Clinical Tropical Medicine Case Studies

Thursday Clinical Correlation, 8 AM lecture

Fred Holmes, M.D., Department of Internal Medicine

1. As county coroner you are asked to perform an autopsy on the body of a 39 year old female anthropologist, who was found dead in her apartment close to the university the day before. She was found by a friend who had a key to her apartment, and was concerned that she had not returned telephone messages for two days. The two had returned from a research trip to Tanzania and Mozambique one month previously where they had been studying Makonde wood carvers. The friend thought she had seemed somewhat unwell when she had dinner with her four days before. She said she had been having the flu. The last person to have seen her alive was an apartment resident who reported that she had seen her in the laundry room three days before and that she had seemed pale and quite confused. Knowing just these facts you have a strong suspicion of what you will find at autopsy.

2. In your primary care practice in a small town in western Kansas you see an 85 year old retired Baptist minister who is accompanied by his daughter. She and her family have been your patients for many years. Recently widowed, the old man has moved from Idaho to live with his daughter just a month before. She wants you to meet him and renew the prescription for the skin cream he uses for his psoriasis. Being a careful and competent physician you take a medical history and examine the old man. He is garrulous and full of stories about his years as a Baptist missionary in India, saying that he retired twenty years previously. He has enjoyed a remarkably healthy life save for occasional episodes of fever which he ascribes to recurrent malaria. He treats this with quinine sent to him by an Indian friend. His psoriasis consists of two large annular skin lesions with raised erythematous edges and hypopigmented flat centers. One is on his abdomen and the other on the back of his neck, under his collar. There is no hair growing from either lesion and they are anesthetic. In addition there is an oblong subcutaneous lump, about 2 by 6 cm, on his neck adjacent to the skin lesion. To your further questioning he says the psoriasis lesions have been present for many years and seem to be controlled with the corticoid cream he uses on them. He thinks the lump has been present for years as well but he is not sure. Because you are an astute young graduate of the School of Medicine of the University of Kansas, you make a diagnosis that had been missed by other physicians for years, perhaps decades.

3. A 32 year old schoolteacher consults you for what she believes is a recurrent urinary tract infection. She has been having intermittent chills and fevers for about a month. Remembering similar problems from the past she has been taking Bactrim (trimethoprim and sulfamethoxazole) sporadically with seemingly good immediate effect but the infection keeps returning. She thinks she could 'lick this problem' with a stronger antibiotic, and asks you to write a prescription for Ciprofloxacin, which she had used with success some years previously. Checking her medical record you note that her last visit was a physical exam before going abroad with the Peace Corps two years ago. Her physical examination is normal, as is her urinalysis. You ask about the Peace Corps and learn that she spent a year teaching English in Tajikistan. Other than occasional bouts of diarrhea, she enjoyed good health while living in Dushanbe. A new diagnostic possibility suddenly pops into your mind.

4. A 20 year old undergraduate student from Lawrence consults you for fever and abdominal pain of two weeksí duration. Fevers are intermittent and associated with night sweats. The abdominal pain is right upper quadrant and has been getting steadily worse. Now even movement causes the pain to worsen. He has enjoyed good health except for a prolonged spell of diarrhea when in Tanzania three months previously. A seemingly knowledgeable local physician there treated him with a number of medications, none of which he can remember, and the diarrhea eventually stopped and his stools have been quite normal for over two months. By your questioning he tells you that he took mefloquine for prevention of malaria every week for four weeks before going to Tanzania, every week while there, and for four weeks after returning home. By your examination he is afebrile and has normal vital signs. He is not jaundiced but his liver is massively enlarged and exquisitely tender. In fact he flinches even before you lay your hand on his abdomen to feel his liver. Even before you get a sonogram you know what will be found.

5. A 17 year old Leawood boy is brought to you by his mother because of abdominal pain with diarrhea and blood in his stool for a month. The mother is quite agitated and ascribes his illness to 'something he picked up' when the family was in Hong Kong six months previously. This family is usually seen by your partner and you do not know them. The boy's chart is thick. It ranges from feeding problems as an infant to a series of stool cultures and examinations for parasites in the past month, all of which are negative. He has been given a variety of medications by your partner during this past month, including ciprofloxacin and metronidazole. He is a thin and nervous teenager with normal vital signs. His abdomen is generally tender and bowel sounds are increased. No masses are felt. Rectal exam reveals no stool but some mucous that is guaiac positive. He is mildly anemic, hemoglobin 10.8 g/dl, and his erythrocyte sedimentation rate is 95 mm/hr. An x-ray of his abdomen is essentially normal. You call your gastroenterology consultant with a pretty good idea of what will be found with further study.

