A 35 yr.-old man with Fever for 3 days

1
A 35 yr.-old man with Fever for 3 days
????????????????

• Interesting case - Medicine
• ??? ?.?.?????? ????????????
• 24 ???????? 2546
• ??????????????????

2
History

• ??????? ?????? ???? 35 ?? (??????? ????)
• ????????????????? 2 ???????? 2546
• ????????? ????????????
• ?????????? ?????????????? 3 ???

3
History (2)

• ??????????????? 3 ???????????.
  ??????????????????????? ? ????????
  ,???????????????????????????,??????????????????,
• ??????????????????????????????????(???????????????
  ??????????????????????????????????????????????),
• ????????????????????????????? 3 ?????
  ????????????,??????????????????(??????????????????
  ??????????????),
• ???????????????
• ????? ???????????,???????????????????????,????????
  ????????

4
History (3)

• ??????????? ?????????????? ??????????????????????
  ??? ???????? 3 ?? ?????????1 ?????(on
  Glibenclamide 12)
• ?????????????? ???????? ?????? 1 ?? ???? 6 ??
• ????????????????????? ,
• ?????????????????, ????????????
• ????????????????????????
• ??????????????? ?? ???????????????????

5
Physical examination

• Vital signT38.5 ?C, P 80/min
  (full,regular),BP110/70 mmHg, RR 18/min
• BW70kg. Ht.170 cm.
• GAgood consciousness,not pale,
  no jaundice , no rash , no petechiae,
  no eschar,no edema, no
  lymphadenopathy
• HEENTeye mild conjunctival injected both sided
  ,pharynxmild injected, tonsil 1 ,no oral thrush
  ,no oral ulcer
• CVS normal S1 S2 ,no murmur
• RSnormal chest movement,normal breath sound both
  lungs,no adventitious sounds

6
Physical examination(2)

• AbdomenNo surgical scar, Soft , Mild tenderness
  at epigastrium , no rebound tenderness, no mass ,
  active bowel sounds , LiverSpleennot
  palpable,Murphys signnegative,
• CVA mild tenderness Rt. side
• PRInternal hemorrhoid gr I-II at 5,7 oclock ,
  no bleeding
• Neuro E4V5M6,pupil 3 mm.BRTL ,
  no stiff neck
  ,Kernig s sign negative ,
  no weakness

XXX
7
Problem list

• 1.Fever for 3 days (Acute
  febrile illness)
• 2.Minimal bloody stool 3 times
  --- Hemorrhoid
• 3.Mild epigastric pain, mild CVA tenderness
• 4.DM ????? 1 ?????

8
Acute Febrile Illness (????????????????)

• Definition ?????????????????????????????????
  38.3 ?C ??????????????? 7 ???
• Fever 7-14 days Subacute fever
• Fever gt14 days FUO
• Classification
• Hospital VS Community
• Adult VS Children
• Immunocompetent VS Immunocompromised Host

9
Cause of Fever

• Infection VS Non-infection
• Virus Malignancy
• Bacteria Autoimmune disease
• Fungus Neurological disease
• Protozoa Endocrine disorder
• Drug
• Most common Viral infection
• Severe ------- Sepsis from bacterial infection
• History taking
  Physical examination

37.3 C 1.Direct 2.IL-2,.TNF,IF
Hypothalamus
10
Acute fever in children

• Viral infection Most common --- URI (1st)
  --- Gastroenteritis(2nd)
• Bacterial infection Uncommon
  BUT! -----High Severity -----Death !!!!

11
Acute Fever in Adult

• Viral infection most common (But decreased)
• Bacterial infection increased
• Other factors Travelling , Host , Underlying
  disease
• 26 ????????????????
  
  ????????????????????????????????????????????
• Localized infection ( ??????????????????? )
• Disseminated infection ( ????????????????????? )
• Systemic infection ( ??????????????????? )

12
Localized infection

• Localized signsymptoms-----Organ
• Inflammatory sign ??? ,??? , ??? , ????
  Ex Arthritis at knee joint
• Secretion discharge Purulent discharge
  ?????????????????
• ExLung / Urinary tract ---Abnormal discharge
• Internal organ without discharge -----
  Investigation CBC / CXR
  ???????????????????????

