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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 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 Family history non-specific Personal history alcohol (-) smoking (-) Review of systems (admit) 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) 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) 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) 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) 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 Blood Cx : All negative Sputum Cx 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 Heterophil Ab (-) EBV EA-DR IgG (-) EBV EA-DR IgM (-) EBV VCA IgM (-) EBV VCA IgG (+) EBV EBNA IgG (+) 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) Respiration rate 20회 -> 40~50회 ABGA 7.472 - 36.9mmHg - 61mmHg - 26.4mmol/L - 92.9% (FiO2 0.3) 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 A large subgroup of the enteroviruses Divided into two groups Group A Group B M/C viral heart disease More pathogenic than the echoviruses Enteroviruses Enteroviruses A variety of illness Group A Herpangina Hand-foot-mouth disease Acute hemorrhagic conjunctivitis Group B Pleurodynia Myocarditis Pericarditis Meningoencephalitis Group A & B Aseptic menigitis Undifferentiated febrile illnesses Hepatitis Paralysis Pathogenesis & pathology Clinical findings Clinical findings Neurologic Aseptic meningitis all type of type B, A7, A9 Fever, malaise, headache, nausea, abd. Pain Paralytic poliomyelitis Recover completely from nonpoliovirus paresis Clinical findings Skin and mucosa Herpangina Severe febrile pharyngitis Group A 2~6,8,10 Abrupt onset of fever and sore-throat Self-limited Hand-foot-mouth disease Oral and pharyngeal ulcerations Vesicular rash of the palms and soles Group A 5,10,16 Clinical findings Cardiac and muscular disease Pleurodynia Group B Fever and stabbing chest pain Self-limited Complete recovery Myocarditis Acute inflammation of heart Group B Permanent heart damage Clinical findings Ocular Acute hemorrhagic conjunctivitis Respiratory infections Common colds Enterovirus 70 Coxsackievirus A24 Coxsackieviruses A21,24,B1,B3~5 Pneumonitis Pul. edema Undifferentiated febrile illness Type 1 DM Coxsackie B viruses Laboratory diagnosis Recovery of virus Throat washing : first few days of illness Stool : first few weeks Nasal secretion CSF fluid Conjunctival swab Serology Neutralizing antibody Treatment Symptomatic treatment No vaccines No antiviral drugs Prevention & control 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 Enterovirus, china 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