Chief Complaint UCSF CME June 24, 2015 27 yo previously healthy - - PowerPoint PPT Presentation
6/24/2015 CPS Chief Complaint UCSF CME June 24, 2015 27 yo previously healthy woman is admitted for severe abdominal pain HPI 3 months ago: anorexia, burping, vomiting, and constipation One month later: subjective fevers, night sweats,
27 yo previously healthy woman is admitted for severe abdominal pain
3 months ago: anorexia, burping, vomiting, and constipation One month later: subjective fevers, night sweats, and a pruritic, nodular rash over her R abdomen migrated to R hip
Aforementioned symptoms developed while in Peru teaching English and yoga
(Current presentation) Travel to Peru Fever, rash GI symptoms In Peru
Exposures
Reported intercourse with new male partner (used condom) Swam in dirty water near a zoo in the jungle Camped and trekked through jungle areas Walked barefoot on farms at the yoga center Ate ceviche and raw vegetables
Sought medical care in Cuzco (2 months before current presentation):
Showed photos of rash to her physician:
CBC with eosinophilia (3000), chem panel and LFTs normal Blood cultures + Salmonella typhi Treated with cipro x10 days constitutional symptoms resolved But rash and GI symptoms persisted
Further w/u for rash and GI sxs (in Cuzco):
Rash biopsy: nonspecific inflammatory changes Stool O+P negative Repeat WBC 14,000 with 44% eos
Treated with ivermectin and triclabendazole (unclear course) Rash, constipation, and crampy abd pain persisted and she returned to the US for further medical care
Upon return, saw PCP started empiric prednisone 40mg daily for possible allergic or autoimmune process 3 days after starting prednisone, presents to local ED with abrupt worsening of abd pain (current presentation)
Current presentation Travel to Peru Fever, rash GI symptoms In Peru
PMH Mild childhood asthma
no intubations no atopic symptoms
G0P0 PSH None NKDA Meds None, except recently
Cipro Ivermectin Triclabendazole Prednisone
FHx Mother: leukemia Otherwise noncontributory HRB No tob, etoh, illicits, IVDU SHx Lives on San Juan Island with her family Most recently teaching English and yoga in Peru No other travel Exposures as per HPI
Abd: soft, mild TTP, +rebound, no guarding. No HSM. Hypoactive BS MSK: normal Neuro: A&Ox3, normal Lymph: no supraclavicular or cervical LAD Skin: indurated red/violaceous thick linear rash over R iliac crest. No fluctuance, mild TTP and warmth
Ca 8.3, Mg 1.6 Albumin 3.0 PT 14.1, PTT 34, INR 1.1
11.3 11.7 279 88 135 3.9 106 21 0.67 11 0.7 46 108 77
Diff: 42% eos
HIV, syphilis, GC/CT, and hepatitis serologies negative Repeat O+P negative x3 Blood cultures pending CT a/p
Inflammation of the ileum and adjacent fluid c/f small perf vs abscess
Started on ceftriaxone for possible typhoid relapse (and possible perf) Blood cultures neg Multiple serologies pending Abdominal pain improved, was discharged on azithromycin and a dose
infection NOS
Continues to get new nodules on her abdomen Eos persistently elevated Serologies returned:
High pos filariasis IgG, neg filariasis IgG4 neg strongyloidiasis Ab Neg fasciola Neg toxocara Neg paragonamous
T y p h
d r e l a p s e F i l a r i a s i s E c h i n
c u s G n a t h
t
i a s i s S t r
g y l
d i a s i s I h a v e n
d e a – c a n ’ t w a . .
5% 41% 15% 22% 5% 12%
Hello Thankfully, my rash began to slowly disappear about 2 weeks after taking Albendazole. I got a 6-month and 1-year check-up and my Eosinophilia has disappeared! I am back on track, feeling very healthy, alive and parasite free :) I have some very minor discoloration where the rash was and a couple of scars from the Peruvian biopsies, but that's it! Thank you again so much for your expertise, persistence, and incredible support! I don't know what I would have done without you. Regards,
– Previous UCSF chief resident, 2012-2013 – Current chief fellow, infectious diseases, UWMC
Map of countries with reported acquisition of gnathostomiasis.
Herman J S , and Chiodini P L Clin. Microbiol. Rev. 2009;22:484-492
Caused by nematode Gnathostoma spinigerum Acquired by eating uncooked food, esp fish (eg ceviche!)
Adult worm lives inside gastric wall of definitive host and expels eggs into GI tract 1st stage larva hatch in the presence of water and are then ingested by intermediate hosts, (small crustaceans) where they mature Ingested by second intermediate hosts (fish, frogs, snakes, chickens, pigs), migrate and mature into 3rd stage larva ready to infect humans Most commonly acquired by consumption of undercooked fish (esp tilapia), poultry or pork
Also acquired via penetration of the skin or prenatal transmission Rusnak, CID, 1993
2 forms of disease, visceral and cutaneous
Cutaneous form: Intermittent migratory skin and subcutaneous swellings, eosinophilia CNS involvement (eosinophilic meningitis)
Symptoms occur ~24-48hrs after ingestion with non-specific sx: malaise, fever, urticaria Migrate through subcutaneous tissue migratory swellings for up to 10-12 years!
Rusnak, CID, 1993
Diagnosis: Western blot, performed in Thailand
Thought to be sensitive and specific for this disease
One study examined a case series from 2000-2001
Median time from symptoms to diagnosis was 12 months Eosinohilia present in 7 patients Treatment: albendazole 400mg BID x 21 days
Moore, EID, 2003