13
Disseminated infection

• Severe infection to multiple organ
• Multiple abscess in Multiple organ
• ?????????????????
• Ex Bacterial infection (Severe)-----Melioidosis
• Tuberculosis
• Fungus
• HIV infection

14
Systemic infection

• Constitutional symptoms ???,????????,???????????
  ????,??????????,??????????????????
• Injected conjunctiva , rash
• Reactive hyperplasia of RE system
  (Lymphadenopathy,hepatomegaly, splenomegaly)
• No purulent discharge --- C/S no growth
• Ex Leptospirosis,Scrub typhus, Malaria,Enteric
  fever,Influenza, DHF

15
Acute Fever of unknown origin

• ?????????????1-2??????? ??????????????????????????
  ??? ??????? ??????????? CBC U/A CXR
  ??????????????? H/C ???? H/C ???????
• ???????? 0.05
• ?????????????????? ??????????????????
• ?????????????????????????? 0 - 4 ??

16

• ?????????????????????????????????????????????.????
  ??????????????? 10 ???? (??2533)
• ???????????????????????????? 61.3
• ????????????????????????? 38.7
• Scrub typhus 7.5
• Influenza 6.0
• DHF 5.7
• Murine typhus 5.3
• Bacteremia 3.0
• Salmonelosis 1.9
• Chikungunya fever 1.1
• Melioidosis 0.6

• Gram neg E.coli,Klebsiella,
  Enterobacter
• Gram Staph.,Beta-Strep, S.pneumoniae

17
?????????????????????????????????

• 1.?????????????????????????????????????
• 2.????????????????????? ??????????????????????????
  ??????????
• 3.?????????????????????????????????????
  
  ??????????????????????????
• 4.????????????????????????????????????

18
???????

• 1.???????????? (Fever pattern or character)
• 2.????????????????????(associated symptoms)
  - - systemic review
• 3.????????????????? - malaria/ scrub typhus ,
  ??????????
• 4.????????? - malaria / ????? melioidosis
• 5.???????????
• ???Toxoplasma gondii,toxocara cati/?? Crypto
  spp.
• 6.???????????????????????????????????????

19

• 7.????? - ????? lepto,melioidosis /??????scrub
  typhus / ??????????? anthrax, brucellosis
• 8.???????????????????????????????
• ??????????????????? / ???????????? /????????????
  
• 9.??????????????
• Ex DM-Staph,Gram neg, melioidosis
• Cirrhosis ---SBP / Neutropenia ----
  Pseudomonas
• HIV --PCP ,Cryptococosis, Rodococosis,Toxo,MAC,her
  pes
• Steroid use --- bacteria , TB ,fungus
• 10.?????????????????????????????
• 11.??????????????

20

• 1.?????????(sustained fever)
• lobar Pneumonia,Scrub typhus,typhiod
  fever,Pf.malaria
• 2.?????????? ? ( intermittent fever,hectic fever
  )
• Abscess , Bacterial endocarditis
• 3.????????????? ???? ???????????????? ----
  malaria
• 4.???????????(saddleback fever , biphasic fever)
  ---- viral
• 5.?????????? ? ??????????? ---- Cholangitis
• 6.??? Pel-Ebstein
• Hodgkinsdisease,brucellosis,relapsing fever
• 7.??????????? --- Salmonella,TB(miliary),Liver
  abscess,BE

21
??????????????

• 1.??????????????
• macolopapular rash,vesicle,pustules,hemorrhagic
  bullae,ulcer,eschar,ecthyma gangrenosum,embolic
  phenominon,needle mark,discoid rash,malar
  rash,warm skin,onycholysis
• 2.?? ???? ??????? ??
• Dental caries,pharynx,tonsils,oral ulcer,oral
  thrush,koplik spots,strawberry tongue,vesicle,
• Chemosis,conjunctival suffusion,conjunctival
  hemorrhage

22

• 3.?????????????
• Generalizedrubella,EBV,CMV,2nd syphilis,primary
  HIV
• Localized
• 4.??????????????????
• new murmur,pericardial effusion
• breath sounds , adventitious sound
• 5.???????????
• tenderness,mass,
• Liver,spleen enlargedEBV,rubella,Hepatitis,malari
  a
• 6.PR PV

23
????????????????????????

