case discussion for cme

8/10/2019 Case Discussion for CME

1/19

Clinical case 1


2/19

History

A 45 y male presented with:

high-grade fever, intermittent,

moderately severe headache lasting 6 days associated with multiple

episodes of vomiting,

and altered sensorium for 2 days

Patient was not a known case of TB, Diabetes, HTN, no surgery performed in

the past.

He was diagnosed with HIV -1 infection 2 yrs ago and was started on ARVs.


3/19

History & Examination

On examination:

Glasgow coma scale of E1M5V1.fever of 100C,

pallor, cachexic

Systemic:

-CNS: Patient had altered sensorium,

showing signs of meningitis (Kernigssign,

Brudzinskissign positive)

-RS, CVS, P/A normal

Relatives informed that the patient would NOTtake his Anti-Retroviral Therapy

medication regularly. Patient was not on any other drugs.


4/19

Investigations

CBC, S. electrolytes, Renal function tests, Liver function tests A lumbar puncture was done & CSF collected

CSF Routine, microscopy, biochemical parameters

CSF for bacterial and fungal cultures


5/19

Labs

Laboratory investigations revealed:

Total leukocyte count = 12,900/cumm with 86% neutrophils. Serum electrolytes, renal function tests, and liver function

tests were within normal limits.

The cerebrospinal fluid (CSF) examination revealed 80 WBCs,predominantly lymphocytes (90%)

with protein of 54.7 mg/dl

Glucose of 38 mg/dl (corresponding blood glucose was 136 mg/dl).

A computerized tomography (CT) scan of the head and a chest X raywere both normal


6/19

Microbiology

Bacterial cultures: negative

India Ink examination of the CSF


7/19

Culture on SDA after 72h incubation at 30C.

Urease positive

Colonies on Sabouraud dextrose agar are cream to

beige and mucoid due to the capsule surrounding

the yeast cells. This was also confirmed with the

Vitek 2 yeast identification system.

Diagnosis: cryptococcal meningitis


8/19

Appearance Protein

( mg/dl)

Glucose

(mg/dl)

WBC /

cumm

Micro/Sero/Other

Normal -

LP

Clear, colorless 10- 45 45 - 80 0 - 5

Acutepyogenic

meningitis

Purulent,slightly yellow,

delicate clot

501500(100- 500

common)

0 - 45 25- 10,000most PMNs

( 80 %)

Grams -60-90 % sens.Culture 80% sens & 100

% specific.

DirectAg up to 70 %

sens, 99 % specific.

TB

meningitis

Opalescent,

clot /cobweb

45 - 500 10 -45 10 -100

most

Lympho-

cytes

AFB25 % sens Culture

-75 % sens PCR is 100%

specific.

Aseptic

Meningitis

Clear, turbid or

xantho-chromic

20 - >200 N 500

usually; first

PMN, later

mono

All bact. culturesve

Seroconversion Specific

IgM Direct Antigen/

PCR Cultures - viral

Fungal

meningitis

Normal 50- 300 Moderate

in 55 %

800

(lympho >

PMN)

India ink50 % sens

Crypto Ag90 %

Culture90 % sens.


9/19

Clinical Case 2


10/19

History

A 25 year old female came with history of

fever since 4 days (continuous and high grade)

headache since 4 days abdominal discomfort & constipation since 3 days

Patient was not a known case of TB, Diabetes, HTN,

no surgery performed in the past. Not on any

medication.


11/19

On examination

On examination:

Fever of 102C

Pulse rate of 90/min

No other significant findings in general or systemic

examination.

USG abdomen showed mild splenomegaly


12/19

Investigations CBC with ESR

PS for MP Widal test

Dengue serology

Blood for C/S


13/19

Labs

The CBC showed WBC count per 6800/ mm3(N =57%, L= 36%,M=04%, E= 03%)

platelet count 220000/L

Hemoglobin 10.2 g/dl.

ESR 60 mm at 1h.

Serum urea and creatinine normal

Urinalysis normal.

Dengue IgM, IgG, NS1 Ag Negative

PS for Malaria- Negative

Widal : O/neg; H/1:20, AH & BH neg.


14/19

Cultures

The next day the bottle

flashed positive in the

automated Blood culture

system

Grams stained smear was

prepared. Showed Gram

negative bacilli. Subcultured

on to Blood agar,

MacConkey agar plates

Sensitivity and identification

performed


15/19

MacConkey Agar

Blood Agar


16/19

Biochemical Reactions Indole

TSI: K/A with H2S Glucose fermented, Gas

Urease

Citrate

Lysine decarboxylase +

Arginine dehydrolase

Ornithine decarboxylase

Oxidase

Motility +

Methyl Red +

Voges proskauer


17/19

Widal test

Significant titer of 1: 160 or more for O and H or either isaccepatable in India (in some countries 1:80 and

greater).

It is important to demonstrate a rising titer after 5-7

days. Single Widal may not be useful in endemic areas Widal may be negative in 1stweek of fever.

Accuracy of widal test has been shown to range form

50% to 85% approx. It is a non specific test

Inferior to Blood cultures for specific diagnosis. Blood

cultures usually positive in 1stweek of fever

Still popular because of cost factor & quick results


18/19

Management

SalmonellaTyphi was reported after confirmation with antisera.

Antimicrobial susceptibility testing was done for

ampicillin,

ceftriaxone,

ciprofloxacin,

co-trimoxazole,

chloramphenicol,

cefixime,

azithromycin.

Found to be Susceptible to cotrimoxazole, ceftriaxone, ampicillin and

azithromycin, intermediate to ciprofloxacin. Patient started onCeftriaxone.


19/19

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case discussion for cme

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