1. Clinical cases from infection
diseases hospital
Part 4
Pavlov State Medical University,
St-Petersburg, Russia
Dr. Andrey Dyachkov
E-mail: cd4@inbox.ru

2. Botkin's hospital was found in 1882

5. Clinical case — Just do it!

6. Case 6: 31 y.o. with haemorrhages in scleras

Time of admission: 15 of April 2012

Complains at admission: high fever, moderate pain in
eyes, residual changes in sclearaes of both eyes
(minimal haemorraghes around iris).

Anamnesis morbi: at 8 of April 2012 patient noticed
fever and pain in eyes which was accompanied by
moderate periorbital edema
and haemorraghes in sclerae
of both eyes. At 9 of April
patient visited ophtalmologist
who prescribed himt an eye
drops with vitamins and told
him that his complains were
related to stress and adviced
him to visit neurologist.

7. Case 6: 31 y.o. with haemorrhages in scleras

Same day patient had visited neurologist who
recommended him to make MRI of a brain. MRI
revealed no significant changes.

At the evening of 9 of April fever had reached 40C,
patient took 1 gr of paracetamol and call
ambulance. By the time doctor arrived fever
decrease to 37C, doctor from ambulance service
told patient he never saw such significant
haemorrages in scleares and recommended
patient to visit infection disease spaecialst (IDS).

Patient visited IDS at 10 of April with complains on
haemorrages in sclera, moderate muscle pain and
fever. Fever raised up to 38-39C and responded to
antipyretics for a short time.

8. Case 6: 31 y.o. with haemorrhages in scleras

IDS ask patient to do a number of tests including
tests for herpes simplex infection of the eyes, but
patient refused to do tests and went home.

For 3 days he stayed at home with high fever
(patient took paracetamol with timely effect),
haemorraghes in scleares gradually decreased.

At 5th day of disease patient visit GP and give
blood for general blood count. No changes in
treatment was made by GP.

Despite of a fever next day he was able to visit his
friend wedding ceremony where he felt generally
weak and didnt have appetite.

On next slide a photo from this ceremony

10. Patient' eyes at 5th day of disease

11. Patient right eye at 10 day of disease

12. Patient right eye at 10 day of disease

13. Case 6: 31 y.o. with haemorrhages in scleras

Epidemiological data: 10 days before patient got ill he
went for a barbique with his wife, daughter and his friend
with bribe. For barbeque they had bought a fresh pork
meat in one of the city' supermarket.

2 days after barbeque patient' wife had diarrhea for 2
days.

7 days later patient friend developed high fever,
moderate muscle pain and periorbital edema.

Patient' daughter and his friend'
bribe had no problem with health.

14. Case 6: 31 y.o. with haemorrhages in scleras

Physical examination: patient looks generally well,
179cm/82kg, skin was clear.

Blood pressure 120/70 mmHg, pulse 83 per minute,
arythmic with few extrasislols

Lungs were clear. No dyspnea.

Liver and spleen was normal in size. Palpation of abdomen
was unpainful.

24 hours urine volume and urine color were normal.

Meningeal symptoms were negative.

Palpation of muscles was unpainful.

15. Case 6: 31 y.o. with haemorrhages in scleras

General blood count 12 of April:

WBC 14,5, RBC 3,45, HGB 13,5 g/dl, EOS 38%,
LYMP 11%, left shift (+)

General blood count 15 of April:

WBC 20,3, RBC 4,1, HGB 13,9 g/dl, EOS 42%,
LYMP 2%, left shift (+)

ALT 35 E/l (N below 40E/l), AST 42 E/l (N below
40E/l), Creatinine phoshocinase 856 E/l (N below
175 E/l), LDH 535 E/l (N below 235 E/l)

16. What is a diagnosis?

23. Paget's disease of bone is a chronic disorder that can result in
enlarged and misshapen bones. The excessive breakdown and
formation of bone tissue causes affected bone to weaken,
resulting in pain, misshapen bones, fractures, and arthritis in the
joints near the affected bones.

24. Case 6: Trichinellosis
- Patient' serology was higly positive for
antibody against Trichinella spiralis.
Later his friend who made barbeque with
him ( look at epidemiology slide) had
same result.
- Trichinella spiralis Own — a nematoda
worm and 5 species of Trichinella
described they are distributed among
carnivorous on all continents
- Adult: Female 4 mm*0,06 mm Male
1,5mm*0,03mm
- Adult live in small intestine for around 2
months, lavrae can survive in striated
muscles for many years

25. Case 6: Trichinellosis

26. Case 6: Trichinellosis

27. Case 6: Trichinellosis
• Adult live in small intestine for
up to 2 months and produce
handreds of larvaes
• After reaching bloodflow larvae
spreaded through different
tissues specifically striated
muscles (but also heart, lungs,
brain) and entering muscle cell
where forming a cyst
• Larvae stimulate angiogenesis
in the area around it and
causing formation of a hyaline
capsule
• After 6 months calcification
takes place

28. Case 6: Trichinellosis
- GI phase usually developed in 12-48
hours after eating infected meat and
accompaning by nausea, vomiting,
diarrhea and abdominal discomfort.
- Within a 3 weeks later due to spreading
of a lavras from small intestine through
bloodflow and lymphatic vessels patient
might develope fever, fascial edema,
hemorrhages in sclerae, MUSCLE PAIN,
heart failure, respiratory symptoms and
meningoencephalitis.
- There is usual eventual complete
recovery in most patients but mascular
pain (60%), fatigue (25%) and heart pain
may persist for 1-6 years.

29. Case 6: Trichinellosis
- Diagnosis is based on:

epidemiological data (eating a
undercooked meat, especially pork,
boar or bear),

high eosinophilia (up to 90%),

serological tests (ELISA)

muscle biopsy (usually from biceps)
- Treatment: 10 days of albendazole (400
mg bid) or mebendazole (200 mg bid)
or thiabendazole (25 mg/kg bid)
together with corticosteroids.
- Prevention: trichinelloscopy of meat,
hygienic pig farming, apropriate
cooking of meat

30. •
More cases - http://www.slideshare.net/drandreyst-
p/clinical-cases-from-infection-diseases-hospital