Prof. Dr. Gamal Esmat’s Unit
Prof. DR. Gamal Esmat
Prof. Dr. Hassan El Garem
Prof. Dr. Maysa El Razeky
Dr. Mohammad Ibrahim
Dr. Wafaa El Aakel
Dr. Ahmad Fouad
Dr. Mohammad Hamed
Dr. Yasmin Saad
Dr. Dina Ismaeel
Dr. Mohamed Abdelhafez
Res. Mahmoud Magdy
Res. Fatma El Kady
Female patient, 19yrs old, student, born & lives in
Bolak El Dakroor, single.
No special habits of medical importance.
No history of contact with canal water.
Menarche at 12yrs ,regular menses, amenorrhea since
the beginning of symptoms.
Fever of 6 months duration.
The condition started 6mths ago by fever of relapsing
pattern of no specific diurnal variation, without rigors
or marked sweating. Fever lasted for about 1 month
then disappeared but recurred again after 1 month.
3mths ago she experienced a syncopal attack preceded
by facial twitches for which she was admitted to an
ICU in a private hospital and received IV fluids and 1
unit of blood then she was discharged 5 days later after
1mth later she started to develop easy fatigability.
1mth ago she developed repeated attacks of tonsilitis
associated with knee arthralgia with limitation of
movement but no arthritis.
No history of perception of body masses, weight loss,
oral or genital ulcers, or photosensitivity.
No history of recent travel or contact with animals.
She sought medical advice many times and received
many treatments one of them was steroids which she
received for 3wks with improvement of fever.
No symptoms of other systems affection.
Not known to be diabetic or hypertensive.
No history of previous operations.
No similar conditions in her family.
The patient is fully conscious, well oriented to time ,
place and person, slightly depressed, and lies
comfortably in bed.
Puffy eyelids and puffy face.
Hairs are sparce.
Temp.: elevated up to 40ºC in several occasions, but
no specific pattern.
Pulse: 130bpm during fever.
Lymph nodes: Firm, mobile, nontender in the
Rt. Posterior cervical (2 x 2cm).
Right small supraclavicular.
Left tiny epitrochlear.
Bilateral inguinal largest 1 x 1cm.
UL: no clubbing, no ecchymotic patches.
LL: no edema, no clubbing.
Rt. lobe about 4 cm below costal margin by light percussion.
Lt. lobe about 8 cm below the xiphisternal junction by light
Spleen: 3 cm, smooth surface rounded edge.
No cardiological or pulmonary abnormalities were
♀ pt., 19yrs old, fever for 6mths, relapsing in nature,
easy fatigability, knee arthralgia.
Marked pallor, tachycardia, lymphadenopathy, HSM.
Stool Analysis: Free.
Occult blood in stool: Negative (repeatedly).
Pus cells: 10-15 / HPF
RBCs: 1-2 / HPF
Casts: Hyaline casts + & Granular casts ++
24hrs urine proteins: 1.2g/day
Urine culture: No growth.
WBC: 16.3 x 103/µL RBC: 2.97 x 106/µL
B: 0 HGB: 6.8 g/dL
E: 1 MCV: 65.8 fL
St.: 25 MCH: 22.8 pg
PLT: 476 x 103/µL
ESR: 150 mm (78mm)
Rtx: 0.2 %
WBC: 10.4 x 103/µL RBC: 2.65 x 106/µL
B: 0 HGB: 6.0 g/dL
E: 5 MCV: 67.1 fL
St.: 15 MCH: 22.5 pg
PLT: 242 x 103/µL
ESR: 100mm (46mm)
WBC: 7.9x 103/µL
RBC: 2.73 x 106/µL
HGB: 5.9 g/dL
MCV: 65.7 fL
MCH: 21.8 pg
PLT: 227 x 103/µL
ESR: 55mm (25mm)
WBC: 9.1 x 103/µL RBC: 2.56 x 106/µL
B: 0 HGB: 5.7 g/dL
E:2 MCV: 65.9 fL
St.:2 MCH: 22.5 pg
PLT: 157x 103/µL
Serum iron: 38 µg/dL ( 37 - 145)
TIBC: 539 µg/dL (274 - 385)
Ferritin: >1500 ng/mL (6.0 – 159)
CRP: 55mg/L (up to 3).
Direct Coomb’s test: negative.
Bone Marrow Aspirate
Liver Function Tests (repeated)
AST: 70 U/L
ALT: 4 U/L
AP: 79 U/L
Proteins: 7.8 g/dL
Alb.: 2.9 g/dL
Urea: 16 mg/dL
Creatinine: 0.72 mg/dL
Liver Function Tests
Bil-T: 0.19 mg/dL
AST: 131 U/L
ALT: 31 U/L
GGT: 122 U/L (8 – 61)
AP: 219 U/L
Proteins: 6.6 g/dL
Alb.: 2.3 g/dL
Urea: 13 mg/dL
Creatinine: 0.5 mg/dL
PC = 71%
INR = 1.32
Electrolytes & Minerals
Normal Na & K.
Normal Calcium and Phosphorus.
Searching for Bacteria
ASOT: 166 IU/mL then 125 IU/mL
Widal and Brucella tests were negative.
Blood culture: No growth.
Splenomegaly: longest axis is 16cm, homogenous.
Minimal pericardial effusion.
????? Rheumatic fever.
Empirical Aspirin of 100mg/kg/day for 5 days was tried
with the following results:
Temp. was normal for the 5 days
Still pericardial effusion. Senior cardiologist abolished the
suggestion of rheumatic activity.
HIV : Negative
EBV IgG: 9.5 A.I. (positive > 1.0).
IgG: >250 AU/mL (< 15)
IgM: 0.236 index (N. up to 0.5)
Upper GIT Endoscopy
WHAT TO DO FURTHER???