The Infectious Disease Diagnosis: A Case Approach

262 Pages·2018·8.76 MB·English

by  Michael David

Michael David
Jean-Luc Benoit
Editors
The Infectious
Disease Diagnosis
A Case Approach
123
The Infectious Disease Diagnosis
Michael David • Jean-Luc Benoit
Editors
The Infectious Disease
Diagnosis
A Case Approach
Editors
Michael David Jean-Luc Benoit
Department of Medicine Department of Medicine
University of Chicago University of Chicago Department
Chicago, IL of Medicine
USA Chicago, IL
USA
ISBN 978-3-319-64905-4 ISBN 978-3-319-64906-1 (eBook)
https://doi.org/10.1007/978-3-319-64906-1
Library of Congress Control Number: 2017959932
© Springer International Publishing AG 2018
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We would like to dedicate this book to Dr. David
Pitrak—teacher, section chief, and friend
Introduction
This volume is intended to be a resource for all health-care providers inter-
ested in infectious diseases and also an educational reference for medical
students, residents, fellows, nursing students, and students in training pro-
grams for physicians’ assistants and other allied health professional fields.
This is neither a textbook nor a manual for use in clinical practice. Instead, it
is a review of common and uncommon infectious diseases that are often in
the differential diagnosis for patients in any medical setting.
We intend for the cases in this book to enable us to share the excitement of
infectious diseases practice and to inspire students and other trainees who are
deciding upon a career path to choose infectious diseases. This field is fasci-
nating and always presents new challenges in diagnosis, prognosis, and ther-
apy. Humans are surrounded by potentially deadly pathogens, but they cause
infections in only very specific circumstances. The diagnosis of an infection
often requires knowledge of pathogens and host risk characteristics. Each
human infection presents a detective story to the physician, and as clues are
assembled in many cases, the most likely diagnosis becomes clear, some-
times quickly and sometimes gradually.
In order to diagnose and treat an infectious diseases patient, the clinician
must consider many facets of the individual’s life and behavior. The infec-
tious diseases doctor has to determine what environmental, pathogen, and
host factors may have aligned to create the “perfect storm” that changed an
environmental or commensal microorganism into the cause of a clinically
significant infection in a patient. In other cases, epidemic spread of a patho-
gen, such as influenza, may lead to an infection. The clinician must take
account of changing pathogen epidemiology, shifting host immunologic sta-
tus, and environmental change. Social and biological factors are constantly
altering the balance between a commensal and a pathological interaction
between people and the microorganisms in their environment. No other field
of medicine requires as close an examination of environmental and behav-
ioral factors in the determination of a diagnosis and in the choice of an
empiric plan for therapy.
While we have many tools to diagnose and treat patients with viral, bacte-
rial, fungal, and parasitic infections, we do not always succeed. While we
have many excellent and effective vaccines and prophylactic strategies, some
infections cannot yet be prevented. While we have many antimicrobial drugs,
there are some infections we still cannot cure. Infectious diseases still kill
many millions of people each year around the world, and thus there are
vii
viii Introduction
exciting opportunities for new experts in clinical and basic research to pursue
novel preventative measures, diagnostic modalities, and treatments for infec-
tious diseases. In some of the cases presented in this book, the limits of our
therapeutic armamentarium are discussed.
The goal of this book is to present a broad, although not comprehensive,
range of cases in infectious diseases, with representation of tropical diseases,
arthropod-borne diseases, human immunodeficiency virus (HIV)/acquired
immune deficiency syndrome (AIDS) medicine, infections arising as a com-
plication of medical care, and general infectious diseases. These types of
cases are all frequently encountered at a typical tertiary medical center in the
United States such as ours. Many of the disease processes described are com-
mon, “bread-and-butter” cases, but there are also more unusual cases in
patients who have had rare exposures or specific vulnerabilities. We included
cases of infection in children and adults, infections arising in the community,
and others arising in the health-care setting.
In each chapter, the author or authors describe the case of different patients,
most of whom were treated at our tertiary care medical center. These cases
were nearly all presented by a clinical fellow at our weekly Thursday afternoon
case conference in the Section of Infectious Diseases and Global Health of the
Department of Medicine of the University of Chicago between 2004 and 2016.
The cases thus have benefited from discussion by a group of experts with many
decades of combined experience in the field. As it was in our conference, each
case is presented here as an unknown, and the reader is invited to develop a dif-
ferential diagnosis as he or she reads it. The history of the illness, relevant past
medical history, family history, social history, exposures, travel, behaviors,
medications, allergies, physical findings, laboratory test results, and findings on
imaging studies are presented. One or more radiographic, clinical, gross patho-
logical, histological, entomologic, or environmental image is shown in nearly
every chapter to enhance the educational impact of the case.
We hope that the reader of our book will gain a greater understanding of
the pathogenic microorganisms that infect humans; the social, biological, and
behavioral factors associated with increased risk of infection or outcome of
an infection; the interaction of infectious diseases with other comorbidities;
the approaches to diagnosis of infectious diseases (including by means of the
history, signs and symptoms, cultures, and serologic, radiographic, molecu-
lar, histological, and surgical data); the considerations in the selection of
medical and surgical treatment modalities; the variety of clinical manifesta-
tions of human infections with the pathogens discussed; the pathogenesis of
infectious diseases within specific organs and organ systems; the vectors
associated with vector-borne diseases; the problems of antimicrobial resis-
tance; and the geographic distribution of the described pathogens. However,
while all of these fascinating aspects of infectious diseases are included in
most of the cases, the primary focus of this book and at the center of each case