• 1.CBC - ????????????????????????????????????
• Hct gt 20 or gt 48DHF,
• anemia Malaria/DIC/BE ( Thick film )
• WBC gt 20,000or neutrophil predominate
  Bacteria (Leptospirosis,thromboembolism,still
  s disease ??????? )
• WBC lt 1000 Gram neg.rod infection
• Atypical lymphocyte DHF ( with low Plt.)
  malaria,rickettsia,mycoplasma ,infectious
  mononucleosis
• Low Plt. virus,malaria,Leptospirosis,rickettsi
  a,DIC,sepsis
• Blood Film malaria , Filariasis ,
  trypanosomiasis

24

• 2.Urine examination
• Protein 1-2,RBC or WBC cast 0-1/HPF,
• RBC10-50,WBC10-50 rickettsia/ Lepto / BE
• Pyelonephritis ---WBC gt50 /HPF
• 3.Liver function test Liver abscess(Alk phos
  High) , biliary tract , TB,Scrub typhus ,sepsis
  , Leptospirosis(Cholestasis
  jx,AST/ALT lt200),
• 4.CXR - alveolar infiltration
• Interstitial infiltration --- mycoplasma
  ,rickettsia , chlamydia,miliary TB
• 5.Hemoculture

25

• 6.Discharge Gramstain culture
• 7.Serology Rickettsia Weil-Felix test ,
  IFA,IIP
• Enteric fever Widal test (??????????????????????
  ??)
• Leptospira titer
• Melioidosis IgM antibody titer
• DHF,JE MacELISA
• EBV monospot IFA , IgM antibody
• HIV ELISA Gel-particle agglutination (Anti-HIV)
  
• Mycoplasma pneumonia complement fixation
• 8.Other --- ultrasonography /CT scan

26
Treatment

• 1.Supportive treatment
• Antipyrexia
• IV fluid
• Dietary
• Oxygen
• 2.Specific treatment ---- ??????????????????
• Virus No antibiotic
• Septicemia empirical antibiotic

27
??????????????????????????????????????????????????
? ??????????????????????????????????????
72??.???
?????????Bacteremia
-????gt40?? ????????????2???
-??? ????????
-????????? gt 20/ ????
-????? gt 90/????
-Leukocytegt12000
or lt4000 orgt10bands
Blood culture
Empirical antibiotic
-Ceftriaxone or Cefotaxime
add Doxycycline in severe scrub typhus
add
Ceftazidime in Melioidosis
??? gt38C ???lt1 WK HXPE ?
???????????????H/C
?????????????????
28
Management

• 1.Acute febrile illneess
• Septic work up
• CBC --- H/C II
• U/A --- MUC
• Stool exam , occult bl. , C/S
• 2.DM
• BS, BUN ,Cr ,Electrolyte

29
Investigation

• CBCHb.11.3g ,Hct35 (MCV77.6)
  Plt245,000/mm3 WBC15,700/mm3(N74,L15,M9,E2)
  
• U/AColorYellow,clear , Spgr1.010, pH6.5,
  Albneg,Sugar 1,Ketoneneg, RBC0-1,
  WBC0-1,Epith0-1
• DTX315 mg
• BUN10mg/dl , Cr. 1.4 mg/dl
• Na143 mmol/L ,K3.8 mmol/L, Cl-104mmol/L,HCo3-
  27 mmol/L

30
Management

• 1.Acute febrile illness with leukocytosis
• DDX Bacterial infection ?
• Investigation (?????????) LFT, CXR
• Start empirical antibiotic
  3rd gen.cephalosporin(Cefotaxime 1 g v q 6
  hr)
• ( criteria gt2/4 underlying disease
  DMlow phagocytic activity---bact.infection)
• 2.DM with hyperglycemia
• BS315 no acidosis (not DKA HHNK)
• ---off oral hypoglycemic drug Control BS with
  insulin (RI NPH)

31
Investigation (2)

• Hemoculture X II no growth
• MUC no growth
• LFTAlb3.2g/dl,Glo2.3g/dl,Total
  bilirubin1.3mg/dl,Direct bilirubin0.7g/dl,SGOT(A
  ST)16U/L,SGPT(ALT)40U/L ,AlK.phosphatase 152
  U/L(35-125)
• CXR - Mild elevation of Rt. diaphragm.
• No Cardio-megaly
• No Abnormal pulmonary infiltration

32
CXR
33
Fever pattern
34
Progress note

• Continue High grade intermittent fever----(on
  cefotaxime 1 g v q 6 hr)
• Add Doxycycline(100) 1 2
• Rt. Shoulder pain in fever day 5-6 (and increased
  severity)
• Mild epigastric pain --- tenderness at RUQ
• No bloody stool
• DM controlable BS with insulin (NPH 8 U/day)

35
Management

• DDX
• 1.Localized infection --- Abscess
• RT shoulder pain Refer pain ???
• Liver abscess ??? ---- U/S upper abdomen
• Perinephric abscess (RT.)--DM!
• Biliary tract infection --Cholecystitis

36

• 2.Disseminated infection -- resistance to ATB
• Melioidosis,TB..
• 3.Systemic infection
• Scrub typhus
• Leptospirosis
• HIV (Acute Retroviral Syndrome)
  --Anti-HIV (negative)
• 4.Non-infection
• Autoimmune disease
• Malignancy
• Drug

37

• ??????????????????????????????????????????????????
  
