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					Prof. Dr. Gamal Esmat’s Unit
Unit’s Members
 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
Personal History
 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.
Complaint
 Fever of 6 months duration.
Present History
 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.
Present History
 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
  improvement.

 1mth later she started to develop easy fatigability.
Present History
 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.
Present History
 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.
Past History
 Not known to be diabetic or hypertensive.
 No history of previous operations.
Family History
 No similar conditions in her family.
Examination
 The patient is fully conscious, well oriented to time ,
  place and person, slightly depressed, and lies
  comfortably in bed.
 Marked pallor.
 Puffy eyelids and puffy face.
 Hairs are sparce.
 B.P. 120/80
 Temp.: elevated up to 40ºC in several occasions, but
  no specific pattern.
 Pulse: 130bpm during fever.
Examination
 Lymph nodes: Firm, mobile, nontender in the
 following sites
   Bilateral submandibular.
   Rt. Posterior cervical (2 x 2cm).
   Right small supraclavicular.
   Bilateral axillary.
   Left tiny epitrochlear.
   Bilateral inguinal largest 1 x 1cm.
Examination
 UL: no clubbing, no ecchymotic patches.
 LL: no edema, no clubbing.
 Abdomen:
   Liver:
     Rt. lobe about 4 cm below costal margin by light percussion.
     Lt. lobe about 8 cm below the xiphisternal junction by light
      percussion.
   Spleen: 3 cm, smooth surface rounded edge.
 No cardiological or pulmonary abnormalities were
  detected.
Summary
 ♀ pt., 19yrs old, fever for 6mths, relapsing in nature,
  easy fatigability, knee arthralgia.
 Marked pallor, tachycardia, lymphadenopathy, HSM.
Investigations
  Stool Analysis: Free.
  Occult blood in stool: Negative (repeatedly).
  Urine analysis:
     Proteiuria +++
     Pus cells: 10-15 / HPF
     RBCs: 1-2 / HPF
     Casts: Hyaline casts + & Granular casts ++
  24hrs urine proteins: 1.2g/day
  Urine culture: No growth.
CBC (21-2-2007)
 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
   Seg.: 67
                        PLT: 476 x 103/µL
   L: 6
                        ESR: 150 mm (78mm)
   M: 1
                        Rtx: 0.2 %
CBC (26-2-2007)
 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
   Seg.: 71
                        PLT: 242 x 103/µL
   L: 10
                        ESR: 100mm (46mm)
   M: 1
CBC (1-3-2007)
 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)
CBC (7-3-2007)
 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
   Seg.: 53
                       PLT: 157x 103/µL
   L: 40
   M:3
Iron Studies
 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
Coagulation Profile
 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.
 Tuberculin: Negative.
 Blood culture: No growth.
Abdominal US
 Bright Hepatomegaly
 Splenomegaly: longest axis is 16cm, homogenous.
CXR
 Normal.
Echocardiography
 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.
Autoimmune Profile
 RF: negative.
 ANA: negative.
 Anti-Sm: negative.
 Anti-dsDNA: negative.
Viral Markers
 HBsAg: negative.
 HCV-Ab: negative.
 HIV : Negative
 EBV IgG: 9.5 A.I. (positive > 1.0).
 CMV:
    IgG: >250 AU/mL (< 15)
    IgM: 0.236 index (N. up to 0.5)
 TSH: Normal.
Upper GIT Endoscopy
 Normal findings.
WHAT TO DO FURTHER???

				
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posted:5/4/2011
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