CPC ประจำเดือน มีนาคม 2554 - อ.ธีระวัฒน์ เหมะจุฑา

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CPC ประจำเดือน มีนาคม 2554

จัดในวันพฤหัสบดีที 31  มีนาคม 2554 เวลา 12.00 น. ห้องประชุมชั้น 1 ตึกอบรมวิชาการ
ผู้อภิปรายหลัก
Clinician:  ศ. นพ. ธีระวัฒน์ เหมะจุฑา
Radiologist: อ. พญ. น้ำผึ้ง นำการุณอรุณโรจน์
Diagnostician: To be announced

ขอเชิญอาจารย์ แพทย์ประจำบ้าน นิสิตแพทย์และท่านที่ให้ความสนใจ เข้าร่วมอภิปรายครับ

สิทธิพงษ์

[chusana]

Dear all:
This fascinating CPC case is a 43-year-old man who presented with a 15-month course of  painful weakness of proximal muscles beginning with lower limbs, then left arm, and finally right arm; dysphagia; painful swelling of the whole left leg; fever and significant weight loss; in accompanying with elevated muscle enzymes, acellular proteinorrhachia, interesting neuromuscular electrophysiologic test, positive cryoglobulinemia and rheumatoid factor, positive D-dimer, abnormal bone marrow with suspected unknown microorganism, abnormal chest CT and echocardiogram showing pulmonary hypertension, mediastinal lymphadenopathy, and lung infiltration.
Every one is very much welcome to make comments or discussion in this difficult case krub!!??!!
Chusana

[chusana]

Dear all Arjans 'Kar Prajum' including Aj DK, KonKlaiBan, Noppacharn:
This case has problems with corresponding to your preference like Pulmonary, Neurology, and Hematology. Please feel free to make comments or discussion krub. We still have a reward for the first one who can make the most correct diagnosis with excellent explanation.
Chusana

[KGB]

หน้าตาเหมือนอมาสติโกทของลิชมาเนีย แต่อาการไม่เหมือนเลย คงตาฝาดไป

[KGB]

Pulmonary hypertension
LymphedenOpathy
Edema, subclinical hypothyroidism

No evidence of monoclonal paraprotein
No polyneuropathy
Might need lymph node biopsy that may show castlemans disease pathology
Inflammatory myositis can be a manifestation of the syndrome

[KGB]

Mixed cryoglobulinemia and hepB? :/
No typical skin change, no renal involvement, rarely present with frank myositis

[chusana]

Dear Aj คนไกลบ้าน:
Yes, the clue is this kind of organism. Is it bacteria, fungus, protozoa, virus or others?
Regarding, neurologic involvement, is it originated from anterior horn cells, roots, nerves in the form of mononeuritis multiplex or aonopathy or demyelinating disease, NMJ, or muscles?
Chusana

[KGB]

It is definitely not a virus which should not be seen at the light microscopic resolution, except there might have inclusion bodies in the cell, which is not this case. The picture shows that the organisms are ingested in a large ill-defined border cell that should be macrophage and some are extracellular. There are lucent lining around the organisms but not as thick as typical capsule of some fungus, so it might be pseudocapsule. Try to enlarge the picture and I couldn't see any dividening of that, septate or budding. So I still think that they are some parasites! Amastigotes of leishmania or trypanosomes! Which are both not local infections. ;(

About the neurological involvements, the gradually progressive proximal muscle weakness, asymmetrical at the onset without typical root pain, non flutating and involve bulbar. No sensory onvolvement.  I prefer  AHC > muscle, but the electrodiagnosis and biopsy shows only evidence of myopathy, some mild inflammation, somewhere is necrotizing granulomatous, irritative myopathy pattern. So there are only evidence for myopathy.
A single Median nerve involvement cannot convince for Mononeuritis multiplex, as it is a common site of entrapment neuropathy.

