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MEDICINE 2 PAPER

CASE

Reyes Salcedo Santos Serafica Suarez


Ruiz Sangca Sarte Sevilla
Suficiencia
CASE
CASE
J.C. 45/M Filipino, married from Pandacan, Manila
Brought to consult due to fever and oliguria

CC: Oliguria

HPI
Px is known diabetic for yrs w/o maintenance
Not known hypertensive
W/o other co-morbidites
CASE
HPI
He has no known recent travel abroad or to local
provinces
No current exposure to domestic or wild animals
No hx of wading in flood or canal water but admits to
have indirect exposure to rodents which inhabit nearby
places
CASE
7 days PTA
Undocumented fever with associated body malaise,
No cough, chest pain, headache, abdominal pain,
jaundice, diarrhea, melena, hemaochezia,
nausea/vomiting and hematemesis
Patient just take Paracetamol and/or Ibuprofen every 6-8
hrs with temporary lysis of fever but only to recur
several hrs after
Px still did not seek consult and continued his work
CASE
In the interim
Undocumented fever was intermittent,
Still no consult
Still take same meds

On succeeding days
Onset of calf pains
No intermittent claudications, cyanosis, dypsnea,
crackles, dysuria, oliguria
CASE
At the day of admission
Still with undocumented fever, myalgia, calf pain
Noted decrease in urine output which was ~less than a
cup
CASE
Past Medical Hx
+ PTB treatment completed (2013, DOTS)
(-) bronchial asthma
(-) allergies to food/meds
(-) known malignancy
(-) previous surgery
CASE
Family Hx
(-) DM, HPN, CAD/CVD
(-) malignancy
(-) hepatitis/PTB
(-) autoimmiune/rheumatologic diseases
(-) other heterofamilial disease
CASE
Personal/Social Hx
Nonsmoker
Alcoholic beverage drinker (~50g/occasion once a week
for 5 years)
Denies illicit drug use
Has one female, heterosexual partner, Filipino, with no
promiscuous sexual history
CASE
ROS
(-) recurrent headache
(-) coughs/colds
(-) dyspnea
(-) orthopnea
(-) polyuria
(-) weight loss

(-) chest pain


(-) abdominal pain
(-)PND
(-) polydipsia
(-) blurring of vision
(-) palpitations

(-) bowl changes


(-) dysuria
(-) joint pains
CASE
Physical Examination
General
Awake, coherent, not in distress, no jaundice, no rashes
VS: BP: 100/80
HR: 108
RR: 18
Temp: 39.1 degree Celsius
O2 Sat % = 98%
CASE
HEENT
Anincteric sclerae, no conjunctival suffusion, pink
palpebral conjunctiva
No cervical lymphadenopathy, no nasaaural discharge,
dry lips, and oral mucosa,
No anterior neck mass
Flat neck veins and no bruit
CASE
Chest /Lungs
Equal chest expansion, no retractions, bronchovesicular
breath sounds

Heart
Adynamic precordium
PMI at 5th ICS LMCL,
Tachycardic, regular rhythm, no murmurs
CASE
Abdomen
Flat, soft, nontender and normoactive bowel sounds
No masses, no organomegaly
No CVA tenderness, no bladder distention

DRE
No external haemorrhoids, no anal fissures, good sphincter tone
Intact rectal vault, no masses, no fecal material on examining finger

Extremities
Full equal pulses, no edema and no cyanosis
CASE
Neuro Cranial Nerves
CN I Smells coffee
CN II Both pupils are reactive to light (3mm 2 mm)
CN III, IV, VI Intact and full EOM
CN V V1-V3 intact
CN VII No facial asymmetry
CN VIII Intact gross hearing
CN IX, X Good gag reflex
CN XI Equal shoulder shrug
CN XII Tongue in the midline upon protrusion
CASE
Neuro Motor
5/5 5/5
5/5 5/5

Neuro Sensory
100 100
100 100
CASE
Neuro - Reflexes

Reflexes are normal (++)


(-) Babinsky reflex, L
(-) Nuchal rigidity
(-) Primitive reflexes
CASE
CBC Clin Chem UA

