Download fever와 drowsy mentality를 주소로 내원한 45세 남자환자

MGR
fever와 drowsy mentality로
내원한 45세 남자
감염내과
R2 손주웅/Prof. 이미숙
11554421
여 O 환 (M/45)
adm : 08.3.24
T/F : 08.3.29
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Chief Complaint
fever
onset ) 내원 5일전
Present illness
01년 9월, 07년 2월 pituitary macroadenoma로
2차례 TSA 와 GKRS 시행한 환자로 내원 5일전
부터 fever, poor oral intake, drowsy mentality
보여 영남대 병원 입원 후 manage 받다가 본원
NS 로 전원하였음. 입원 후 antibiotics 사용하였
으나 fever 지속되어 감염내과로 T/F.
other associated sx. with fever : non-specific

Past medical history
DM/HTN/Hepatitis/Tbc (-/-/-/-)
Op Hx. (+) : TSA & GKRS – d/t pituitary macroadenoma
2001, 2007 at KHMC NS
Panhypopituitarism (+) : prednisolone 5 mg,
levothyroxine 0.15 mg
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Family history
non-specific
Personal history
alcohol (-)
smoking (-)
Review of systems (admit)
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General
: fever (+), chilling (-), wt. loss (-)
Skin
: rash (-), pigmentation (-)
H&N
: headache (-), sore-throat (+)
Respiratory : cough (-), sputum (-), dyspnea (-)
Cardiac
: chest pain (-), orthopnea (-), palpitation (-)
GI
: A/N/V/D/C (-/-/-/-/-), Abd. discomfort (+)
Urinary
: dysuria (-), frequency (-), incontinence (-)
Musculoskeletal : myalgia (-), arthralgia (-)
Nervous
: syncope (-), seizure (-), dizziness (-)
Physical examination (admit)
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Vital sign
100/60mmHg - 130회/min - 24회/min - 390C
General
Drowsy mentality (GCS 12점)
Acute ill-looking appearance
Skin
No rash, no pigmentation
Skin turgor : intact
Head & Neck Neck vein engorgement (-)
Lymph node enlargement (-)
Thyroid gland enlargement (-)
Eye & ENT
Isocoric pupil with PLR (++/++)
Whitish sclera, pinkish conjunctiva
PTH(-/-), PI(-)
Physical examination (admit)
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Thorax
Symmetric expansion
Clear brething sound without crackle
Regular heart beat without murmur
Abdomen
Soft & flat
Normoactive bowel sound
Tenderness (-), rebound tenderness (-)
Back & Ext. CVA tenderness (-/-)
Pretial pitting edema (-/-)
Neurorogy
Cranial n. : intact
Sensory : intact
Motor : intact
Initial Lab Finding (admit)
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CBC/DC
8160/mm3-10.8g/dL-31.8%-332K/mm3 (seg: 61.3%)
INR 1.09
aPTT 32.1 sec
Chemistry
TB/DB
0.77/0.11 mg/dl
AST/ALT
39/38 U/L
ALP/GGT
55/32 U/L
Prot./Alb
5.8/2.8 g/dl
BUN/Cr
3/0.8 mg/dl
Na/K/Cl
134/3.4/102 mmol/L
CRP
27.1 mg/dl
U/A
RBC 5~9 WBC 5~9
Protein (-), Glucose (-)
Chest PA
EKG
Brain CT
CSF examination(3/28)
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RBC : 0 /mm3
WBC : 0 /mm3
Protein : 94 mg/dl
Glucose : 108 mg/dl (serum 192 mg/dl)
AFB (-)
Gram staining (-)
Fungus Cx (-)
Clinical course(T/F전)
39.5
40
35
39
30
38.5
25
38
20
15
37.5
10
37
Ceftriaxone+Levofloxacin
5
36.5
0
03월 03월 03월 03월 03월 03월
24일 25일 26일 27일 28일 29일
WBC 8160
(seg) (61.3)
5940
(67.5)
4730
(60.7)
5150
(62.6)
8900
(75.8)
15190
(93)
BT
CRP
Initial problem list
1. Fever
2. Drowsy mentality
3. Known panhypopituitarism
S/P TSA
lnitial assessment
#1. Fever
A) viral infection
noninfectious inflammatory disease
extrapulmonary tuberculosis
fungal infection
atypical bacterial infection
#2. Drowsy mentality
A) encephalitis d/t viral infection
#3. Known panhypopituitarism, s/p TSA
Diagnostic plan
#1. Fever
P) EBV, Adenovirus, coxsackievirus
Korean Ab
Mycoplasma Ab
Serology
F/U blood Cx, CSF exam
USG, Chest CT
#2. Drowsy mentality
P) Brain MRI, EEG, F/U CSF
#3. Known panhypopituitarism, s/p TSA
P) Steroid 증량
Blood Cx (3/24) : negative
Urine Cx (3/24) : negative
Sputum Cx (3/24) : negative
Clinical course
39.5
39
38.5
38
37.5
37
36.5
36
35.5
35
MRSA
A. baumannii
P. aeruginosa
Pip/taz
cipro
vancomycin
Colistin+mero+vanco
일 일 일 일 일 일 일 일 일 일 일 일 일
29 31 03 07 10 12 14 16 18 21 24 02 06
월 3월 4월 4월 4월 4월 4월 4월 4월 4월 4월 5월 5월
3
0 0 0
0 0 0 0 0 0 0
0 0 0
45
40
35
30
25
20
15
10
5
0
BT
CRP
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Blood Cx : All negative
Sputum Cx
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MRSA : 3/26, 3/28, 4/1, 4/12
A. baumannii : 4/4
P. aeruginosa : 4/5, 4/10, 4/12, 4/21, 4/29
Hypernatremia
3/25
4/2
4/4
4/6
4/7
Na
134
161
160
164
169
Urine
osmol
437
463
176
Plasma
osmol
280
337
335
Pitressin stimulation test
Urine
osmol
Plasma
osmol
0
30
60
195
393
407
389
368
386
Central DI
Pitressin 5U sc.
