Case history The patient was a 42-year-old man who presented with fever and headache he claimed to be an active man(driver). Onset of symptom: 2 week ago first admision primary symptoms :weakness,malaise, myalgia,generalized bone pain Fever : no specific pattern / headache : mild,generalized with nausea without vomiting No Weight loss, No night sweating Case history No history of cough, sputum, abdominal pain,diarrhea, urgency,frequency he complain of mild radiating pain in left groin area and mild swelling scorotom. The patient hadnt history of smoking,opium addiction,alchole abuse. There was no diet medication use, risk factors for HIV, and use of any illegal drugs.No travel in 3 month ago Her past medical history:not diabet,not HTN, not IHD Ph/EX The patient was well developed, well nourished, and in no acute distress. Vital sign: weight: 90 kg, height: 180 cm. BP: 130/90,pulse: 100 beats/min, RR:18,SaO2: 96%, T=38 axillary. Head &neck: There was no scleral icterus. The nasal passages are patent. No neck stiffness ophthalmoscopy:NL thyriod gland NL. Ph/EX There werent cervical lymphadenopathy. Skin: There were no rashes or nodules. The heart had a regular rate and rhythm with a normal S1 and S2. There were no cardiac murmurs, rubs, or gallops. Pulmonary: Lungs were normal to auscultation and percussion. There were no wheezes, rhonchi, or rales. Abdomen: The abdomen was soft and non tender without evidence of hepatosplenomegaly Ph/Ex Extremities: No clubbing, no cyanosis, or edema. Neurologic: The cranial nerves were intact. Muscle strength was normal, and her gait was normal. Kerning sign -,Brudzinski sign - Genital :swelling left testis LAB test(23/4/94) he was admited in other hospital Wbc:6000 / HB:16 /plt:50000 /urea :45 /cr :1/BS :95 /ESR :1 /CRP :++ /AST:52/ALT:61/Alkph:125/Bili T :0/6 Wright,2ME : - B/C : - CXRey : NL CXRey Brain CT Dilation latral ventrichles Mild Hydrocephaly Feeling short of breath Assesment Abdominal sonography : Fatty liver grade 1,spleen NL, pacreas NL Kidney size and echo NL Prostate is measuring 28 ml volume and homogenous echo Multiple left epididymal masses in head and tail.reactive lymph node in inguinal area that largest is 10 mm 1/5/94 admit in afzalipour hospital Wbc :4500,HB :13/1, plt :81000, AST :58,ALT:49,ALK Ph :240, urea :31,cr :1.2,pt:15,ptt:45, INR :1.3 ESR :20,CRP +, U/A : wbc 6-8, bacteria -, nitrit -,epithelial cell 4-5 Assesment(10/5/94) LP : Csf pressure :NL, apreance :clear,color:colorless, Wbc 10,poly 70%,lymph 30%, RBC :800,glocose 43,protein 40 U/C - B/C :- Wright,2 ME ESR : 67,CRP 2+,PBS: no malaria Fever and headach continued Assesment ECHO : EF 60% PAP 25,NL LV SIZE and function /NO vegetation Brain ct report :mild hydrocephaly Neorology consult :neurologic examination NL dont need neurologic managment but recommended brain MRI Abdominal sonography : NL assesment Testis and prostate sono :left epididym in body and tail hetroecho and increase diameter,left hydrocel Urology consult :acute epidydimitis,antibiotic Assesment Report MRI : mild dilation af latral ventrichles Neurosergery cosult : NO surgical manegment Hematologic consult: isolated thrombocytopenia, underling disease.No BMA &BMB Question? DDX? Next step ? management? Epididymitis ? Meningitis? Primary managment LP WBC 10,poly 70% Fever + headache Meropenem, vancomycin dexamethazon Chronic meningitis Chronic meningitis defined as meningitis lasting for four weeks or more and is a complex entity with both infectious and noninfectious causes Chronic meningitis Infection Mycobacterium tuberclosis,spirochetal (treponema pallidum,leptospira ),bacteria (brucella,nocardia,listeria,actinomyces ),viral (CMV,EBV,HSV,VZV ),Fungal (cryptococcus,Histoplasma ),parasitis (taenia solium ) Non infection malignancy,Rheumatologic disease, Drug Drug induce meningitis NSAIDs Amoxicillin Azathioprine Methotrexate Intravenous immunoglobulin Isoniazid Allopurinol Lamotrigine Ranitidine Sulfamethoxazole Unexplained chronic meningitis CSF cell count,protein,glocose cytology, crypyococcal antigen test,culture Serology 1: fungal serology test for Histoplasma,cryptococcus 2:Toxoplasma serology 3:HIV Ab 4:lyme serology 5:VDRL 6:brucella serology Imaging :CT or MRI Other:tuberculin skin test, BMA &BMB with culture,meningeal or cortical biopsy Reassesment Rheumatologic sign : No ANA -,Anti DsDNA -,PANCA -,C3 C4 CH50 NL Viral marker : HIV Ab -,HBsAg -,Hcv Ab VDRL -,wright -,2ME -,Coombs wright - No Drug No sign of malignancy Lp WBC :10 wide spread antibiotic 3 week after admit in afzalipour hospital Wide spread antibiotic administrated Fever continued (Tempreture 40) Increse feeling short of breath Mild cough Next step ? Emprical managment Decrease O2Sat, cough, sputum Sweeling knees,symmetrical Acute diffuse Nodular pattarn emprical therapy (tuberclosis ) Diffuse nodular density in both lung DDX Acute nodular pattern :miliary TB,Histoplasmosis,viral infection Subacute or chronich nodular pattern: sarchoidosis, HP, CWP,silicosis,metastatic carcinoma,HX Nodular pattern Interstitial Size 10 malignancy Zone :upper (silicosis,CWP,sarchiodosis,HX) Lower (asbestosis,hematogenous metastase, hematogenous infection, fungal infection or miliary Tb) Miliary TB interstitial Nodular pattern,