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Pathology Conference

Pathology Conference. Presented by F1 潘恆之 Commented by Dr. 薛綏 2011/08/24. Case 1: 9578264 Case 2 : 20690936. Case 1: 9578264. General Data. Age: 57-year-old Gender: Male Ethnic: Taiwanese Marital status: Married Occupation: Worker Admission date: 2011/05/13. Chief Complaint.

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Pathology Conference

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  1. Pathology Conference Presented by F1 潘恆之 Commented by Dr.薛綏 2011/08/24

  2. Case 1: 9578264Case 2: 20690936

  3. Case 1: 9578264

  4. General Data • Age: 57-year-old • Gender: Male • Ethnic: Taiwanese • Marital status: Married • Occupation:Worker • Admission date: 2011/05/13

  5. Chief Complaint • Progressive bilateral lower legs swelling for 1 month

  6. Present Illness • This 57-year-old male has diagnosed as a victim of diabetes mellitus and hypertension in 2011/02. • He suffered from progressive bilateral lower legs swelling for 1 month, accompanied with poor appetite, abdominal fullness, decrease urine amount, and foamy urine. Mild nausea sensation and dyspnea also developed since 2 weeks before this admission.

  7. At the beginning, he visited 大千 hospital, where nephrotic syndrome was diagnosed. • Then the patient was referred to our nephrologic and ophthalmic clinic for help. Diabetic retinopathywas diagnosed by our ophthalmologist. Lab data showed heavy proteinuria, hypoalbuminemia, dyslipidemia, decreased IgG and elevated IgE level. • However, bilateral lower legs swelling progressed in spite of diet restriction andmedicationgiven. So the patient was admitted to 桃園長庚 for further management.

  8. Past History • Hypertension was diagnosed in 2011/02 • Type 2 diabetes mellitus was diagnosed in 2011/02

  9. Medication History • 2011/04/07 Nephro OPD • Furosemide (40mg) --------- 2# QD • Sennoside (12mg) ----------- 2# HS • Metoclopramide (3.84mg)-- 1# TID • 2011/04/28 Nephro OPD • Furosemide (40mg) --------- 3# BID • Sennoside (12mg) ----------- 2# HS • Exforge (Amlodipine 5mg + Valsartan 80mg) ---------------------------------- 1# QD • Rosuvastatin (10mg) ------- 1# QD

  10. Medication History • 2011/04/15 Meta OPD • Glucomet (Glyburide 5mg + Metformin 500mg) -------------------------------- 2# QD

  11. Personal History • No known allergy to drugs or food • Smoking: 1PPD for 10+ years • Alcohol: heavy drinker, quit for 6 months • Betel nuts chewing: quit for 10 years

  12. Physical Examination • Vital signs: BT:37.3/℃ HR:84/min RR:20/min BP:227/153mmHg • General appearance: fair • Consciousness: alert and oriented • HEENT: conjunctiva: not pale, sclera: anicteric • Chest: symmetrical expansion, bilateral clear breathing sounds. • Heart: regular heart beats, no murmurs. • Abdomen: soft and flat normal bowel sounds, shifting dullness (+) • Extremity: freely movable, bilateral legs grade III pitting edema

  13. Laboratory Findings

  14. *

  15. 2011/04/14(OPD) Kidneys echo Left Kidney Length: 12.7cm / Right Kidney Length: 12.8cm The contour of both kidneys are normal. The cortical echogenicity is mildly increased with adequate cortical thickness. The pelvocalyceal systems are not dilated. There is no stone, mass or cyst. Impression: Bilateral large kidneys.

