Académique Documents
Professionnel Documents
Culture Documents
General Data:
R.A., 31 y/o male, married balikbayan, native of Isabela was admitted on Dec. 22, 1995.
HPI:
While in the USA working as a clerk at Mt. Sinai Hospital in Chicago, the patient was diagnosed to
have cysticercosis in October 1995 in the USA and was now treated with tapering doses of Dexamethasone.
He developed diarrhea on Nov. 26, 1995, while still in the US, which persisted until he arrived in the
Philippines on Nov. 29, 1995. He first stayed in Navotas, and then proceeded to Isabela, where he was
confined at a hospital for persistence of diarrhea, despite taking antidiarrheals. Another consult for
persistence of diarrhea was made. The management consisted of IV fluid rehydration. The diarrhea ceased
temporarily, but was replaced by nausea, vomiting, abdominal distention and fever, prompting transfer to our
institution.
PMH:
Labile hypertension and elevated BUN – 1 year PTA, for which he was taking Atenolol and
Allopurinol.
PE:
BP= 90/60, HR= 104 bpm, RR = 21 cpm, T = 37.3°C
General Survey:
Weak looking, fairly nourished, well-developed male, conscious, coherent, oriented to time, place
and person. He appears his chronologic age of 31 years.
Skin: No abnormalities noted.
Head: Moon Facies noted
Eyes: Right and Left: pupils 2-3 mm equally reactive to light, EOMs intact, (+)
ROR, (-) for hemorrhage, exudates
Ears: Right and left: Rinne AC>BC, Weber midline
Nose: no gross deformity
Throat Tonsils not enlarged, (-) exudates
Chest and Lungs: symmetrical chest expansion, no retractions, bronchovesicular breath sounds
CVS: adynamic precordium, normal rate, regular rhythm, no murmurs
Abdomen: distended, hypoactive bowel sounds, tympanitic and tenderness all over
Extremities: with muscle wasting and grade II bipedal edema
Neurologic Exam: no abnormalities noted
2nd CPC 1
Lab Work ups:
Urinalysis
Color Yellow
pH 6.0
Specific gravity 1.010
Sugar Negative
Albumin Negative
RBC 0-1/HPF
WBC 0-1/HPF
Epithelial Cells Rare
Casts negative
Fecalysis
Color Dark brown
Consistency Formed
RBC Negative
WBC Negative
Mucus Negative
Ova and Parasites Negative
Clinical Chemistry
Patient’s Result
Na 134 mmol/L
K 3.8 mmol/L
Cl 90 mmol/L
LDH 184 U/L
AST 29 U/L
ALT 6 U/L
Ca 1.8 mmol/L
Total Bilirubin 11.9 umol/L
Total Protein 32 g/L
Albumin 14 g/L
Globulin 18 g/L
Cholesterol 1.6 mmol/L
RBS 7.2 mmol/L
CK 55 U/L
Phosphorus 0.9 mmol/L
Alkaline Phosphatase 15 U/L
Uric Acid 0.27 mmol/L
BUN 1.6 mmol/L
Creatinine 44 umol/L
EEG: Normal
Proctosigmoidoscopy
Anus: external hemorrhoids
Rectum: no mass
Procto: scope inserted up to 25cm. The mucosa is rough, bumpy, with patches of chronic and acute
inflammatory changes. Exudates noted.
Impression: Colitis r/o dysentery
2nd CPC 2
Impression: Multiple duodenal and gastric ulcers with gastritis and duodenitis.
X-rays:
Chest: haziness, left base, with blunting of costophrenic angle. Impression: Pneumonia, left base.
Follow-up Chest X-ray: right parahilar densities increasing in size, probably secondary to pneumonia.
Abdomen (supine and upright): slight dilatation of small and large bowels. Impression: Paralytic ileus.
KUB: no localizing signs
Lungs
- Focal areas of necrosis and hemorrhages
- Polymorphonuclear infiltrates
o Interstitial pneumonia with severe superimposed bronchopneumonia
- Septated hyphae with mycelia
o Hemorrhagic infarcts Hyphae within the blood vessels
o Recent organizing thrombi
- Acute Respiratory Distress Syndrome
Esophagus
- Focal areas of erosions mostly on distal third
Stomach
- Blood all over mucosal surface with focal areas of erosions, antrum severely eroded
Small Intestines
- Worms in duodenum
o Severe infestations of adult worms measuring 2.0 to 4.0 mm.
o Foreign Body giant cells around infested crypts
- Worms in the jejunum
Large Intestines
- Severe congestion with occasional ulcers and infiltrated mainly by mononuclear cells. Lymph
vessels dilated causing lymphangiectasias
Spleen
- Normal
Liver
- Moderate fatty changes
Heart
- Occasional hypertrophy of muscles fibers with focal interstitial fibrosis
Kidneys
- Except for congestion, microscopic sections were normal
Adrenals
- Unremarkable
Brain
- areas of necrosis with histiocytic infiltrates at the region of pontine, nuclei and longitudinal fibers of
the cortico-spinal and cortico-bulbar tract with small recent hemorrhages of the pons
2nd CPC 3
4. Recent small hemorrhages, Pons with areas of recent necrosis and histiocytic infiltrates at
the region of pontine nuclei and longitudinal fibers of the cortico-spinal and cortico-bulbar
tract
Pathophysiology
Just some additional notes taken during the “super fast” lecture.
- CBC: Eosinophilia is not elevated in Capillariasis
- Distal 3rd of the jejunum was affected
- The patient had Diffused Epithelial Damage
- Cause of Death: Hypovolemic Shock
- Drug of Choice for Capillariasis: Mebendazole and Albendazole
- The patient had a Class II hemorrhage
Capillariasis (from Harrison’s because I can’t find anything in Robbins, I’m so sorry.)
- Caused by ingestion of raw fish infected with Capillaria philippinensis
- Autoinfection can lead to severe wasting syndrome
- Occurs in the Philippines, Thailand and elsewhere in Asia
- Involves fish from fresh and brackish water.
- When humans eat infected raw fish, the larvae matures in the intestines into adult worms, which
produce invasive larvae that cause intestinal inflammation and villous loss.
- It has an insidious onset with nonspecific abdominal pain and watery diarrhea
- If untreated, progressive autoinfection can lead to protein-losing enteropathy and severe
malabsorption and ultimately to death from cachexia, cardiac failure, or superinfection.
- The diagnosis is established by identification of the characteristic peanut-shaped (20 by 40 um) eggs
on stool examination. Severely ill patients require hospitalization and supportive therapy in addition
to prolonged anthelmintic treatment with mebendazole or albendazole.
Guys, please read your robbins on each disease the patient had, as well as the cause of
death… thanks
2nd CPC 4