WBC 14.9 BUN 4.7 Color Yellow


Crea 105 (H)
Neut 61.7 Transparency Slightly
Na 131 (L) turbid
Lymp 23.4
K 3.6 Epith cell Few
Mono 14.9
Cl 94 (L) Mucus Threads Few
RBC 5.8
Alb 35
Hgb 15.8 AU None
Ca 2.16 (L)
Hct 46.3 AP
Mg 0.82
MCV 79.8 CreaCl WBC 1-2
MCH 27.2 ALT RBC 0-1
MCHC 34.1 AST Albumin +2
RDW BUA
Sugar +3
Platelet 107 FBS
SG 1.03
Retic Count TG
TC pH 6.0

Bacteria Few
SALIENT FEATURES
PERTINENT POSITIVES PERTINENT NEGATIVES
HISTORY OF PRESENT ILLNESS HISTORY OF PRESENT PAST MEDICAL HISTORY
Diabetic for 5 yrs with no maintenance ILLNESS No allergies to food
meds Not hypertensive and meds
Indirect exposure to rodents No other co-morbidities
No known malignancy
Undocumented fever with body malaise No history of travel
Onset of calf pain No current exposure to No previous surgery
Myalgia domestic or wild
Decrease in urine output animals PHYSICAL EXAMINATION
No history of wading in No jaundice
PAST MEDICAL HISTORY flood or canal water No rash
PTB Tx completed (2013, DOTS) Anicteric sclerae
REVIEW OF SYSTEMS No conjunctival
REVIEW OF SYSTEMS No recurrent headache suffusion
(+) Blurring of vision No cough and colds
No cervical
No dyspnea nor
orthopnea lymphadenopathy
No dysuria nor polyuria No cardiopulmonary
No joint pains changes
No abdominal pain No abdominal changes
No bowel changes No peripheral changes
No weight loss No nuchal rigidity
APPROACH TO
DIAGNOSIS
(-) cough/colds
APPROACH TO DX (-) abdominal
changes

Leptospiro
sis
Fever, Body malaise, Bacterial
Typhoid
fever
Non Flu
Myalgia

infectious
Viral Dengue
Infectious
Chikungun
ya
Parasitic Malaria

Fungal
DIFFERENTIAL
DIAGNOSES
DENGUE
RULE IN RULE OUT
Fever (-) skin rash
Body Malaise (+) calf pains
Oliguria (-) headache
Myalgia (-) nausea and vomiting
(-) abdominal pain
Decreased platelet concentration (-) hematochezia
(-) hematemesis
(+) Leucocytosis

Normal Hct

RULE OUT
World Health Organization, Special Programme for Research, Training in Tropical Diseases, World Health Organization. Department of Control of Neglected
Tropical Diseases, World Health Organization. Epidemic, & Pandemic Alert. (2009).Dengue: guidelines for diagnosis, treatment, prevention and control.
World Health Organization.
MALARIA
RULE IN RULE OUT
Fever (-) Chills
Oliguria (-) Sweating
Body malaise (+) Calf pains
Myalgia (-) abdominal pain
(-) history of travel

(-) anemia
Normal Hct
RULE OUT

World Health Organization. (2015).Guidelines for the treatment of malaria. World Health Organization.
CHIKUNGUNYA
RULE IN RULE OUT
Fever (+) Oliguria
Myalgia (+) High Crea
Calf Pain
Leukocytosis
Low Platelet Count

RULE OUT

016). Chikungunya virus Symptoms. Retrieved from https://www.cdc.gov/chikungunya/symptoms/index.html. Retrieved on Sept.6, 2017
LEPTOSPIROSIS
RULE IN RULE OUT
Indirect exposure to rodents (-) Jaundice
Fever (-) Anemia
Myalgia
Calf Pain
Oliguria
Leucocytosis
Low platelet count
High Creatinine
Blurring of Vision*
CANNOT BE RULED OUT

