18

CASE 18


A 38-year-old man was seen by his family physician for two weeks of fever, productive cough, right-sided pleuritic chest pain, a 12-lb. weight loss, and a painful lesion on his left arm.


The patient, a long time resident of Tennessee, had no significant past medical history. He had worked outdoors as a landscaper for the last 18 years. Family history was unremarkable. He had been treated with oral cefuroxime and erythromycin for suspected pneumonia 10 days prior to this visit, but his symptoms had not improved.



PHYSICAL EXAMINATION



VS: T 38.3°C, P 90/min, R 34/min, BP 126/76 mmHg

PE: Examination was remarkable for crackles in the left lung and a verrucous skin lesion (1 × 1 cm) on his left arm that was tender and erythematous.


LABORATORY STUDIES



Blood



Hematocrit: 38%

WBC: 19,000/μL

Differential: 79% PMNs

Platelets: 612,000/μL

Blood gases: Normal

Serum chemistries: Normal


Imaging


A chest x-ray revealed multiple nodular lesions, some of which were cavitating, in the left upper lobe. Left arm x-ray revealed no bony abnormalities.



Diagnostic Work-Up


Table 18-1 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 sputum or bronchoscopic specimen and a tissue biopsy (lesions)

• Mycologic cultures of bronchoscopic specimen and a biopsy of lesion

• DNA test using chemiluminescent DNA probes

TABLE 18-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Carcinoma

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 18

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