A58-Year-Old woman ith a skin ulcer, fever, and Lymphadenopathy Case 4-2016 from NEJM 李菁2014级硕士导师:张继明教授
Case 4-2016 from NEJM A 58-Year-Old Woman with a Skin Ulcer, Fever, and Lymphadenopathy 李菁 2014级硕士 导师：张继明教授
General information Sex: female Age: 58-year-old Symptom: an ulcerated lesion on the forehead, fever, and cervical lymphadenopathy
Sex: female Age : 58-year-old Symptom：an ulcerated lesion on the forehead, fever, and cervical lymphadenopathy 1 General information
2Present history 8 days before admission ( other hospital ): a pimplelike lesion on the left side of her forehead 5 days before admission other hospital ) a temperature of 394C, chills, myalgias, and malaise the lesion increased in size 2 days before admission other hospital ): a temperatures of 400C, chills, and myalgias tender swelling of the left side of her neck the lesion continued to enlarge, took on the appearance of a blister containing dark fluid, and then ulcerated
2 Present history : 8 days before admission（other hospital）: a pimplelike lesion on the left side of her forehead 5 days before admission（other hospital）: a temperature of 39.4°C, chills, myalgias, and malaise. the lesion increased in size 2 days before admission（other hospital）： a temperatures of 40.0°C, chills, and myalgias tender swelling of the left side of her neck the lesion continued to enlarge, took on the appearance of a blister containing dark Pluid, and then ulcerated
2 Present history Chest radiograph: normal Contrast-enhanced CT: substantial asymmetric lymphadenopathy involving the head, face, and neck on the left side Contrast-enhanced ct scans of the head and neck Intravenous clindamycin was administered and discharged home with a prescription for oral clindamycin
2 Present history Chest radiograph: normal Contrast-enhanced CT: substantial asymmetric lymphadenopathy involving the head, face, and neck on the left side Contrast-enhanced CT scans of the head and neck. Intravenous clindamycin was administered and discharged home with a prescrip6on for oral clindamycin
2 Present history 1 day before admission ( other hospital) the lesion enlarged and was painful On examination( other hospital): a temperature of 39.4 C and persistent myalgias and malaise, fatigue and weakness Additional antibiotics were administered intravenously and the patient was transferred to this hospital by ambulance
2 Present history : 1 day before admission（other hospital）： the lesion enlarged and was painful On examination（other hospital）： a temperature of 39.4°C and persistent myalgias and malaise, fatigue and weakness Addi6onal an6bio6cs were administered intravenously, and the pa6ent was transferred to this hospital by ambulance
Present histol On examination( this hospital ). PE: T:38.0°C;P:107;BP:126/68mmHg; R:20 An ulcer at the hairline eft cervical lymphadenopathy with firm, tender, mobile nodes was present heard at the right upper sternal A systolic murmur (grade 2 /6)w Clinical Photographs border Specimens of blood and urine were sent for culture. Normal saline and broad-spectrum antibiotics were administered intravenously
2 Present history : On examination（this hospital）： PE: T: 38.0°C; P:107; BP:126/68 mm Hg; R:20 An ulcer at the hairline Left cervical lymphadenopathy with Pirm, tender, mobile nodes was present. A systolic murmur (grade 2/6) was heard at the right upper sternal border. Specimens of blood and urine were sent for culture .Normal saline and broad-spectrum an6bio6cs were administered intravenously. Clinical Photographs
3 Personal history She had a remote history of a cesarean section she had no known allergies She lived with her husband and dog and was a homemaker During the 2 months before the onset of illness, she had been living in a wooded area of coastal New England; she took frequent walks to ponds and to the beach, kayaked, and had seen deer skunks, and rabbits Several months before the onset of illness, she had taken a hiking trip in southern California Consumed alcohol in moderation, did not smoke or use illicit drugs, and had no exposure to sick persons A sister had systemic lupus erythematosus, and other family members had hypertension, cataracts, and glaucoma
3 Personal history : She had a remote history of a cesarean section she had no known allergies She lived with her husband and dog and was a homemaker. During the 2 months before the onset of illness, she had been living in a wooded area of coastal New England; she took frequent walks to ponds and to the beach, kayaked, and had seen deer, skunks, and rabbits. Several months before the onset of illness, she had taken a hiking trip in southern California Consumed alcohol in moderation, did not smoke or use illicit drugs, and had no exposure to sick persons. A sister had systemic lupus erythematosus, and other family members had hypertension, cataracts, and glaucoma
4 Laboratory Data Other Hospital, Other Hospital, Reference Range, 5 Days before 2 Days before Other Hospital, This Hospital, Variable Adults? Admission Admission Day of Admission on Admission Hematocrit (9) 36.0-46.0 38(ref37-47) 31.9 Hemoglobin(g/dl) 120-16.013.1(ref12.0-160) 13.5 12.3 11.0 White-cell count(per mm) 4500-1100011600(ref4500 5100 7400 7100 11,000) ifferential count(%) Neutrophils 40-70 87(ref28-62) 72.3 Lymphocytes 22-44 6(ref21-49) 9.5 Monocytes 4-11 7(ref2-10) 17.5 Basophils 0-3 1(ref0-2) 0.3 Platelet count(per mm) 150000-400,000289000(ref 173,000 225.000 180.000 150.000-450.000) Sodium(mmol/ liter) 135-145 130(ref133-145) 128 Potassium(mmol/ liter) 3.4-4.8 3.6(ref3.3-5.1) 3.6 3.2 Chloride(mmol /liter) 100-108 91(ref96-108) Carbon dioxide(mmol/ liter) 23.0-31.9 26(ref22-31) Phosphorus(mg/dl) 2.6-4.5 2.2 mucose(mg/dl) 70-110 122(ref70-10 127 127 Alanine aminotransferase(U/liter) 15(ref-33) 104 163 Aspartate aminotransferase(U/ liter) 9-32 15ref10-35) 120 Alkaline phosphatase(U/liter) 30-100 69(ref35-104) 108 Amylase(U/liter 68(ref28-100)
4 Laboratory Data
4 Laboratory Data Other Hospital, Other Hospital, Reference Range, 5 Days before 2 Days before Other Hospital, This Hospital, variable Adults Ad mission Admission Day of Admission on Admission Borrelia burgdorfer IgG and igM Negative Negative Negative Negative antibodies Blood-smear examination for parasites No parasites seen No parasites seen No parasites seen Babesia microti DNa Negative Negative Negative Negative B duncani dNA Negative Negative Negati Negative B divergens or B MO1 DNA Negative Negative Negative Negative Anaplasma phagocytophilum DNA Negative Negative Negative Negative Ehrlichia chaffeensis DNA Negative Negative Negative Negative E. ewingii or E canis DNA Negative Negative Negative Negative E. muris-like DNA Negative Negative Negative Negative Francisella tularensis antibodies <1:20 <1:20
4 Laboratory Data
5 Problems What is the diagnosis? (What should we do next?
5 Problems What should we do next? What is the diagnosis?