*Leptospirosis Clinical Practice Guidelines (2010), PSMID, PSN and PCCP


*Ghosh, S., Das, R., Saha, M. and Das, D., (2011) J Clinic Experiment Ophthalmology. Neuroretinitis as an Unusual
Manifestation of Leptospirosis: A Case Report. R. G. Kar Medical College, Kolkata, WB, India. Regional Institute of
Ophthalmology, Guwahati, Assam, India Retrieved from http://dx.doi.org/10.4172/2155-9570.1000124 Retrieved on
Sept. 6, 2017
WORKING
DIAGNOSIS
LEPTOSPIROSIS
Leptospirosis is a globally important zoonotic disease
caused by pathogenic Leptospira species
It Is endemic in the Philippines with an average of 680
cases and 40 deaths every year (2010)
Feral and domestic animals constitue the reservoir of
the agent, transmitted through contact of mucous
membranes or broken skin.
SUSPECTED CASE
Any individual presenting with acute febrile illness of at least
2 days AND either residing in a flooded area or has high-
risk exposure AND presenting with at least two of the following:
Myalgia
Calf tenderness
Conjunctival suffusion
Chills
Abdominal pain
Headache
Jaundice
Oliguria
PRESUMPTIVE DX
(+) Rapid screening test such as IgM ELISA, latex agglutination
test, dipstick

CONFIRMATORY DX

Isolation from blood or other specimen through culture


(+) PCR
4x or greater rise in titer or seroconversion in MAT on paired
samples obtained atleast 2 weeks apart
MILD LEPTOSPIROSIS
IP is usually 1-2 weeks but ranges from 1 30 days
Any suspected case + acute febrile illness and various
manifestations BUT with stable vital signs, anicteric
sclerae with good urine output and no evidence of
meningismus/meningeal irritation, sepsis/septic shock,
difficulty of breathing nor jaundice and can take oral
medications
Can be managed in an out-patient setting
SEVERE LEPTOSPIROSIS
Any suspected case + acute febrile illness associated
with unstable vital signs, jaundice/icteric sclerae,
abdominal pain, nausea, vomiting and diarrhea,
oliguria/anuria, meningismus, sepsis/septic shock,
altered mental states or difficulty of breathing and
hemoptysis (MOD-SEVERE)
Best managed in healthcare/hospital setting
SEVERE LEPTOSPIROSIS
Weils syndrome
Jaundice (Occurs in 5-10%)
Renal dysnfunction
Hemorrhagic diathesis
Case fatality rate from 1-50%
PATHOPHYSIOLOGY
Main pathogenesis of Leptospirosis: CELLULAR TOXICITY
- Inflammatory Causing:
Release of: Response and
- Necrosis
increase in
- Leptospiral Vascular - Endothelial
phospholipase, Permeability Edema
Endotoxin and - Lymphocytic
Enzymes - Capillary infiltration
Damage and
Vasculitis
Capillary Vasculitis appears to be the pathology for most of the
manifested by endothelial edema, necrosis, and lymphocytic
infiltration.
Loss of RBCs and fluid through enlarged junctions and fenestrae,
which cause secondary tissue injury, accounts for many of the clinical
findings.
PATHOPHYSIOLOGY
Leptospira enters the human
body, and causes direct invasion
of tissues.

Release of Leptospiral Inflammatory Response


and FEVER.
phospholipases, Endotoxins and
Enzymes

Loss of RBCs and fluids via enlarged
junctions and fenestrae

Capillary Vasculitis
PATHOPHYSIOLOGY
Capillary Vasculitis

- Tubular Necrosis & - Edema, & Myofibril -Centrilobular necrosis in the


Interstitial Nephritis vacuolation, vessel liver and hepatocellular
damage dysfunction
- Hypovolemia and
altered capillary - Alveolar and interstitial
permeability Damage to contractile vascular damage.
apparatus

Decrease Urine Output Calf pain


TREATMENT &
MANAGEMENT
Criteria for Admission
Acute febrile illness with
Unstable vital signs
Jaundice/icteric sclerae
Oliguria/anuria
Meningismus / Meningeal Irritation
Sepsis/septic shock
Altered mental status
Difficulty of breathing
Hemoptysis
Monitor for development of severe
leptospirosis
Liver function tests (AST/ALT ratio >4x; Bilirubin >
190 umol/L
Bleeding parameters (prolonged prothrombin time
<85%)
Serum potassium (>4 mmol/L)
Arterial blood gas (severe metabolic acidosis)
Chest radiograph (extensive alveolar infiltrates)
Electrocardiogram (signs of heart block,
myocarditis, repolarization abnormalities)
Tx : MILD LEPTOSPIROSIS
DOC: Doxycycline
Alternative Drug:
Amoxicillin
Azithromycin dihydrate ( Grade B)

