17

CASE 17


Five workers between the ages of 29 and 48 years presented to an acute care clinic with a 1-week history of fever, chills, night sweats, cough, headache, fatigue, myalgia, and weight loss.


Two weeks before the onset of symptoms, these five workers had begun partial demolition of an abandoned building in a small city near the Ohio River. At the time of demolition, a colony of pigeons was observed in the building, and pigeon droppings were found throughout the building. During the demolition, none of the workers wore personal protective equipment (i.e., respirators, eye protection, gloves, or protective clothing).



PHYSICAL EXAMINATION


Physical examination of one of the workers (Patient X) is presented here:


VS: T 38.3°C, P 96/min, R 24/min, BP 124/82 mmHg

PE: Crackles were noted on auscultation of the lung.


LABORATORY STUDIES (PATIENT X)



Blood



Hematocrit: 36%

WBC: 12,200/μL

Differential: 70% PMNs, 15% lymphs, 15% monos

Platelets: 360,000/μL

Blood gases: pO2 68 mmHg

Serum chemistries: Normal


Imaging


A chest x-ray from Patient X was remarkable for enlarged hilar and mediastinal nodes and multiple nodular infiltrates (Fig. 17-1).


image

FIGURE 17-1 Chest film showing multiple nodular infiltrates in both lung fields and a cavitary lesion in the right middle lobe in this patient. Note popcorn calcification (arrow).


(Courtesy of Dr. Paul Southern, Departments of Pathology and Medicine, University of Texas Southwestern Medical Center, Dallas, TX.)



Diagnostic Work-Up


Table 17-1 lists the likely causes of illness (differential diagnosis). Gram and acid-fast stains of sputum, blood culture, and routine bacterial cultures of respiratory specimens may be necessary to rule out the agents included in the differential diagnosis. More specific investigational approach may include


• Direct microscopy of tissue (lung, spleen) biopsy sections or aspirate stained with Gomori methenamine silver stain

• Antigen detection test in serum or urine by immunodiffusion

• Serology (also by immunodiffusion) test

• Mycologic cultures

TABLE 17-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Blastomycosis

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 17

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