21

CASE 21


A 20-year-old man presented to the emergency department with a 3-week history of moderate fever, cough, shortness of breath, weight loss, and anorexia. He complained about a draining lesion on his left chest wall.


The patient had recently emigrated from Pakistan and had a history of severe periodontal disease.



PHYSICAL EXAMINATION



VS: T 38°C, P 82/min, R 24/min, BP 136/84 mmHg

PE: The patient was ill appearing and had a productive cough with foul-smelling sputum. Abnormal breath sounds were heard, and a sinus tract from the right chest wall with drainage containing yellow granules was noted.


LABORATORY STUDIES



Blood



Hematocrit: 32%

WBC: 5200/μL

Differential: 78% PMNs, 18% lymphs

Serum chemistries: Normal


Imaging


Chest x-ray revealed left lung infiltrates with upper lobe cavity (Fig. 21-1).


image

FIGURE 21-1 An admission chest film showing left lung infiltrates with upper lobe cavity in this patient.


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



Diagnostic Work-Up


Table 21-1 lists the likely causes of illness (differential diagnosis). Laboratory investigation may be initiated with microscopic examination of sulfur granules in pus (from sinus tract), crushed and examined by


• Gram stain for Nocardia or Actinomyces

• Tissue stain (e.g., H & E, Giemsa, silver)

TABLE 21-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Actinomycosis

Anaerobic lung abscess

Endemic mycosis (e.g., blastomycosis)

Nocardiosis

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 21

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