19

CASE 19


A 35-year-old man was admitted to the hospital with a 3-week history of fever, night sweats, headache, joint pains, dry cough, and severe fatigue. He had lost 16 lb in the past two weeks.


The patient had returned to his home in New York, one month after a brief visit with his mother in Phoenix, Arizona.



PHYSICAL EXAMINATION



VS: T 38.9°C, P 106/min, R 28/min, BP 130/58 mmHg

PE: The patient appeared ill and slightly pale. Rales were heard in the right lower lobe. Erythema nodosum lesions on his back were noted.


LABORATORY STUDIES



Blood



Hematocrit: 32%

ESR: 62 mm/h

WBC: 8,600/μL

Differential: 60% PMN, 18% lymphs, 6% monos, 16% eosinophils

Blood gases: pO2 72 mmHg

Serum chemistries: Normal


Imaging


A chest x-ray revealed infiltrates in both lung fields with a large cavity in the right upper lobe (Fig. 19-1).


image

FIGURE 19-1 An admission chest film showing bilateral infiltrates with a large cavity in the right upper lobe in this patient.


(Courtesy of Dr. Daniel Skiest, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX.)



Diagnostic Work-Up


Table 19-1 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 to visualize fungal structures in silver-, Giemsa-, or Wright-stained biopsy or aspirate specimens

• Serology:
• Immunodiffusion (ID) test

• Complement fixation using paired sera

• Fungal cultures (State Laboratory or CDC)

TABLE 19-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Blastomycosis

Coccidioidomycosis

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 19

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