Desmopressin intranasal
4/8
4/10
4/14
4/24
4/28
Na
160
146
156
150
135
Urine
osmol
429
519
391
338
499
Plasma
osmol
358
356
342
339
301
Serology
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Heterophil Ab (-)
EBV EA-DR IgG (-)
EBV EA-DR IgM (-)
EBV VCA IgM (-)
EBV VCA IgG (+)
EBV EBNA IgG (+)
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Adenovirus (-)
Hantaan Ab (-)
Leptospira Ab (-)
R. tsutsugamusi (-)
R. typhi (-)
Coxsackie virus B
4/3
4/10
Type 3
1:4
1:4
Type 4
1:4
1:16
Type 5
1:4
1:4
Clinical course (HD 20)
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Respiration rate 20회 -> 40~50회
ABGA
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7.472 - 36.9mmHg - 61mmHg - 26.4mmol/L - 92.9% (FiO2 0.3)
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7.414 - 42.1mmHg - 54.7mmHg - 26.3mmol/L - 88.8% (FiO2 0.5)
D-dimer : 12.51 ug/dL
Chest PA (HD 20)
Chest CT
Final Diagnosis
#1.
#2.
#3.
#4.
#5.
Coxsackie virus B type 4 infection
Encephalitis
Known panhypopituitarism, s/p TSA
Central DI
Pul. Thromboembolism
Disease review
Coxsackie virus infection
Coxsackieviruses
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A large subgroup of the enteroviruses
Divided into two groups
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Group A
Group B
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M/C viral heart disease
More pathogenic than the echoviruses
Enteroviruses
Enteroviruses
A variety of illness
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Group A
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Herpangina
Hand-foot-mouth
disease
Acute hemorrhagic
conjunctivitis
Group B
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Pleurodynia
Myocarditis
Pericarditis
Meningoencephalitis
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Group A & B
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Aseptic menigitis
Undifferentiated
febrile illnesses
Hepatitis
Paralysis
Pathogenesis & pathology
Clinical findings
Clinical findings
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Neurologic
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Aseptic meningitis
all type of type B, A7, A9
 Fever, malaise, headache, nausea, abd. Pain
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Paralytic poliomyelitis
Recover completely from nonpoliovirus paresis
Clinical findings
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Skin and mucosa
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Herpangina
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Severe febrile pharyngitis
Group A 2~6,8,10
Abrupt onset of fever and sore-throat
Self-limited
Hand-foot-mouth disease
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Oral and pharyngeal ulcerations
Vesicular rash of the palms and soles
Group A 5,10,16
Clinical findings
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Cardiac and muscular disease
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Pleurodynia
Group B
 Fever and stabbing chest pain
 Self-limited
 Complete recovery
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Myocarditis
Acute inflammation of heart
 Group B
 Permanent heart damage
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Clinical findings
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Ocular
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Acute hemorrhagic conjunctivitis
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Respiratory infections
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Common colds
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Enterovirus 70
Coxsackievirus A24
Coxsackieviruses A21,24,B1,B3~5
Pneumonitis
Pul. edema
Undifferentiated febrile illness
Type 1 DM
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Coxsackie B viruses
Laboratory diagnosis
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Recovery of virus
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Throat washing : first few days of illness
Stool : first few weeks
Nasal secretion
CSF fluid
Conjunctival swab
Serology
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Neutralizing antibody
Treatment
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Symptomatic treatment
No vaccines
No antiviral drugs
Prevention & control
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Hand washing
Patient isolation
Journal of pediatric endocrinology metabolism
8(4) : 310-304, 1995
37-year-old woman without serious past illness
Hand tremor, unsteadiness, and a 2-day history of headache
high fever (39.3°C), neck stiffness, intentional tremor of bilateral upper extremities,
and truncal ataxia.
MRI and results of laboratory blood tests were normal.
CSF tap showed 305 leukocytes/mm3
During the illness, CSF was negative for bacteria and viruses
Enterovirus-specific RNA was detected from a stool sample on day 16
the virus was identified as EV71 by sequence analysis
Serum neutralizing antibody titer against EV71 increased
Her 1-year-old son was affected with HFMD.
Also developed in her other 2 sons, 5 and 7 years of age
Emerging infectious diseases
14(5).828-830 May. 2008
76-year-old man
acute onset of fever, lumbar pain, and dyspnea.
37.9°C and bilateral pulmonary crackles
leukocytes 9,600 cells ×106/L (90.6% neutrophils), CRP 21.6 mg/L
Chest radiograph was unremarkable
ARDS developed, and the patient required mechanical ventilation.
BAL was performed; BAL was positive in 2 enteroviral PCR assays
Serologic testing for enterovirus showed an 8-fold increase in enterovirus
antibody titration
Emerging infectious diseases
13(7) 1084-6 Jul. 2007
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Enterovirus, china
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5, may, 2008
Total 4496 cases, including 22 deaths
Hand-foot-mouth disease d/t enterovirus 71
Serious complication such as neurogenic
pulmonary edema
Weekly epidemiological record
83(19).169-170 May. 9 2008
New England Journal of Medicine
341(13) 929-935 23.SEP.1999
New England Journal of Medicine
341(13) 929-935 23.SEP.1999
New England Journal of Medicine
341(13) 929-935 23.SEP.1999