Материал: 100_Cases_in_Clinical_Medicine

ANSWER 76

This patient has bacterial meningitis. He has presented with sudden onset of severe headache, vomiting, confusion, photophobia and neck stiffness. The presence of hypotension, leucocytosis and renal impairment suggest acute bacterial infection rather than viral meningitis. The most likely causative bacteria are Neisseria meningitidis, Haemophilus influenzae and Streptococcus pneumonia. In patients in this age group Streptococcus pneumonia or Neisseria meningitidis are the most likely organisms. Meningococcal meningitis (Neisseria meningitidis) is usually associated with a generalized vasculitic rash.

The most severe headaches are experienced in meningitis, subarachnoid haemorrhage and classic migraine. Meningitis and subarachnoid haemorrhage present as single episodes of headaches. Meningitis usually presents over hours, whereas subarachnoid haemorrhage usually presents very suddenly. Fundoscopy in patients with subarachnoid haemorrhage may show subhyaloid haemorrhage. Meningeal irritation can be seen in many acute febrile conditions particularly in children. Local infections of the neck/spine may cause neck stiffness. Other causes of meningitis include viral, fungal, cryptococcal and tuberculous meningitis which can be distinguished by analysis of the CSF.

When meningitis is suspected appropriate antibioic treatment should be started even before the diagnosis is confirmed. In the absence of a history of significant penicillin allergy the most common treatment would be intravenous ceftriaxone or cefotaxime.

Patients with no papilloedema or lateralizing neurological signs that suggest a spaceoccupying lesion should be lumbar punctured immediately (even before a CT scan is obtained). If there are localized neurological signs it is essential to perform a CT scan first to avoid the dangers of coning which can occur when a lumbar puncture is performed in the presence of raised intracranial pressure.

The combination of #1000 neutrophils/mL CSF, a CSF glucose !40 per cent of the simultaneous blood level and a CSF protein 1.4 g/L is strongly suggestive of bacterial meningitis. The Gram stain and culture will give the definitive diagnosis. In this case, the Gram stain demonstrated Gram-positive cocci consistent with Streptococcus pneumonia infection. Intravenous antibiotics must be started immediately. The patient must be nursed in a manner appropriate for the decreased conscious level. Adequate analgesia with opiates should be given. The patient has mild hyponatraemia due to the syndrome of inappropriate antidiuretic hormone (ADH) secretion, and fluid losses should be treated with normal saline. Inotropes may be needed to treat hypotension.

The two children aged 3 and 4 years must be considered. It is not clear from the history who is looking after them. They should be examined, and if meningococcal meningitis is suspected or the organism is uncertain they should be given prophylactic treatment with rifampicin and vaccinated against meningococcal meningitis.

KEY POINTS

•Bacterial meningitis causes severe headache, neck stiffness, drowsiness and photophobia.

•The main differential diagnoses are subarachnoid haemorrhage and migraine.

•When bacterial meningitis is strongly suspected antibiotic treatment should be started before bacteriological confirmation is available.

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CASE 77: ABDOMINAL PAIN

History

A 70-year-old woman has been complaining of upper abdominal pain which has increased over the last 3 days. It has been a general ache in the upper abdomen and there have been some more severe waves of pain. She has vomited three times in the last 24 h. On two or three occasions in the past 5 years she has had a more severe pain in the right upper abdomen. This has sometimes been associated with feeling as if she had a fever and she was treated with antibiotics on one occasion. Her appetite is generally good but she has been off her food over the last week. She has not lost any weight. There have been no urinary or bowel problems but she does say that her urine may have been darker than usual for a few days and she thinks the problem may be a urinary infection.

In her previous medical history she has had hypothyroidism and is on replacement thyroxine. She has annual blood tests to check on the dose; the last test was 3 months ago. She has had some episodes of chest pain on exercise once or twice a week for 6 months and has been given atenolol 50 mg daily and a glyceryl trinitrate spray to use sublingually as needed.

Examination

Her sclerae are yellow. Her pulse is 56/min and regular. Her blood pressure is 122/80 mmHg. There are no abnormalities in the cardiovascular system or respiratory system. She is tender in the right upper abdomen and there is marked pain when feeling for the liver during inspiration. No masses are palpable in the abdomen. She is clinically euthyroid.

INVESTIGATIONS

Questions

•How do you interpret these findings?

•What is the appropriate management?

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ANSWER 77

This woman has a 5-year history of intermittent upper abdominal pain. Her current pain has lasted longer than previous episodes and on examination she is jaundiced. The acute pain on inspiration while palpating in the right upper quadrant is a positive Murphy’s sign of inflammation of the gallbladder. The relative bradycardia in the presence of the acute illness is likely to be related to the beta-blocker therapy (atenolol) rather than hypothyroidism or any other problem. The dark urine would fit with increased conjugated bilirubin because of obstruction. The conjugated bilirubin is water soluble and excreted in the urine. Without conjugated bilirubin entering the bowel one would expect pale stools.