• Alcoholic hepatitis,allergic alveolitis,aortitis
• Bechets syndrome
• Drug fever
• Erythema multiforme
• Fabrys disease,factitious fever
• Granulomotous hepatitis
• Hemolytic anemia,histiocytosis X,hypereosinophilic
  syndrome
• Immunoblastic lymphadenopathy,Inflammatory bowel
  disease
• Metal fume fever
• Pancreatitis,pericarditis,paroxysmal
  hemoglobinuria,pheochromocytoma
• pulmonary embolism,postpericardiotomy syndrome
• Sarcoidosis,serum sickness
• Thrombophebitis,thrombotic thrombocytopenic
  purpura,thyroiditis
• Wegeners granulomatosis

38
Drug fever

• ??????????
• methyldopa,quinidine,procainamide,hydralazine,nife
  dipine
• ?????????????
• bleomycin,daunorubicin,procarbazine,catarabine,L-a
  sparagenase,chlorambucil,hydroxyurea
• ??????????
• penicillin,ampicillin,cloxacillin,tetracycline,lin
  comycin,sulfonamide,vancomycin, isoniazid,PAS
• ????????????
• diphenyldilantoin,carbamazepine,haloperidol,thiori
  dazine,amphetamine
• ??????????? ibuprofen , aspirin
• ?????? ? cimetidine,metoclopamide,clofibrate,allop
  urinol,folate,propiouracil,interferon

39
Ultrasound

• There is inhomogeneous hypoechoic area in
  posterior aspect of right hepatic lobe .Size is 7
  cm. in diameter.Lesion is not liquified
  apparently.
• Impression Liver abscess in posterior subphrenic
  location of Rt. lobe..

40
U/S
41
(No Transcript)
42
(No Transcript)
43
Liver abscess

• ??????????? 0.17 ??????????????????????????????
  (??.?????????)
• Amoebic liver abscess (ALA) 64
• Pyogenic liver abscess (PLA) 22
• Melioidosis liver abscess (MLA) 0.4
• Mixed liver abscess 4.5

44
Patient demographics

• ?????? ??????? ???????
• ALA ??? ???? 5.7 - 9 1
• PLA 1.1 1
• MLA 3.9 1
• ???????????????????????????? (?????????? 40-49
  ??)

45
Clinical manifestation
?????????????????????????????? liver abscess 101
???
46
?????????????????

• ?????????????????????
• ??? (?????? ? ?????????)
• ??????????????????????????/???
• ??????????????????????? ? ????????????????????????
  ??
• 20 Jaundice (mild to severe) ????????????????????
  ???(?????? Hilum)
• 15 Hx of colitis (????????,???????,?????????????
  ????)
• ?????????????????????????????(????????????????????
  )
• ?????????????????-Pleuritis/Pleural
  effusion/Pericarditis/Peritonitis

47
(No Transcript)
48
Investigation in liver abscess

• CBC ????????????????????????????
• Anemia 35-48 in ALA , 45-82 in PLA
• Leukocytosis to WBC gt 30,000 all (
  ??????WBC12000-18000 /N70-90)
• LFT
• Hyperbilirubinemia all
  Except ! TB gt10 mg/dl---PLA 21 (ALA
  0)
• Elevation of AST/ALT common (but not high level)
• Alkaline phosphatase abnormal 70-90(but High
  level gt3 times PLAgtALA)

49

• CXR abnormal 32-70 (ALA,PLA)
  57(MLA) Elevation of right dome of
  diaphragmRt.basal lung infiltrationRt.Pleural
  effusion
  ?????????????????????????????
• Ultrasonography CT scan
• Single abscess ALA gt PLA
• (????????????????? PLA ?? single
  abscess?????????/ALA ?? multiple abscess ???1??3)
• Multiple Abscess (4 Abscess) or Abscess in both
  lobes ????????????? PLA ???????
• ???????????????????????
• Splenic abscess ???? Clue ???????????? MLA

50

• Serological Diagnosis ?????????? !
• E.histolytica titer IHA / ELISA---ALA
• Sensitivity 85-98 / Cut off value 1512
• (in Thailand 82-97 / 1256)
• Aware of past infection in endermic area
• if negative R/O ALA
• Melioidosis titer cut off gt1640 (IHA)
• sensitivity 58 specificity 85
• Examination of aspirated pus ?????????
  ???????????????????

