Jaundice and AKI after return from Papua

A 36 year old soldier developed a flu-like illness (fever, chills, headache, myalgia) 4 days after returning to Jakarta, Indonesia, from a 1 year posting to Papua New Guinea. He was known to have chronic hepatitis B infection, with chronically mildly abnormal liver function tests, but was not on any treatment for this, and had otherwise been well. 3 days later he developed nausea and vomiting and abdominal pain, and jaundice was noted. After a week of this illness he was admitted to hospital where he was thought to have obstructive jaundice, so on the 10th day of his illness he was transferred to a tertiary centre.

Papua New Guinea. CC-BY; credits at foot of page

From the UK Kidney Association’s international case presentation series. This case contributed by Dr Jonny and colleagues from Jakarta, Indonesia.

On transfer he was initially alert, deeply jaundiced, apyrexial, BP 107/53, but becoming obtunded. Some upper abdominal tenderness was noted. Ultrasound showed normal liver oultline no obstruction, thickened gallbladder wall with sludge. Elastography suggested severe liver fibrosis. Blood test results are shown (click to enlarge). The urea converts to 117 mmol/l, Creat 1160 micromol/l. High enough for uraemic encephalopathy. He was also oliguric. He was anaemic, Hb 7.6 g/dl, wbc 19.9 (neutrophilia), plats 462.

The initial suspicion was that he had an acute exacerbation of chronic HBV hepatitis, possibly with acute cholecystitis, complicated by AKI.

  • Do you agree? What other conditions would you want to rule out?
  • Suggest up to three investigations to rule in or out your key differentials.

Write what you think

What happened next

There are interesting lists of simultaneous jaundice and renal disease

  • infective (e.g. Leptospirosis)
  • toxic (many, including paracetamol)
  • just secondary to severe hepatic disease – hepatorenal syndrome and (perhaps controversially, is it just an epiphenomenon?) bilirubin cast nephropathy.

The key result here was a blood smear.

A revealing test

A blood smear showed Plasmodium falciparum gametocytes, 63 per 500 erythrocytes, 1008 parasites per microlitre. The patient therefore has severe falciparum malaria, with ‘blackwater fever’ and possibly cerebral manifestations (though this could have been just uraemia). The urine did indeed look very dark, which you can also see in rhabdomyolysis, but you can sometimes see similar in severe ATN. Especially perhaps if a patient is jaundiced.

Outcome and further information

He developed multi-organ failure and despite anti-malarial therapy and CVVH (continuous haemofiltration) he deteriorated, developing secondary sepsis, and unfortunately died of septic shock.

Malaria is endemic in Papua New Guinea, but not in Jakarta. He had not been taking prophylaxis while away. The lack of substantial fever probably hindered recognition, and he was treated too late. Simple things.

Further Information

 

A breathless 20 year old with cough and fever

A 20 year old man complains of 3 weeks of cough and fever, and 4 days of oedema of his feet. On examination he is breathless.  There is marked engorgement of his neck veins, JVP higher than ears, ascites, 2+ oedema of his feet. P130/min irregularly irregular, of waxing and waning volume, apex rate 160. BP 95/80. Liver 4cm. There was dullness and reduced breath sounds at R lung base. His chest radiograph is shown.

ECG showed inverted T waves across anterolateral chest leads.

Questions

What is the likely diagnosis. What complication sounds imminent, and what would you do about it. What is the most likely cause?

Write what you think

Show what happened next

He has a pericardial effusion with tamponade. 500 mls of bloody fluid were drained from the pericardium, with immediate improvement in breathlessness and blood pressure. 1000 ml of similar fluid was drained from the right pleural cavity. Microscopy did not show a cause.

The effusion recurred a week later, so a pericardial biopsy was undertaken. Don’t try this at home.

A week later the problem recurred. A biopsy was undertaken.

What might it show?

Show the outcome

The fluid again did not give a diagnosis, but the pericardial biopsy showed giant cell granulomas. A guinea pig was inoculated with the fluid, and 5 weeks later it had developed tuberculous lesions, confirming the diagnosis.

TB is a rare cause in UK practice. Viral causes are probably the most common cause of symptomatic acute pericarditis, followed by autoimmunity. However big effusions causing tamponade are probably most likely after cardiac surgery or myocardial injury (Dressler Syndrome), and in malignancy. Infections are a less common cause.

Further info

This case is from Sanghvi et al 1958, Sawai Man Singh Hospital and Medical College Rajasthan (Pericardial biopsy with Vim-Silverman needle, Archives of Internal Medicine 101:1147-10). Pushing a big biopsy needle towards the heart sounds hazardous, and probably fortunately the approach didn’t catch on. Guinea pig inoculation was a quicker, less demanding technique than TB cultures, though these had been developed in the 1930s.