  16. 2011/05/13CXR

  17. Admission course 05/13 ~ 05/20 Taoyuanordinary ward * 5/20 S/S: Spiking fever with chills and shock => Colloid fluid hydration, Teicoplanin + Fortum, inotropic agent  TaoyuanICU (05/20) • 05/20~05/26 TaoyuanICU • S/S: fever, abdominal fullness • 05/23 Whole body CT • Consult GS : suggest MRCP • Consult INF: a. shift antibiotics to Tienam • b. arrange Cardiac 2D echo • for FUO survey • c. Check tumor markers • Transffer to Linkou 8D ward

  18. Admission course • 05/26 ~ 06/24 8D ward • S/S: Intermittent mild fever and mild epigastralgia* • 5/30 PES: Erythematous gastritis and duodenitis • 5/30 Gallium-67 scan: probably infection/ inflammatory response over LLL and probably reactive lymphadenopathy over mediastinum • 6/07 MRI: Pleural effusion, ascites, cholecystopathy, bilateral edematous kidneys 06/21Arrange renal biopsy 06/24Discharge

  19. Diagnosis • Membranoproliferativeglomerulonephritis • Cholecystopathy, favor cholecystitis • Septic shock episode, favor intra-abdominal infection due to cholecystitis • Diabetes mellitus with diabetic retinopathy and nephropathy

  20. Discussion

  21. Case 2: 20690936

  22. General Data • Age: 44-year-old • Gender: Male • Ethnic: Taiwanese • Marital status: Married • Occupation: Worker • Admission date: 2011/08/14

  23. Chief Complaint • Intermittent high fever for one week.

  24. Present illness • This 44-year-old male has unremarkable medical history before. • This time, he had experienced intermittent fever up to 40 centigrade, accompanied with thrombingheadache, general weakness, bilateral flank soreness, mild dyspnea, severe sore throat, mild cough since 08/07. Intermittent abdominal cramping pain, vomited with dark-green vomitus, and decreased urine output developed since 08/10. • He denied dizziness, diplopia, chest pain, tarry stool , bloody stool or leg swelling.

  25. Tracing back history, he had just visited 苗栗法華寺 and got insect bite (mosquitoe and leech) on 07/30. There was no recent drug or toxin intake episode but he had some volatile chemicalexposure on 08/06. No other family member or colleague had similar symptoms. • Due to above, he had came to local hospital for help several times where progressive deteriorated renal function was noted. Under personal factors, he was transffered to our ER for further management.

  26. Past History • Denied hypertension, diabetes mellitus or other systemic diseases

  27. Personal History • No known allergy to drug or food • He denies smoking, alcohol, or betel nut chewing.

  28. Physical Examination • Vital signs: BT:37.3/℃ HR:84/min RR:18/min BP:126/71/mmHg • General appearance: fair • Consciousness: alert and oriented • HEENT: conjunctiva: not pale, sclera:anicteric • Chest: symmetrical expansion, bilateral clear breathing sounds. • Heart: regular heart beats, no murmurs. • Abdomen: soft and flat normal bowel sounds • Extremity: freely movable, no pitting edema.

  29. Laboratory Findings

  30. 2011/08/14 CXR

  31. 2011/08/14 Abdominal CT • Impression: No renal stone or hydronephrosis in both kidneys. APN was less likely.

  32. Admission course – 0/8/14~08/19 • 08/14 ER  8D ward • S/S: fever, nausea vomiting • Rocephin 1g q12h • 08/15 • Arrange kidneys echo • 通報leptospirosis, Q fever, srub typhus, • murine typhus • Rocephin 1g q12h + Doxycyline 100mg BID 08/16 S/S: Fever subsided, no nausea nor vomiting => Arrange renal biopsy *

  33. Admission course – 0/8/14~08/19 • 08/18 • BUN/Cr:27.4/1.66, AST/ALT:41/61, Bil(T):0.2 • CDC report: LeptospiralIgM– positive • Pathology report: tubulointerstitial nephritis • 08/19 • Discharge • Cefuroxime 250mg BID • + Doxycycline 250mg BID x 3 days

  34. Diagnosis • Tubulointerstitial nephritis due to leptospirosis

  35. Discussion

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