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هدية من لا يخطأ فهو لا يعمل الفعاليات القادمة
استطلاع الرأي إلى أي مدى تعتبر أنّ الدراسة النظريّة للطبّ في كليتنا ستخدمك سريرياً في المستقبل؟ أعتبر أنّ الفائدة معدومة في ظل النظام التدريسيّ الحالي. 28% الفائدة كبيرة جداً، وهي أساس التميز العملي. 6% الأمر نسبي، يختلف من طالب لآخر، ومن مادة لأخرى. 67% عدد الأصوات: 240 أهلاً بك ! تفضل الإبحار |
A 68- year-old woman with headache and photophobia
mbs2380 - السبت, 2008-07-12 21:48 |
الوصف الكامل Background: الشكوى الرئيسية CC: This 68-year-old, right-handed woman was admitted to the
hospital because of headaches that began about one month earlier. القصة المرضية HPI: She was in good general health. About one month prior to
admission she developed progressively severe headaches and vertigo (a sensation that her environment was spinning around her). Shortly after the onset of these complaints, she noted photophobia (discomfort from light, to the extent that room lighting caused her eyes to hurt). The photopho- bia increased to the point that she had to wear sunglasses to cope with Christmas tree lights indoors. She was observed by her family to become increasingly lethargic (drowsy) and forgetful, prompting her hospitalization. الأجهزة الأخرى ROS: السوابق المرضية الشخصية PMH: السوابق المرضية العائلية FMH: الوضع الصحي والاجتماعي SH: الفحص السريري Clinical Exam: Physical examination revealed a lethargic woman who was
oriented to person and place but not to time. (She knew her name and where she was, but not the month or the year or that Christmas and New Year's Day had just passed.) The temperature was 98.9°F. There was moderate resistance to anterior flexion of her neck beyond 60 ° . The lungs had crackles at both bases (consistent, in this instance, with findings described below in the chest X-ray). Neurologic examination revealed pain when her straightened legs were raised beyond 45 ° (evidence, with the resistance to neck flexion, that there was at least moderate inflammation of the meninges). In addition, when reaching for objects with her hands, she consistently over-reached and missed them ("past-pointing," indicative of cerebellar dysfunction). This latter finding was worse on the left than on the right. التشخيص التفريقي DD: الاستقصاءات Investigations: Computerized tomography of the head revealed only mild
cerebral atrophy (shrinkage--probably age-related). Because of the signs of meningeal irritation, a lumbar punc- ture was performed shortly after admission to the hospital. The peripheral white blood cell count was 11,800/pl (normal between 5000 and 10,000), with 83 percent polymorphonu- clear leukocytes, 9 percent band forms, 4 percent lympho-cytes, and 4 percent monocytes (a slight increase in imma- ture granulocytes, suggesting an acute inflammatory pro- cess somewhere within the patient). The chest X-ray revealed diffuse interstitial infiltrates of both lower lobes (that is, increased fluid in the septa separating very minute air spaces). The cerebrospinal fluid (CSF) obtained during the lumbar puncture was clear and colorless, with a total white blood cell count of 18/pl (normal up to 4), with 75 percent poly- morphonuclear leukocytes and 25 percent lymphocytes. (Polymorphonuclear leukocytes are never normally present in CSF.) The CSF glucose was 28 mg/dl with simultaneous blood glucose of 119 mg/dl. (The blood glucose was within normal limits; but CSF glucose considerably less than 50 percent of blood glucose suggests that a viable micro- organism is present in the subarachnoid space.) The CSF protein concentration was 58 mg/dl (very slightly above the upper limit of normal for this patient's age). التدبير Managment: كتابة حرة وطرح موضوع النقاش!: While performing the white blood cell count on the CSF, an
alert laboratory technician observed structures that did not resemble white blood cells. A sample of CSF was cen- trifuged and the sediment resuspended in India ink. Under the microscope, in dramatic relief among the India ink parti- cles, were the organisms shown in the figure.
The most likely etiology of this patient's meningitis is: to be continued |
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Cryptococcus neoformans؟
great
The organism that grew from cultures of CSF and blood
was Cryptococcus neoformans. Despite very aggressive
therapy with amphotericin B, both intravenously and
instilled directly into a lateral cerebral ventricle, the patient
followed a relentless downhill course and died on the eighth
day of treatment. Autopsy confirmed severe meningitis due
to Cryptococcus neoformans.
strongly suggestive of a defect in cell-mediated immunity,
and its presence in this patient caused the clinicians caring
for her to suspect that she had a malignant lymphoma.
(This patient was treated in the early 1980s, prior to the
emergence of human immunodeficiency virus (HIV) as a
significant cause of severely impaired cell-mediated immu-
nity. Moreover, she had none of the known risk factors that
might lead to HIV infection.) In addition to the cryptococcal
disease itself, autopsy revealed a clinically inapparent
malignant lymphoma that was limited to the patient's uri-
nary bladder and fallopian tubes.
The lymphoma did not cause this patient's death the way
many cancerous tumors do, that is, by causing failure of a
vital organ. Instead, the profound defect in cell-mediated
immunity that accompanies lymphomas (as well as a num-
ber of other clinical entities) created in this patient a predis-
position to infection with an organism whose progression
she could not resist. As Cryptococcus neoformans often
does, it attacked her central nervous system preferentially.
By the time this infection created clinical symptoms of
headache, photophobia, and vertigo, it had passed the
point of reversibility, and caused her death.
It is characteristic of malignancies that are accompanied by an
immune defect that death is the result of an overwhelming
infection. By correlaling the immune defect with the underlying
disease, one may often anticipate the complicating infection,
and intervene in time to enjoy a favorable clinical outcome.
Or, as with this patient, the presence of an opportunistic infeclion (one that takes particular advantage of individuals with an
immune compromise) may herald the clinical onset of an
immune-compromising disease. It is therefore quite important
to be able to match an organism with the list of illnesses asso-
ciated with the corresponding immune defect.[b]
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thanks