Pericarditis from TB is rarely encountered in developed countries now, but still not rare worldwide. Drug resistance, and co-infection with HIV, are important issues. Surgery may be required in chronic examples, but is not always available in the areas of highest incidence.

Further further info

History of tuberculosis (Wikipedia) and Timeline of tuberculosis (Wikipedia) are both fascinating.

The image shows a modified Vim Silverman needle, the predecessor of the ‘Trucut’ cutting needle developed for liver biopsies, extended in the mid 1950s to renal biopsies (Renal biopsy becomes mainstream, 1954).

A girl with facial swelling

[pic from Thyolo] A 14 yearl old schoolgirl is referred from Thyolo District Hospital, Malawi, complaining of facial swelling for 3 weeks, worse in the morning.  3 days later she developed bilateral leg swelling and increasing abdominal distension with some suprapubic colicky pains.  She reported concentrated urine but no haematuria.  There was no significant past medical history but 1-2 weeks previous to her symptoms she was treated for malaria when she had a fever.  Anaemia was noted at that time and she was given Albendazole and ferrous sulphate.  A week before admission she was treated for vaginal discharge with Gentamicin 240mg IM one dose, and a course of Doxycycline and Metronidazole.  She had also taken some herbal medicines for her symptoms.

She now complains of feeling ill, anorexia, and is vomiting once or twice a day.

Her father works on a tea estate as a labourer.  The family can afford 3 meals a day.

On examination she was unwell but not distressed, appeared well nourished.  Temperature 36.5C, pulse 96, BP 168/94, respiratory rate 16.  She had pale conjunctivae and facial oedema that she said was improved.  Pedal oedema had also mostly resolved.  There were no skin lesions or rash.  Throat was normal and she had no lymphadenopathy.  Her JVP was not elevated. Heart sounds were normal.  There was evidence of some ascites but again this seemed to be improved.

Urine dipstick showed blood 3+, protein 3+, and was negative for leucocytes and nitrite

Before showing results, what syndrome does she have?  What do you think the diagnosis is likely to be?

Case contributed by Emmanuel Mwabutwa

Show test results

  • HIV test negative
  • Pregnancy test negative
  • Hb 5.3 (MCV 70), wbc 4.3, plats 170
  • Creatinine was 19.3 mg/dl (1700 micromol/l) 3 days ago, having risen from 15.3 mg/dl (1350 micromol/l) 4 days previously.
  • Ultrasound showed kidneys to be normal in size but bright in echo pattern.  It confirmed ascites.  A cardiac echo showed a 1.6cm pericardial effusion but normal ejection fraction (76%) and appearances. The right atrium and hepatic veins were dilated.

Now write what you think and what you'd do

Show what the experts thought?

She has acute nephritic syndrome – fluid retention, hypertension (BP very high for a 14 year old) and renal impairment with strongly positive dipstick tests for haematuria and proteinuria.  These confirm glomerular disease.

The most likely diagnosis is classic post-infectious glomerulonephritis.  The normal kidney size and lack of left ventricular hypertrophy support an acute condition, rather than an exacerbation of something chronic.

She also has severe anaemia with microcytosis suggesting iron-deficiency.  Anaemia is frequent in the population and can be multifactorial related to malaria, diet, or other factors.

Her renal impairment is severe and life-threatening.  We do not have a potassium result.  Usually post-infectious glomerulonephritis in children resolves spontaneously, and there are probably many sub-clinical cases. At its most severe, dialysis may be required, but good recovery is still usual.  Even severe cases can usually be managed conservatively:

  • Diet:  Limit salt intake (about zero is right if they are oedematous and hypertensive); limit potassium intake
  • Restrict protein intake but provide plenty of calories.  Oedema can hide severe wasting
  • Loop diuretics relieve fluid retention in all but the most severe cases, and improvement in fluid balance improves blood pressure, though additional measures may be required.

Further info

A swollen leg

A 39 year old subsistence farmer is referred to the dermatology clinic with massive left leg swelling, present for several years.  His main complaint is of “leaking” and malodour, and he is reluctant to remove the tubifast dressing that he has applied himself.

What is the likely diagnosis?

What advice and treatment would you give?

Write what you think and what you'd do

Show the answer?

He has elephantiasis which is characterised by skin thickening and swelling of the underlying tissue leading to enlargement of his limb.  This is secondary to underlying problems with lymphatic drainage, and in this case the most likely cause is lymphatic filariasis.

The old bandages that he has applied should be removed and he should be shown/advised how to clean to reduce infection.  Emollients may be used to restore and maintain skin suppleness.

Further info

Case contributed by Levie Mwale and Ann Sergeant

A 56 year old farmer with lip ulceration

A 56 year old farmer who lives in a village near Blantyre, Malawi, presents with painful oral ulceration which is making eating difficult.  On further questioning he also admits that he has pain on micturition as he has painful penile ulceration. You also see that he has inflamed conjunctivae.