Tx: MOD-SEV LEPTOSPIROSIS


DOC: Penicillin G
Alternative Drug
Parenteral Ampicillin
3rd Gen Cephalosporins (cefotaxime, ceftriaxone)
Parenteral Azithromycin dihydrate ( Grade A)
FLUID
RESUSCITATION
Antibiotics Recommended for
Leptospirosis
Antibiotics Recommended for
Leptospirosis w/ Renal Impairment
Should be completed for 7 days except for azithromycin
dihydrate which should be given for 3 days (Grade A)
Antibiotic therapy should be started as soon as the
diagnosis regardless of the phase disease or duration of
symptoms
Management of Co-
morbidities
Monitor hyperglycemia
Prescribe maintenance medications for diabetes
Lifestyle changes
COMPLICATIONS
&PROGNOSIS
COMPLICATIONS
Renal
Pulmonary
LEPTOSPIROSIS-ASSOCIATED
AKI
Acute kidney injury (AKI) is one of the major
complications of leptospirosis. The incidence varies from
10 % to 60 %
Its presence is a marker of severity and is an
indication for hospitalization as it may portend a poorer
prognosis
CLINICAL FEATURES OF LAAKI
Features may span from mild proteinuria to severe
anuric acute renal failure
Possible clinical presentations:
Non-oliguric renal failure w/ mild hypokalemia
Oliguria w/ hypekalemia (POORER PROGNOSIS)
PATHOLOGY OF LAAKI
Combination of:
Acute tubular damage
Tubulo-interstitial nephritis
Tubular dysfunction usually leads to hypokalemia and
polyuria
PULMONARY COMPLICATIONS
The incidence of pulmonary involvement varies, but
ranges from 20-70%
There is a pronounced male predominance due to
outdoor activity during heavy rainfall and flooding
However, with the increasing female social roles more
cases are now reported in women.
Leptospira interrogens bataviae is the most common
serotype seen in patients with pulmonary involvement
LAB FINDINGS IN LAAKI
Creatinine 3 mg/dL
Platelet count - < 70000 u/L
Oliguria
Hyponatremia
Hypokalemia
Pyuria
Hematuria
Proteinuria
Crystalluria
Increased serum or urine NGAL
X-ray: ARDS or pulmonary hemorrhage
CLINICAL DX OF PULMO
COMPLICATIONS
Tachypnea (RR:>30/min) 1st sign of pulmonary
involvement
Cough
Hemoptysis
Dyspnea
Pulmonary symptoms usually appears between 4th and
6th day of disease
PREDICTORS OF PULMO
COMPLICATIONS
Delayed antibiotic treatment
Thrombocytopenia at the onset of the disease
FEATURES OF PULMO COMPLICATIONS
Longer duration of fever at presentation
Platelet count - < 100 x10^9 L
Serum creatinine > 177 umol/L
Bilirubin - > 34.2 umol/L
TYPES OF PULMO COMPLICATIONS
Pulmonary hemorrhage
Acute Respiratory Distress Syndrome (ARDS)
Both are associated with worse prognosis and high mortality
PULMONARY HEMORRHAGE (DAH)
Presentation
Hemoptysis (main manifestation)
Dyspnea
X ray: alveolar infiltrates
Vary from mild to severe
Pathogenesis
Deposition of IgG, IgA and C3 along the alveolar basement
membrane -> Inflammation and eventual disruption of the
vascular endothelium -> increase in permeability -> alveolar
bleeding
PULMONARY HEMORRHAGE (DAH)
Physical Examination:
Tachypnea
Crackles
Rhonchi
Wheezing
Cyanosis
ACUTE RESPIRATORY DISTRESS
SYNDROME
Characterized by impairment of the alveolar-capillary barrier
Presentation:
Dyspnea
Fever
Myalgia
Jaundice
Hemoptysis
Cough
Elevated serum bilirubin
Anemia
Leukocytosis
Thrombocytopenia
Elevated prothrombin time
Acidosis
X-ray: bilateral pulmonary infiltrates
PROGNOSIS
Most pxs with leptospirosis recover
Post-leptospirosis may occur and persist for years after
acute disease
Mortality rates are highest among pxs who are elderly
and those who have severe disease
END
MEDICINE 2 PAPER
CASE
MEDICINE 2 PAPER
CASE

Reyes Salcedo Santos Serafica Suarez


Ruiz Sangca Sarte Sevilla
Suficiencia