
ReplyDeleteHowever, male UTI in a young chap is uncommon, and the cocci on microscopy maybe simply contaminants due to improper collection. (In any case, you'd expect to see gram negative rods, rather than cocci).
Am worried about tuberculosis, which can transiently respond to ciprofloxacin. Do you have facilities to send three consecutive early morning urine samples for AFB? A chext X-ray may be useful because of similar reasons.
...tnx...yestday's Platelet count stood at 90000/cmm and past experience shows there will be further fall in a couple of days...hence necessitating his extended stay...to which he has agreed...CXR PA appeared NAD...yes will ask for the consecutive 3samples of urine...paucity of funds is a deterring factor...as told to earlier Widal test was +ve nd with Platelets goin down....the pattern is again the same,with alarming regularity in the clinic... as told to you earlier in last mail...though Widal definitely is not definitive....but on the flip side Thrombocytopenia in Typhoid will it be severe as to mimic DF....???
DeleteI can't figure this out. I have checked the haematological manifestations of typhoid and low PLT is not one of them.
DeleteSo do all these patients have DF? However, flank pain suggests pyelonephritis, and the musculoskeletal pain of DF would be expected to be more widespread....unless some of them have HIV. HIV can cause thrombocytopenia and should be considered when there is regular contact with sex workers.
...yes, ur rt....will cross chk again...HIV is screened upon entry to the country...no documented living HIV case so far here...pl comment on the Sapon &Forhad case as I got another one Mazharul m/23,this eve. with pyuria ,nocturnal seminal discharge for a long period now & just like Forhad diminution in organ size & loss of libido, anxiety leading to Anorexia nd subsequent loss of wt....Male UTI ,I thought, outnumber females in my clinic a couple of case daily on an average....I remembered u while examining a case:Abul m/35,arriving only today frm a resort whr he works as Commiss2 in the kitchen,with complaints of B/L feet swelling 15 days with pain,nd Lt.Elbow jt pain of 2 days origin with severe neck strain,there is no history of fever,L/E reveals B/L Nonpitting type pedal edema dorsum of foot around ankles,recent Xray @Health outpost is Normal.His nature of job is standing long hrs in the kitchen dressing Fish & meat products...Vitals r normal..upon his agreement Inv has been sought: I asked for a CBC,ESR,ASOT,RA factor,S.Uric acid,CRP,S.Calcium,Phosphorus,RBS,S.AlkPhosphatase,S.Alb & Glob,CK,is there a need for a FP smear,which I missed...pl let me know wht else I missed in ordering an inv..?...Tnx...
Delete....I got a link ...got to chk its authenticity....Typhoid & Thrombocytopenia.....Typhoid Fever Presenting as Acute Cerebellar Ataxia and Severe Thrombocytopenia
DeleteCheong, B.M.K., (2008) Typhoid Fever Presenting as Acute Cerebellar Ataxia and Severe Thrombocytopenia. Medical Journal of Malaysia, 63 (1). pp. 77-78. ISSN 0300-5283
About the guy with the joint pains, I'd wait until I see the ESR and CRP before investigating further, as it could all be related to his nature of work. Long hours of work in unfavourable postures leading to elbow and neck pain and perhaps orthostatic oedema related to long periods of weightbearing (and low albumin?). Wouldn't take it further unless ESR, CRP raised.
Delete...this is the abstract...."....Typhoid fever being a systemic infection can present in a multitude of ways, involving various systems. Here we describe a case of typhoid fever presenting with acute cerebellar ataxia and marked thrombocytopenia. This atypical presentation is not common in typhoid fever and can lead to misdiagnosis as well as a delay in the initiation of appropriate therapy. Prompt clinical improvement and the return of platelet counts to normal were noted after the patient was started on IV Ceftriaxone
DeleteThe ECG shows notching on R waves in the inferior leads. When present in all three inferior leads and accompanied by partial RBBB, it is thought to be a sensitive and specific sign for secundum type ASD and correlates with the size and severity of left to right shunt. However, crochetage, as it's called because of resemblance to a crochet needle, can also be prsent less often in VSD and pulmonary stenosis.
ReplyDelete....superb...!!
Delete....surprisingly male Urinary inf.are a common presentation....last Eve.Sapon m/26 presented with severe burning sensation Micturition with white clump like discharges,low grade fever,Low back pain.Routine Urine Inv.revealed RBC& Pus cells>100/hpf.Upon prodding he confessed to recent contact with a sex worker.The history is 1 wk old.Urine C/s is ordered & previous experience will make me anticipate,E.Coli & Klebsiella,Proteus & Enterobacter in tht descending order of freq. ranging frm 2+ to 4+....many cases of High color Urine in these young males will reveal UTI...its also a regular pattern here....if fund permits I will ask for STD panel & possibly do a KUB scan....