He started antiretroviral drugs for newly diagnosed HIV infection 1 week ago (lamivudine, nevirapine and stavudine).

What diagnoses would you consider?

How would you manage him?

Write what you think and what you'd do

Show the answer?

It is important to examine the whole of the patient’s skin and mucous membranes to determine the extent of disease, and in this case this established that there was mucous membrane involvement only.

The most likely diagnosis is Stevens-Johnson Syndrome (SJS), an idiosyncratic drug eruption, with nevirapine being the most likely cause.  Other diagnoses to consider include immunobullous disease such as mucous membrane pemphigoid or pemphigus vulgaris, or inflammatory disease such as erosive lichen planus – these are rare conditions which follow a chronic course.  Although infections (eg. mucocutaneous herpes simplex virus infection) should be considered the involvement of all mucous membranes would make this very unusual.

It is important to stop the offending drug quickly, and so nevirapine was stopped and the patient was admitted to hospital.

Other measures are supportive: analgesia, mouth and eye care, antiseptics for skin/genital involvement, may require IV hydration/nasogastric feeding, may require catheterisation.  Long term complications include scarring of genitals (which may lead to phimosis) and scarring of eyes which in the worst cases may lead to blindness – treatment aims to avoid these complications.

In this case the following treatments were used: paracetemol was adequate for pain control, saline mouth washes, tetracycline eye drops, gentian violet as antiseptic to penile ulceration.  He was regularly assessed for signs of infection.  He was able to tolerate oral intake and did not require a catheter.  He was referred to the antiretroviral clinic to institute another drug to complete his HAART regime.  He developed no new lesions and his ulceration gradually improved to allow discharge from hospital.

Further info

Case contributed by Levie Mwale and Ann Sergeant

A 19 year old albino with a skin lesion

A 19 year old lady from Blantyre, Malawi, attends with a scaly lesion which has been present on her right cheek for 3 months.

  1. Can you describe what you see?
  2. What is the diagnosis?
  3. What is your management?

Write what you think and what you'd do

Show the answer?

This is an albino woman with a small (approx 1 cm) superficial looking red scaly lesion on her right lateral cheek.  She has some lentigines (the brown marks) and coarse wrinkled neck skin.  If palpated the skin over the red lesion feels rough.

This is an actinic keratosis (actinic/solar – sunlight (UV) induced, keratosis – scaly/horny growth).  Considered to be pre-malignant, actinic keratoses are most often seen in exposed skin in fair skinned individuals who have had excessive UV light.

An actinic keratosis may follow 1 of 3 paths: it may regress, it may persist unchanged, or it may progress to invasive squamous cell carcinoma. The actual percentage that progress to invasive squamous cell carcinoma remains unknown, and estimates have varied from as low as 0.1% to as high as 10%.  Generally, thicker lesions are more likely to progress.

She should be advised to avoid further damaging sun exposure by wearing a wide-brimmed hat, clothing which covers the skin and a high factor sunscreen on exposed sites.  The actinic keratosis can be treated in several ways including medical management with creams and surgical management.  As she has several further actinic keratoses on her neck and other cheek (not seen in the photo above) and as other treatment modalities are not available in the clinic she is treated with imiquimod.  This is an expensive treatment, but had been donated to the clinic from an overseas organisation.

Further info

A man with a foot ulcer

A 42 year old man attends the dermatology clinic in Queen Elizabeth Central Hospital, Blantyre in 2012 with an ulcer on the sole of his right foot.  He says that it has been present since 2004 but that he underwent surgery 1 and a half years ago.  He was told it was a squamous cell carcinoma.  It initially healed, but since then the skin has broken down and the ulcer is enlarging in size.  He went back to see the surgeons and they have sent him on to dermatology to get dressings.

  1. Can you describe what you see?
  2. What diagnoses would you consider? Is there any information that would be ideal to have that would help point you towards the most likely diagnosis?
  3. Would you like to examine any other part of his body?
  4. What would you do next?

Write what you think and what you'd do

Show the answer?

This is a deep, irregulary shaped ulcer on the mid-sole of the right foot.  There is no cm scale in the photo, but it must be at least 5 cm in diameter.  The ulcer looks relatively clean.  The base of the ulcer comprises of  red fleshy tissue.  It is not possible to see bone or tendons.

In this case the most likely explanation is recurrence of squamous cell carcinoma (SCC). It would be helpful to get his pathology report from his operation 18 months ago to confirm that it was SCC and to see whether it was completely excised at the time.