Trypanosomoe can cause myositis, mixed essential cryoglobulinemia (RF positive, cryo +) and can effect the lungs 

[chusana]

Dear all:
Another clue in this patient is at least he had temporal heterogeneity of muscle injury at different times. Apart from bacteria especially Gram-positive bacteria and some viruses like Flu, are there any Kingdom of microorganisms that can cause this kind of muscle injury especially in accompanying with nerves/nerve roots as well as other extra-neural systems including pulmonary HT and some positive serologic parameters.
Another clue, there is dissociation between BM aspiration and BM Bx. Microorganisms were found only in BM aspiration; what this implies?
From the picture of BM aspiration, there is some unique feature that help clinician to identify it. What is it?
Aj DK, please comment regarding pulmonary HT and abnormal CXR and CT scan krub.
Chusana

[KGB]

Gram-positive bacteria Staphylococcus aureus*
 Group A Streptococcus**
 Streptococcus (groups A, B, C, and G, S. pneumoniae, S. anginosus)***
Gram-negative bacteria Aeromonas hydrophila***
 Burkholderia mallei, B. pseudomallei***
 Citrobacter freundii**
 Enterobacter spp.**
 Escherichia coli**
 Haemophilus influenzae***
 Klebsiella oxytoca, K. pneumoniae***
 Morganella morganni***
 Neisseria gonorrhoeae***
 Pasteurella spp.***
 Proteus spp.**
 Pseudomonas spp.**
 Salmonella spp.**
 Serratia marcescens***
 Vibrio vulnificus***
 Yersinia enterocolitica***
Anaerobic bacteria Bacteroides spp.**
 Clostridium spp.**
 Fusobacterium necrophorum and F. nucleatum***
 Streptococcus spp. (anaerobic, e.g., Peptostreptococcus)**
 Veillonella spp.***
Mycobacterium spp. Mycobacterium avium complex***
 Mycobacterium bovis***
 Mycobacterium haemophilum***
 Mycobacterium leprae***
 Mycobacterium tuberculosis**
Atypical bacteria Actinomyces spp.***
 Bacillus spp.***
 Bartonella spp.***
 Borrelia burdorferi***
 Brucella spp.**
 Coxiella burnetii***
 Francisella tularensis***
 Legionella pneumophila***
 Leptospira spp.***
 Mycoplasma pneumoniae**
 Nocardia spp.***
 Rickettsia rickettsii and R. conorii***
 Treponema pallidum***
Fungi Aspergillus spp.***
 Blastomyces dermatitidis***
 Candida spp.*
 Coccidioides spp.***
 Cryptococcus neoformans***
 Fusarium spp.***
 Histoplasma capsulatum***
 Pneumocystis jiroveci***
Parasites Entamoeba histolytica***
 Echinococcus spp.***
 Microspordia spp. (Brachiola, Trachipleistophora, Pleistophora)***
 Onchocerca volvulus***
 Plasmodium spp.**
 Sarcocystis spp.**
 Schistosoma spp.***
 Spirometra mansonoides***
 Taenia solium**
 Toxocara canis***
 Toxoplasma gondii***
 Trichinella spp.*
 Trypanosoma cruzi***
Viruses Adenovirus***
 Cytomegalovirus***
 Dengue virus***
 Enteroviruses (coxsackie B virus and ECHO virus)**
 Epstein-Barr virus***
 Hepatitis B and C viruses***
 Herpes simplex virus 2***
 HIV**
 HTLV-1**
 Influenza A and B viruses*
 Mumps virus***
 Parainfluenza virus***
 Parvovirus B19***
 Varicella-zoster virus***
 West Nile virus***
 which one 555

[KGB]

Actually, as I have said that there are lucent areas around the organisms, so I change my mind to histoplasma capsulatum. :p.
But I cannot answer your question about why it is only found in aspiration, not in the marrow. It seems to be in the blood circulations? If in that case, it should be another blood parasites. I can not figure out!!!!!!!!!!!!!!!!!!!!!!!!!

[KGB]

Ok, I am now quite sure that it should be Histoplasma capsulatum and the clinical syndrome are now fit for this fungus!
Apologize for my confusion with parasites.

 I might stay too long in the lab looking at some cancer cells (HeLa) on the confocal laser scanning microscope until I forget this fungus. 

[KGB]

มีพรายกระซิบว่าอาจจะไม่ใช่ที่คิด

งั้นก็เหลือ พวก zoonosis ทั้งหลาย อาทิtoxoplasma, sarcocystis, echinococcus แต่หน้าตาไม่รู้เหมือนตัวไหนดี เอา toxo ดีกว่า เพราะเกิด myositis, polyradiculoneuritis, immune activate ได้เหมือนกัน

[KGB]

Microsporidia. อีกตัวแต่ไม่แน่ใจว่ามันเห็นได้จาก LM?

[KGB]

Just come across a paper of misdiagnosis toxoplasma for histoplasma in a cat. hopefully this is the case.