This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here early winter-spring 2016 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion initiated by patient's primary care physician in-charge:
Patient history notes by JR doctor:
O/E images:
Patient history notes by JR doctor:
Investigation images:
Radiological images:
Conversational decision support:
Rakesh Biswas Viral markers negative. A quick search revealed nocardia and cryptococcosis for consideration (Dr Prakhar, Dr Deepika) other than the standard culprits Mycobacteria and Staph. Gram staining and ZN staining is negative. What other differentials can team tabula-rasa suggest (Dr Nidhi, DrBharati, Dr Swagata, Dr Amy, Dr Bhavik, Dr Boudhayan, Dr David, DrSanchita, Dr Anasua for further inputs)
Boudhayan Dm Diabetes status??? I assume HIV is negative........ Primary immunodeficiency diseases...... Michele Meltzer maam ur inputs on the last one
Bhavik Shah In addition to the most common culprit in such cases in India which is tuberculosis, here are some of the possibilities:
Sarcoidosis, http://www.ncbi.nlm.nih.gov/pubmed/19753742
Salmonellosis in sickle cell, http://www.ncbi.nlm.nih.gov/pubmed/9251432
Crohn's, http://www.ncbi.nlm.nih.gov/pubmed/22386738
T cell leukemia, http://www.ncbi.nlm.nih.gov/pubmed/1791347
Strep pneumoniae, http://www.ncbi.nlm.nih.gov/pubmed/12226693
Nocardiosis (detailed history needed to find out the primary source of infection), http://www.ncbi.nlm.nih.gov/pubmed/11960139
Sarcoidosis, http://www.ncbi.nlm.nih.gov/pubmed/19753742
Salmonellosis in sickle cell, http://www.ncbi.nlm.nih.gov/pubmed/9251432
Crohn's, http://www.ncbi.nlm.nih.gov/pubmed/22386738
T cell leukemia, http://www.ncbi.nlm.nih.gov/pubmed/1791347
Strep pneumoniae, http://www.ncbi.nlm.nih.gov/pubmed/12226693
Nocardiosis (detailed history needed to find out the primary source of infection), http://www.ncbi.nlm.nih.gov/pubmed/11960139
Rakesh Biswas Bhavik can you help us choose the best empirical regime for Nocardiosis as well as empirical Rx for Cryptococcosis with dose?
Bhavik Shah I'm copy-pasting here an article from UpToDate; I think TMP-SMX with Linezolid would be great, but please go through it once! It's complicated for Nocardiosis frown emoticon
Prakhar Gupta yes sir. It's too high, the patient is on catheter as for now. He is too weak to go washroom. We are monitoring his daily input output. Will repeat the values tomorrow to see if its worsening or improving.
Prakhar Gupta sir he also has severe hypoglycemia (30-50 mg/dl) and is able to maintain glucose levels on repeated administration of dextrose only. Which again points towards renal failure that developed over a relatively short time. We are trying to figure out what caused this severe damage in a short time.
Sanchita Das Multiple abscesses makes one think of the pathogenesis. If you think about it, it has to be a blood borne route of infection. Unless you have evidence of direct inoculation. And MSSA/ MRSA comes to mind first. Though the cachexia doesn't quite fit in. Any blood or abscess drain cultures?
Prakhar Gupta he has oral candidiasis and possibly esophageal too because he has troubling odynophagia.
Rakesh Biswas Prakhar what is his repeat creatinine? As far as i remember his creatinine was 1.6 and later normalized to 1.0?
Prakhar Gupta That was leptospirosis patient sir, who had improvement in Urea and creatinine values.
Boudhayan Dm Sir what has the patient been started on? ...... Primary immunodeficiency diseases..... Inputs from Michele Meltzer maam pls..... I guess an Immunology opinion can be helpful at this stage......Able Lawrence...
...has an underlying malignancy been ruled out???
...has an underlying malignancy been ruled out???
Able Lawrence Rakesh Biswas Boudhayan Dm Can someone summarize the temporal sequence. Are there multiple abscesses in a single event or multiple events of abscesses. The two situations are qualitatively different. And what are the culture reports. If it is a case of recurrent abscesses (despite accurate microbiological identification and effective treatment), then the immunodeficiency, mainly defects in granulocyte function may be considered but the possibility of a resistant or difficult organism or one that has not been effectively treated should be considered. Staphylococcal infections can be difficult to eradicate (especially with short courses of antibiotics or antibiotics like vanco/teico/linezolid as these antibiotics are unable to kill intracellular staphylococci. Indeed staph uses granulocytes as Trojan horses to spread across the body. Sometimes patients with Nasal carriage also can have recurrent infections. Once these have been considered, patient should get have an NBT (these days dihydrorhodamine reduction test using FACS is done. It can be done in Lucknow)
Rakesh Biswas Prakhar would be great if you can summarize the temporal sequence for Prof Able Lawrence and also brief Boudhayan on her current therapy. Able the bacterial cultures should be available tomorrow but smears (gm and ZN) were negative.
Able Lawrence Nocardia may take several days to grow. We have also seen MDR TB presenting as abscesses. Staph is the easiest.
Rakesh Biswas Done along with covering nocardia, cryptococcus and tomorrow will put him on DOTs
No comments:
Post a Comment