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A Year Old Woman with Severe A Year Old Woman with headache

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A Year Old Woman with Severe A Year Old Woman with  headache Powered By Docstoc
					A 45-Year-Old Woman With
Severe Headache
               Eugene G. Martin, Ph.D.
               Associate Professor of Pathology & Laboratory Medicine

     Based upon: LABORATORY MEDICINE CASEBOOK.
     An introduction to clinical reasoning

     Jana Raskova, MD
       Professor of Pathology & Laboratory Medicine
     Stephen Shea, MD
       Professor of Pathology & Laboratory Medicine
     Frederick Skvara, MD
       Associate Professor of Pathology & Laboratory Medicine
     Nagy Mikhail, MD
       Assistant Professor of Pathology & Laboratory Medicine
     UMDNJ-Robert Wood Johnson Medical School
     Piscataway, NJ
History - Physical Examination
   45-Year-Old woman presented with severe headache, fever, nausea,
    vomiting and photophobia of 4 day duration
       Flu-like illness with sore throat 3 days prior to presentation
   Physical exam:
      Obese female
      No current medications
      Fully oriented
      Temp. 102.3 oF
      BP: 128/74
      HR: 130 bpm
      Neck stiffness on forward flexion
      Petechial rash involving back and both lower posterior
       extremities
      Neurological exam – no motor or sensory deficit.
      Lumbar puncture ordered
Chest x-ray – AP



                      Normal
 HEMATOLOGY
          Patient            Normal
WBC       12.83 X 103/uL     (4.5-11.0)
  Neut    83.7 %             (44-88)
  Lymph   7.3%               (12-43)
  Mono    5.4%               (2-11)
  Eos     2.6%               (0-5)
RBC       4.98 X 106/uL      (3.9-5.0)
Hgb       13.8 g/dL          (12.0-15.0)
HCT       42.6%              (36.0-44.0)
MCV       85.6 fL            (79.0-99.0)
MCH       27.8 pg            (26.0-32.0)
Plts      381 thousands/uL   (150-400)
 Urinalysis
               Patient           Normal
pH             6.0               (5.0-7.50)
Protein        Neg               (Neg)
Glucose        Neg               (Neg)
Ketone         Neg               (Neg)
Bile           Neg               (Neg)
Occult Blood   1+                (Neg)
Color          Light Amber       (Yellow)
Clarity        Slightly Cloudy   (Clear)
WBC            5-9/HPF           (0-5)
RBC            5-9/HPF           (0-2)
Epith. Cells   20-29/HPF         (0)
Bacteria       3+                (Neg)
Mucus          1+                (Neg)
Urobilinogen   Neg               (Neg)
Conclusions: Urinalysis
   No symptoms
   Presence of small numbers of RBCs, WBCs,
    epithelial cells and bacteria
   Absence of casts

   CONCLUSION: Evidence insufficient to conclude
    glomerulonephritis, tubular or interstitial disease
   DDx: Await culture results to decide on whether
    patient has bacteriuria or an aseptic pyuria
CHEMISTRY
Test          Patient     Normal
Glucose       96 mg/dL    (65-110)
BUN           11 mg/dL    (7-24)
Creatinine    1.0 mg/dL   (0.7-1.4)
Uric Acid     5.1 mg/dL   (3.0-7.5)
Cholesterol   198 mg/dL   (150-240)
Calcium       8.6 mg/dL   (8.5-10.5)
Protein       6.9 g/dL    (6-8)
Albumin       3.6 g/dL    (3.7-5.0)
LDH           157 U/L     (100-225)
Alk. Phos.    70 U/L      (30-120)
AST           8 U/L       (0-55)
GGTP          50 U/L      (0-50)
Bilirubin     0.5 mg/dL   (0.0-1.5)
Other Tests
Test              Patient     Normal
Na                134 mEq/L   (134-143)
K                 4.1 mEq/L   (3.5-4.9)
Cl                102 mEq/L   (95-108)
CO2               20 mEq/L    (21-32)