6. A 35 year old salesman consults you for what his brother-in-law, a physician, has told him is likely infectious mononucleosus. For two weeks he has been fatigued and has had low-grade fever. His throat has been sore and he is aware of tender lymph nodes in his neck. In asking about other recent problems he reluctantly admits that he had an episode of dysuria and urethral discharge one month previously when he was in Bangkok. He was told by the local doctor he consulted there that it was probably gonorrhea. A single injection of medicine was given and the problem promptly cleared up. Your examination shows that his pharynx is injected and that he has tender lymphadenopathy in his neck, axillae, and groin. His screening laboratory profile is unremarkable and his mononucleosis test is negative. You fear that he has acquired the currently epidemic tropical disease.

7. A 42 year old over-the-road truck driver presents at the KUMC Emergency Service with sudden onset of profuse watery diarrhea of seven hours' duration. He has passed over 20 stools, and has nausea. He is so weak that he can hardly stand. His pulse rate is 130 per minute and his blood pressure is 80/60. He immediately improves when an intravenous infusion of saline is started but the diarrhea persists. Looking in the bedpan you see opaque white watery fluid flecked with mucous. His abdomen is soft and not tender. He has no pain when passing a stool. Further intravenous fluids bring his pulse rate and blood pressure to normal. He tells you that he lives in Chicago and that his regular run takes him from Chicago to Biloxi to New Orleans to Houston and than back to Chicago through Kansas City. He especially likes this run because he particularly enjoys the shellfish he gets in restaurants along the Gulf Coast. He is admitted and by the next morning is feeling quite well. His diarrhea has stopped and he is quite hungry. In spite of your pleading he leaves the hospital against medical advice to get his truck back to Chicago. You never see him again. Two days later the hospital laboratory calls you to tell you that they have found an unusual organism in his stool. You are quite surprised when they tell you what it is.

8. A 66 year old man is brought to the Emergency Service by friends. They have been camping and hunting in Colorado and are returning by car to Bangor, Maine. The patient has had malaise, headache, restlessness, nausea, and back pain for about 24 hours. In the past three hours he has had severe chills and fever. He is the only one of the party of four who is sick. You examine him and find his pulse to be rapid. His face is flushed and his eyes are bloodshot. His temperature is 40.5 ^oC. Heart, lungs, and abdomen are normal as is a cursory neurological examination. He has groin and axillary lymphadenopathy. You suspect a disease uncommonly seen in North America.

9. A graduate student from Nigeria brings his 10 year old son to see you. The child has been in America with his father only for about two months. It is a sad story. The boy's mother and the boyís two sibs died in a bus accident in rural Nigeria and the father has brought his sole surviving child to be with him in America. The father is worried about the boy's easy fatiguability and thinks there is something wrong with him, even beyond the problems of grief and dislocation from his home. It is difficult to get a history, the boy does not know much English and the father knows little about his sonsís life for the past several years that he [the father] has been in America separated from his family. Your examination finds little. The boy has very pale conjunctivae and a loud systolic heart murmur at the pulmonic area. To your great surprise his hemoglobin turns out to be 6.3 g/dl and his MCV 63 fl. Being an astute physician, you order a stool examination for ova and parasites. What is it you are looking for?

10. You are asked to see the 76 year old mother of a Chinese friend. She has recently come to Kansas City for a family visit from her home on Hainan Island. He is concerned about her coughing. To her great surprise his wife found blood in the sputum her mother-in-law expectorated in the sink. Your friend is terrified that his mother has pulmonary tuberculosis and that she has already infected his children. It is difficult to get a clear history out of the patient, given the language barrier. She speaks only her native Hainan dialect. However, she adamantly denies that she has tuberculosis and says that she has had the cough and hemoptysis for many years. She says it is a common disease on Hainan Island and not infectious. Her son has been away from China too long and his Hainan dialect is rusty. He doesnít recognize the name of the disease. She has some wheezing and crackles in her chest to your examination and prominent clubbing of her fingers. She has an abnormal chest x-ray with nodules and infiltrates in both lungs. You get her to expectorate some sputum and note it to be white and mucoid with reddish-brown flecks in it. This is a family crisis, the wife is furious, she never did like her mother-in-law and was against the visit from the start. The husband is beside himself. Only the old lady is calm and can't see why everyone is so upset. As it turns out she is right. How is the diagnosis made and what is it?