1. Internal medicine cases
Dr. Hayam Hebah.

2. Case 1:

3. 55 year old male presents to clinic with fever , myalgia and generalised malaise for several weeks.
There is history of abdominal pain, weight loss and lack of energy . Prior to the assessment she had left foot drop.
O/E: B.P: 160/90, Pulse 104/min, temp: 38.3°C , no LL edema, tender proximal muscles
left peroneal nerve damage .
Skin shows the following picture:

5. What is the lesion?
What is the DD?
What is missing in examination?
WHAT ARE REQUIRED INVERSTIGATIONS?

6. livedo reticularis Primary Secondary:
Vasculitis autoimmune conditions:
Livedoid vasculitis - Polyarteritis nodosa ,Systemic lupus erythematosus[, Dermatomyositis, Rheumatoid arthritis ,Lymphoma Pancreatitis[
Tuberculosis
Drug-related:
Amantadine  ,Bromocriptine 
Obstruction of capillaries:
Cryoglobulinaemia - Antiphospholipid syndrome  ,Hypercalcaemia 
Haematological disorders of polycythaemia rubra vera or thrombocytosis (excessive red cells or platelets)
Infections (syphilis, tuberculosis, Lyme disease)
Associated with acute renal failure due to cholesterol emboli status after cardiac catheterization
Arteriosclerosis (cholesterol emboli)

7. CBC: WBCs 14,000/mL
RBCs: 4.5 ; Hb: 10.2
ESR: 105 mm/h
Occult blood in stool: positive
ANCA and ANA showed negative results
HBsAg is positive
DD?
FURTHER INVESTIGATIONS?

8. Few days later the patient start to develop oliguria and hematuria with worsening of BP reaching 180/110 .
Investigations:
Urine---RBCs:10-15/HPF, Prot +
S.creatinine mg/dl
Abd u/s---

10. What is the diagnosis?
What is the mechanism of renal injury in this condition?
Nephrotic syndrome
Diffuse GN
Granuloma
Necrotizing vasculitis of vessels
Small vessel involvement.

11. How to confirm diagnosis?
Angiography
Muscle or sural nerve biopsy

12. Polyarteritis nodosa
Any 3 of the following 10 findings is sufficient for the diagnosis of PAN (sensitivity 82%, specificity 86%):
Mononeuritis multiplex
Myalgias with muscle tenderness
Livedo reticularis
Testicular pain or tenderness
Renal impairment (elevated BUN and creatinine levels)
Weight loss of 4 kg or more
Diastolic blood pressure greater than 90 mm Hg
Hepatitis B positive
Arteriography showing small and large aneurysms and focal constrictions between dilated segments
Biopsy of small- or medium-sized arteries containing white blood cell infiltrate
Peripheral eosinophilia (common and an important clue to PAN)

15. Case 2:

16. A 17 year old Pakistani male was admitted with high-grade fever associated with chills and rigors (40.5–41 °C) for 2 weeks prior to admission. During a course of oral antibiotics he had taken for 5 days, his symptoms had subsided, however the fever recurred on discontinuation of therapy.
On examination, the patient, a lean, thin individual, appeared toxic and dehydrated. He was tachypneic, tachycardiac and febrile at 38 °C, with an occasional spike up to 40 °C. He was started on symptomatic treatment.

17. Biochemical tests on admission showed :
a low white blood cell (WBC) count, with neutrophilic predominance.
His malaria work-up was negative.
Direct bilirubin of 0.5.
Gamma-GT of 178
alkaline phosphatase 205.
lactate dehydrogenase of 2380.

18. A screening ultrasound done showed para-aortic, retro-peritoneal and mesenteric lymphadenopathy, especially in the right iliac fossa and the aorto-caval regions.
Q:D.D INCLUDES which of the following?
Tuberculosis
malignancy.
Typhoid fever
Inflammatory bowel disease
malaria

19. However, 2 days later, the blood culture reports showed that the patient had actually been suffering from enteric fever, with the causative organism Salmonella paratyphi(S. paratyphi) A being sensitive to ampicillin, chloramphenicol, ceftriaxone, co-trimoxazole, and cefixime, and resistant to ciprofloxacin.

21. Typhoid fever
 The diagnosis is primarily a clinical one, but a definitive diagnosis requires isolation from blood, bone marrow, stool or urine cultures and the diagnosis of typhoid fever is not a simple one, due to its non- specific clinical features and lack of an immediate confirmatory test.
Initially the drugs of choice for enteric fever were ampicillin, chloramphenicol and co-trimoxazole, however when resistance developed to these drugs ,ciprofloxacin was shown to be very effective.

22. Thank you