51
????????????????? (ALA VS PLA )

• 1.?????????? ALA???????? 15-30 ALA
  ?????????Colitis
• 2.ALA ?????????????????????????PLA
• 3.ALA ????????????????????????/
  PLA ????????????????????????
  
• 4.Ultrasound ALA 94 single abscess,84Rt.lobe
• 5.ALA tenderness at Rt .lobe of liver
  (PLA- multiple
  abscess---tenderness all)
• 6.Aspirated pus ALA Anchovy sauce pus
  ,?????????, WBC ????,?????trophozoite of
  E.histolytica,??Charcot-leyden crystal ??? 10-15
  (PLA ?????????????????????????,
  Bact.WBC???,gram stain ???????,C/S ???????

52
Anchovy sauce pus
53
Treatment of liver abscess(Amoebic Liver abscess)

• 1.Medical treatment
• 2.Percutaneous needle aspiration
• 3.Percutaneous transhepatic drainage (PTD)
• 4.Surgery

54
Medical treatment in ALA

• ???????
• Metronidazole 400-800 mg PO tid--- 5-10
  ???(Efficacy95)
• ???? 2.4 g. ???????? 3-4 ????---1-3 ??? (Efficacy
  97)
• Tinidazole 2 g. ?????????? (Efficacy 95)
• Ornidazole 2 g. ?????????? (Efficacy 97)
• Dehydroemetine
• Chloroquin
• ????????? (?????????????????)
• Diloxanide furoate 500 mg PO tid ---- 10 ???
• ??Metronidazole 400-80 mg PO tid -- 10 ???

55
Percutaneous needle aspiration

• ????????????????????
• Diagnosis treatment
• Abscess lt 5 cm. ---- medical only
• Abscess gt 5 cm. ---- Aspiration ????????????
• Clinical improved 3 ???

56
(No Transcript)
57
(No Transcript)
58
Trichome Stain stain
Charcot-leyden crystal
59
Amoeba trophozoite
Amoeba cyst
60
Percutaneous transhepatic drainage (PTD)

• ??????????????????????? 2 ???????
• ???????????????????????????? (?????? Ruptured
  Abscess)
• ???????? ALA ???????????? 2 ???????????????

61
Surgery

• Indication
• Rupture into peritoneal cavity
• (Rupture into pleural/pericardial cavity may Rx
  by aspiration ICD)
• Failure of medical treatment
• Inadequate drainage of lt. Lobe liver abscess

62
Impression

• Amoebic Liver abscess
• Because Single abscess in Rt. Lobe,
  no jaundice, Hx of colitis
• Management
• liver aspiration
• Serology
• RX Metronidazole 500 mg iv q 8 hr

63
Liver aspiration

• Anchovy sauce pus(??????????) 10 ml.
• Cell countWBC22,400 Cell/mm3
  RBC1,600 Cell/mm3
• Cell Differentiation N 86 ,L 14
• Protein 5.3 g
• Sugar 287 mg
• Amoeba not found
• Charcot leyden are seen
• Pus Culture no growth
• Serology
• E.histolytica titer Positive gt 1640

64
Diagnosis

• Amoebic liver abscess
• Hx PE
• High grade intermittent acute fever
• Mild epigastric pain --- progressive RUQ pain
• Bloody stool diarrhea ? ( Colitis 15 )
• Rt.Shoulder pain refer pain
• Lab
• CBC Leukocytosis
• CXR mild elevated Rt. diaphragm
• U/S hypoechoic mass at Rt.lobe of liver
• Aspirated pus Anchovy, C/S no growth
• E.histolytica titer positive gt1640

65
(No Transcript)
66
Progress note

• Decreased Fever pain
• Rx Metronidazole change to oral form
• D/C(14June) plan F/U with repeated U / S again
• HM
• Metronidazole (200mg) 23
• Glibenclamide 1/2 1
• PCM (500mg) 2prn q 6 hr

67
Conclusion

• ???????????? common
• ????????????? ?????????????????????-----????????
  
• Investigation (CBC,U/A) CXR H/C
• Common cause viral infection ------- Rx no
  antibiotic
• Bacterial infection ----severe ----- empirical
  antibiotic
• Hxtravel ---- Malaria , scrub typhus

68
THANK YOU FOR YOUR ATTENTION

• SPACIAL THANKS
• ??.?????? ????????????
• ??.???? ????????
• ??.????? ??????????
• ????????????????????????????????
• ????????????????????????