Test              Status
Lyme antibodies   PENDING
Blood Culture     PENDING
CSF Culture       PENDING
Urine Culture     PENDING
Throat Culture    PENDING
 CSF
Test             Patient        Normal
Color            Colorless      (Colorless)
Clarity          Clear          (Clear)
WBC              105/ uL        (0-10)
  Lymph          75%            (0-10)
  Neut           15%            (0)
RBC              20/uL          (0)
Glucose          63 mg/dl       (40-80)
Protein, total   53 mg/dl       (15-45)
VDRL             Non-reactive   (Non-reactive)
CSF Interpretation
   Interpreted late in the patient’s symptomatology
   Glucose – normal
   WBCs ↑ – but not enormously
   Predominantly mononuclear cells
   A few RBCs
   Gram stain showed no organisms
   Protein increased a little

   Diagnosis: Aseptic meningitis
   In a typical pyogenic infection
       WBCs ↑ –enormously (thousands)
       Glucose ↓
       Protein ↑ > 100 mg/dl
Differentiating Viral from
Bacterial
   Viral Meningitis                Bacterial Meningitis
       CSF clear to cloudy            CSF clear to purulent
       ↑ initial pressure             ↑ initial pressure
       ↑ protein                      ↑ protein
       normal glucose                 ↓ glucose
       ↑ cells (not over              ↑ polys (often more
        1000/mcL, polys on day          than 1000/mcL)
        1, then more lymphs)           ↑ lymphs (some,
       a specific virus is             typically after
        incriminated by rising          treatment)
        titer after patient is         positive gram stain,
        better                          culture, and/or
                                        meningitis antigens
Labs
          CSF Gram Stain (x197)
              No microorganisms present
              WBC elevated
              Primarily lymphocytes




          URINE SEDIMENT –
           Unstained/Phase Microscopy
              Several squamous
               epithelial cells
              WBCs
              Bacterial
Aseptic Meningitis
   Age: 90% < 30
   Characterized by meningeal symptoms, fever, CSF
    pleocytosis, and sterile cultures
   Acute and self-limiting – usually not associated with loss of
    consciousness
   CSF abnormalities are most apparent following 4-6 days of
    illness may persist for several weeks
   Causes:
       Virus
       Fungi
       Rickettsia
       Protozoa
       Non-Infectious Processes: Sarcoidosis, SLE
Viral Meningitis

   90% caused by enteroviruses
       Coxsackieviruses and echoviruses.
       These viruses are more common during
        summer and fall months.
       Herpesviruses and the mumps virus can
        also cause viral meningitis.
      Brain – Aseptic meningitis (              H&E x31)




                                       Subarachanoid space -
                                        widened due to fluid and a
                                        cellular infiltrate which
                                        extends into the Virchow-
                                        Robin space
                                       Does not involve cerebral
                                        cortex
                                       No bacterial organisms,
                                        neutrophils or necrosis are
                                        present


Cellular Infiltrate and fluid
             Virchow-Robins space
       Brain – Aseptic meningitis (            H&E x100)




                                      Subarachanoid space -
                                       widened due to fluid and a
                                       cellular infiltrate which extends
                                       into the Virchow-Robin space
                                      Does not involve cerebral
                                       cortex
                                      Cellular infiltrate: lymphocytes
                                       and macrophages
                                      Cellular infiltrate DOES NOT
                                       include acute inflammatory
                                       cells and bacterial organisms


Cellular Infiltrate and fluid

            Virchow-Robins space
 Test Results - Late
Test              Status
Lyme antibodies   Negative
Blood Culture     No growth in 5 days
CSF Culture       No growth in 5 days
                  No fungus – 3 weeks
                  No acid-fast bacilli – 6 weeks
Urine Culture     24 hr culture – Gram-negative rods
                  (5000 cfu/mL)
Throat Culture    PENDING

				
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posted:1/26/2011
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