The differential diagnoses includes a neuropathic ulcer (this is less likely as the ulcer does not correspond to the area of sole with maximal pressure, and he has no history of neuropathy) and infection (which in this geographical setting may include fungi and mycobacteria: but note there is little discharge, swelling or surrounding inflammation).

You would want to examine his ipsilateral inguinal and femoral lymph nodes to check for signs of metastasis and if they are palpable a fine needle aspirate (or lymph node biopsy) should be sent to pathology.

A biopsy of the base of the ulcer for pathology would confirm or refute the diagnosis of recurrence of SCC.

A surgical opinion as to whether this is operable should be sought.

This case was contributed by Levie Mwale and Ann Sergeant

An unwell lady with a history of breast cancer

A 53 year old female presents to the Queen Elizabeth Hospital, Blantyre with a 2 day history of drowsiness, diarrhoea and vomiting.

Her past medical history includes hypertension, diabetes and recently diagnosed breast cancer.

On examination she is dehydrated, BP 95/60, pulse 120/min, temp 380C, O2 sats 90% on air and Glasgow Coma Score of 14/15 (E4V4M6).

  1. What other history is required?
  2. What diagnoses would you consider?
  3. What immediate tests are indicated?
  4. What treatment would you start?


Write what you think and what you'd do


Show the answer?


Is she on chemotherapy for her breast cancer? If so you would worry about the possibility of neutropenic sepsis.  Immediate tests would include a blood sugar level (quick to do and vital in anyone with a history drowsiness – and we know she has diabetes), urgent full blood count (FBC) and blood cultures.  Less urgent tests include a chest X ray, urine dipstick (send for microscopy and culture if indicated) and urea and electrolytes.

Intravenous (IV) fluids,  IV broad spectrum antibiotics and oxygen should be started as soon as possible.

FBC results: Hb 66, WCC 0.8, Plt 34.

This case was contributed by Ewan Brown and Leo Masamba.

 



A 4 year old boy with patchy hair loss

A healthy 4 year old boy is brought to the Dermatology clinic at Queen Elizabeth Central Hospital, Blantyre by his parents.  He has been scratching his head, and they have recently noticed that he has developed several small scaly areas with associated hair loss.

What is your diagnosis and how would you treat him?

Write what you think and what you'd do

Show the answer?

The diagnosis is tinea capitis (scalp “ringworm”).  This is a cutaneous fungal infection which invades the hair shaft and is often due to Trichophyton tonsurans (caught from other children) or Microsporum canis (caught from kittens or puppies). Without treatment it gets better spontaneously at puberty.  After puberty it only occurs in patients with underlying immunosuppression.

Treatment of choice is oral griseofulvin 15-20mg/kg/day for 6 weeks.  Additional application of a topical antifungal, during the early stages of treatment, may reduce the risk of transmission.  Terbinafine is an unlicensed alternative, but may not be as effective for infections with M. canis.   The only oral antifungal available in the department is ketoconazole, so he is prescribed this and topical Whitfield’s ointment.  His parents then tell you that his elder sister was treated with the same treatment successfully earlier this year.

Other siblings with infection should also be treated and if the family pet’s fur is falling out it must be treated too.

The other differential diagnosis to consider in this case is alopecia areata but the presence of scale distinguishes these diagnoses.

Further info

 

This case contributed by Levie Mwale and Ann Sergeant

 

A 22 year old man with a painful rash

A 22 year old plumber attends the drop-in clinic in the dermatology department at Queen Elizabeth Central Hospital, Blantyre.  He has a 1 day history of a painful vesicular rash on his right buttock and posterior thigh. He feels unwell with fever.

Right posterior thigh

  1. What is your diagnosis?
  2. What is your management?

Write what you think and what you'd do

Show the answer?

This is herpes zoster infection also known as “shingles”.  Varicella zoster virus (VZV) lies dormant in the posterior root ganglion after chicken pox.  Reactivation causes the virus to travel down the cutaneous nerves to infect epidermal cells in the skin.    The presence of pain and the dermatomal distribution is classical.  As the rash is less than 72 hours old it is worthwhile treating with antiviral medication such as aciclovir, famciclovir or valaciclovir, if available.  They inhibit VZV replication and reduce the severity and duration of the rash.  Postherpetic neuralgia (pain which persists >3months after the rash has resolved) is more common in elderly patients and may respond to tricyclic antidepressant drugs, which should be started early if possible.

He is treated with aciclovir 800mg 5 times daily for 7 days and regular paracetemol.

In a young man in an HIV prevalent region, underlying HIV should be suspected (Herpes zoster is categorised by the World Health Organisation as clinical stage 2 of HIV infection) and an HIV test performed.

His HIV test was positive.  His CD4 count should be checked and if ≤350 cells/mm3 antiretroviral therapy commenced.

Further info

This case contributed by Levie Mwale and Ann Sergeant