DeleteSTDs should cause STD, not UTI in males, unless we are talking about urethritis, which can lead to dysuria, frequency discharge etc. Different bugs- chlamydia, mycoplasma, gonorrhoea, etc.
DeleteOTOH, females often develop cystitis after sexual contact because of their short urethra.
...yes,...urethritis,prostatocystitis r very common here....imported gonorhoea frm B'desh,Chlamydia inf r there....but Dysuria feature is quite common.....nocturnal seminal discharge is a common complaint here....
Delete....Forhad m/22 is in melancholia for a long time now....his presenting complaint of 2yrs of duration @my clinic is not suitably addressed...he had been over the years observing loss of libido, ED & marked diminution in male organ size...under my care he learnt he had HTN 160/100,Deranged Lipid profile with TG >300mg/dl,S.Chol as 280mg/dl & has been taking regular t/t with a fair control now..however his presenting complaint still un addressed nd not much improvement...Forhad is a regular group of pts here having left home for an avg 5 to 10 yrs nd hard physical labour in the Constn.industry.Physical exam over these group of pts will invariably reveal stark diminution in organ size as tht of a 6yr old, lack of proper erection & PME, also these groups would report Nocturnal seminal discharge nd upon straining at defecation........this is a regular feature & considerable heart burn & melancholia amongst these group....they r not ecstatic about correction of their underlying HTN,DLP,Diabetes or Hyperuricemia which often presents as Gout , but melancholic du2 the child like organ size or lack of Sex Power as they put it....Male' is not a conservative capital,but on the contrary lot of internation meet ups nd collusions with the opp.sex happen....long hrs of hard wrk....makes possibly jack a dull boy....Stringent Drug control leads to lack of availability of Medicines which hitherto is available else whr....making my job tough.....
ReplyDeleteShonkus, no experience at all of these kind of patients, so completely stumped. You sure this is not all psychosomatic and anxiety related stuff?
Delete.....the dramatic diminution in organ size is evident upon physical exam....hard labour, away frm home syndrome,anxiety r all causative agents I guess,propounding a theory of Disuse atrophy....lack of Libido,ED all could be Psychosomatic ...but significant diminution in organ size...?& this cuts across all age barriers except the v old....
Delete.....Mazharul the B/L swollen feet nd ankle jt pain pt has ASOT >200, & CRP positive with all other inv asked for in normal range....the non pitting edema how its to be tackled now..?...will it wane all by itself?...will a Hydrocortisone Iv inj aggravate the Edema?...will past history of un accounted DF,Chikingunya an incriminating factor here..?..for in remote Islands Fever is not Dx nd symptomatically treated...!!!!
DeleteNo Shonkus, he has acute rheumatic fever! He has arthritis and carditis, the latter manifesting as swollen legs associated with heart failure. Apart from those 2 major criteria, he has at least one minor criterion in the form of raised CRP and supportive evidence of strep infection in raised ASO titre.
ReplyDeleteI'd listen to his chest to document any murmurs, get an ECG and an Echo, but would start him on Penicillin-V 500 mg TDS for 10 days without delay along with NSAIDs (not steroids, which can damage inflamed myocardium). Best NSAID for RF is still aspirin but you'll need big doses- 4 g daily in divided doses along with lansoproazole or omeprazole.
Subsequently, if echo confirms valvular regurgitation or stenosis and reduced ventricular function, I'd maintain him on lifelong prophylaxis with Benzathine penicillin (Penicillin-G), 1.2 million units IM every 4 weeks. If he is in AF, he'll need warfarin.
If he is penicillin allergic, choice is between azithromycin, clarithromycin and clindamycin.
......Superb....!!!....yes with raised ASO T nd Bangladesh having a Rheumatic fever & Rheumatic heart diseases fame( epidemiology) with all pts making a bee line to CMC Vellore & Devi Shetty's(famous Cardiothoracic Surgeon) Narayana Hrudayalaya @Bangalore for surgery.....gud news is I hv already put him on Lasilactone & Ecosprin,pending ECG & Echo;primafacie the heart sounds were normal,but definitely will strain max to auscultate again...Penicillin V tabs r available,will order tomorrow asap nd Inj.Penidure can easily be obtained frm B'desh easily...Tnx....also will attempt a reply to your Arthralgia case with POTS tomorrow...!!!
DeleteForgot to add, you will need diuretics for the leg swelling and associated heart failure.
ReplyDelete