Her investigations show a raised bilirubin. The alanine aminotransferase is slightly raised but the main abnormalities in the liver enzymes are high values of alkaline phosphatase and gamma-glutamyl transpeptidase. This is the pattern of obstructive jaundice which can be caused by mechanical obstruction by tumour or by gallstones, or by adverse effects of some drugs, e.g. phenothiazines, flucloxacillin. The drugs she is taking are not likely causes of liver problems.

The previous episodes of pain and fever over the last 5 years are likely to have been cholecystitis secondary to gallstones. If the gallbladder were to be palpable on examination this would suggest an alternative diagnosis of malignant obstruction, since by this time these previous episodes of cholecystitis would usually have caused scarring and contraction of the gallbladder. In order to produce obstructive jaundice one or more of her gallstones must have moved out of the gallbladder and impacted in the common bile duct. Migration of gallstones from the gallbladder occurs in around 15 per cent of cases.

Her thyroid condition seems to be stable and not relevant to the current problem. Her angina is indicative of coronary artery disease and needs to be considered when treatment is being planned for her gallstones. An electrocardiogram (ECG) should be part of her management.

Only a minority of gallstones are radio-opaque and visible on a plain radiograph so the next investigation should be an ultrasound of the liver and biliary tract. Ultrasound will show dilatation of the biliary tree but is not so reliable for identifying common bile duct stones. Endoscopic retrograde cholangiopancreatography (ERCP) is the best tool for this, and sphincterotomy with or without stone retrieval may be possible to remove stones obstructing the common bile duct.

KEY POINTS

•Obstructive jaundice with a dilated, palpable gallbladder is likely to be caused by carcinoma at the head of the pancreas (Courvoisier’s sign).

•Obstructive jaundice causes preferential elevation of alkaline phosphatase and gammaglutamyl transpeptidase.

•When the main rise is in alanine aminotransferase, this indicates primarily hepatocellular damage.

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CASE 78: FEVER

History

A 36-year-old man presents to his general practitioner (GP) complaining of a fever and generalized aching in muscles around the back and legs. At first he thought that this was probably influenza but the symptoms have now been present for 9 or 10 days. For 3 days he had diarrhoea but this has settled now. He has complained of a sore mouth over the last week or so which has made it difficult to eat, but he has not felt very hungry during this time and thinks he may have lost a few kilograms in weight. Around the time that the symptoms started he noticed a mild erythematous rash over his chest and abdomen but this has faded.

He has visited the practice occasionally in the past for minor complaints. He has been to the practice to obtain vaccinations for visits to Vietnam and Thailand over the last 3 years. His last travel abroad was 3 months ago. He smokes 10 cigarettes daily, drinks 20–30 units of alcohol weekly and takes no illicit drugs. He had no other relevant medical or family history. He works as a solicitor. He is single and lives alone. He has had a number of heterosexual and homosexual relationships in the past. Twelve months ago he had an HIV test which was negative.

Examination

He had a temperature of 38°C. Pulse rate was 94/min, respiratory rate 16/min and blood pressure 124/78 mmHg. There were no abnormalities in the cardiovascular or respiratory system. On examination of the mouth there were two ulcers in the oral mucosa, 5–10 mm in diameter. There were a number of palpable cervical lymph nodes on both sides of the neck, which were a little tender. There were no other nodes and no enlargement of liver or spleen. There were no rashes on the skin.

INVESTIGATIONS

Question

• Suggest some possible diagnoses.

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ANSWER 78

This seems likely to be an infective problem which has gone on for over a week. The length of the history makes influenza unlikely. The other positive features are the cervical lymphadenopathy and the oral ulceration. The temperature is still up and there has been a rash which has resolved. The blood results are all normal including the test for glandular fever (infectious mononucleosis) which was a reasonable diagnosis with these features.

The previous homosexual contact increases the possibility of sexually transmitted infections. It is possible that travel to Vietnam and Thailand may have been associated with high-risk sexual exposure. He is known to have had a negative HIV test 12 months ago. However, it is quite possible that this might be an HIV seroconversion illness. In around half of those who acquire the virus this occurs within 4–6 weeks of acquisition. Although the HIV test will still be negative, this can be diagnosed by finding the presence of the HIV virus or its p24 antigen in the blood. He should have been counselled about precautions to reduce the risk of transmission of sexually transmitted diseases at the time of the HIV testing 12 months before.

The picture might fit for secondary syphilis which occurs 6–8 weeks after the primary lesion. However, in that case the rash would often be more extensive and the lymph nodes are not usually tender. A serological test for syphilis should certainly be performed.

Other viral illnesses are possible. Hepatitis may present with this more general prodrome but the normal liver function tests make this much less likely. Lymphoma can present with lymphadenopathy and fever but the oral ulceration and the rash are not typical of lymphoma. If the serological tests proved negative, lymph node biopsy might be considered.

In this case, tests for an HIV viraemia were positive. Antiretroviral treatment at the time of known or high-risk exposure is useful in reducing the risk of infection. At this stage, treatment is supportive with explanation and arrangements for monitoring of viral load.

KEY POINTS

•A seroconversion illness occurs in around 50 per cent of those acquiring HIV infection. The severity varies.

•In cases of known or high-risk exposure, such as needlestick injuries, an immediate course of antiretroviral treatment is often indicated. Immediate advice should be sought.

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