is the differential diagnosis.
Often before the diagnosis is revealed in each case, the reader’s attention
is importantly directed to a table listing the relevant differential diagnosis. In
most of the cases, the authors also provided in the text a discussion of the
differential diagnosis as applied to the specific circumstances of the patient
Introduction ix
presented, examining the factors that make certain diagnoses more or less
likely. This teaching exercise is meant to enhance the reader’s skills of
deductive reasoning in clinical medicine. This is the detective work of infec-
tious diseases.
An index is provided in an appendix at the end of the book that includes
each diagnosis listed in the tables of differential diagnosis from all chapters.
This “differential diagnosis index” is a very unusual and important resource.
For each pathogen, by consulting this index, it is possible to review all cases
in the book for which that pathogen was a diagnostic consideration. Thus,
from the cases in this book, the reader is able to review the potential presenta-
tions of many pathogens and to understand how to narrow the differential
diagnosis rapidly and efficiently and how to distinguish that pathogen from
others with a similar clinical presentation. This index expands the value of
our book because it can be used to shape the clinician’s approach to consider-
ing a specific diagnosis in a number of different clinical circumstances.
The editors have attempted to reproduce much of the teaching value of our
case conference in this volume. The 47 cases presented have been drawn
from more than 12 years of our weekly case discussions. During those
12 years in the first part of the twenty-first century, clinicians in our inpatient
and outpatient services provided care for many thousands of patients. Among
these, more than 450 patients were chosen by clinical fellows and faculty for
case presentations at our weekly conferences. The editors chose approxi-
mately 10% of these presented cases to represent the breadth of the pathology
as well as some of the most intriguing and confusing patients whom we have
encountered at out medical center. Many “generations” of pediatric and adult
clinical fellows have contributed to this effort, some overlapping in their time
at our medical center and others not. Many of them have now practiced else-
where and enhanced their knowledge of infectious disease in a variety of
practices across the United States. These authors are responsible for the rigor-
ous and stimulating content of this book.
It is our hope that once the reader has finished the cases presented here, the
volume can later be consulted as an adjunct to preparation for clinical rotations
in infectious diseases, board examinations, teaching in the clinical context,
and a quick and fairly comprehensive reference to concise descriptions of the
key elements related to a pathogen, a syndrome, or a differential diagnosis.
We hope that in the cases presented in this volume, we can transmit to you
some of our great enthusiasm for the dynamic and exciting field of infectious
diseases. If you are considering choosing infectious diseases as a specialty,
we encourage you to do this! The field provides constant challenges and fas-
cinating problems affecting all organ systems in the human body, a broad
range of human behaviors, data derived from almost innumerable sources, a
fascinating view of humanity’s interaction with the microbial world sur-
rounding us, a unique perspective on humanity’s interaction with the environ-
ment, a succession of mysteries almost everyday to solve, and the great
satisfaction of often providing a successful cure.
Michael Z. David
Jean-Luc Benoit
Contents
1 Traveler to Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Nirav Shah and Eric Bhaimia
2 Visual Loss in a Hematopoietic Stem
Cell Transplant Recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Kathleen Linder and Kevin Gregg
3 Like Mother, Like Daughter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Emily Obringer
4 From the Lungs to the Brain: A Case of Pneumonia
in an Immunocompromised Patient . . . . . . . . . . . . . . . . . . . . . . . . 19
Fredy Chaparro-Rojas
5 Student with Fever and Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Moira McNulty
6 Fever, a Rash, and a … “Bug Bite”? . . . . . . . . . . . . . . . . . . . . . . . . 29
Karl O.A. Yu and Jennifer L. Burns
7 Primed for Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Shirley Stephenson
8 The Gift That Keeps on Giving . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Frances Lahrman and Stephen Schrantz
9 A Man with Heart Failure and Night Sweats . . . . . . . . . . . . . . . . . 49
Amutha Rajagopal
10 Seizure and Confusion in an Elderly Woman
with Bacteremia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Leona Ebara
11 Don’t Toss Your Turtle! Seizures and Fever in an Infant . . . . . . . 59
Muayad Alali
12 Intermittent Fevers in a Renal Transplant Recipient . . . . . . . . . . 65
Kathleen Linder and Kevin Gregg
13 A Young Adult with Cough and Wheezing Since Infancy . . . . . . . 71
M. Ellen Acree
xi
xii Contents
14 Elevated Liver Enzymes in Pregnancy . . . . . . . . . . . . . . . . . . . . . . 77
Daniela Pellegrini
15 Eye Pain and Visual Disturbance in an HIV/AIDS Patient. . . . . . 81
Fredy Chaparro-Rojas
16 Undetected: When Medication Nonadherence
Accompanies an Undetectable Viral Load . . . . . . . . . . . . . . . . . . . 85
Matthew Richards and Connor Williams
17 Danger in Paradise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Margaret Newman
18 Man with AIDS Presents with a Headache . . . . . . . . . . . . . . . . . . . 99
David Kopelman and Emily Landon
19 Vexing Vectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Shirley Stephenson
20 A Toddler with Pica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
M. Ellen Acree
21 Hidden Sphere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Jessica Ridgway
22 The Importance of a Complete Social History . . . . . . . . . . . . . . . 119
Lindsay A. Petty and Kenneth Pursell
23 Myalgias and Joint Pain in a Traveler to India . . . . . . . . . . . . . . 123
Oana Denisa Majorant and Sara Hurtado Bares
24 A Marathon Runner with a Change in Mental Status . . . . . . . . 131
Michael Z. David
25 Unmasking One of the Great Masqueraders . . . . . . . . . . . . . . . . 137
Ralph Villaran
26 Pulmonary Infection in a Patient After Stem
Cell Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Dima Dandachi and Vagish Hemmige
27 An HIV Patient with Nausea, Vomiting, and Hiccups . . . . . . . . . 147
Moira McNulty
28 A Real Nail-Biter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Jessica Ridgway
29 Nodular Skin Lesions in a Patient with Leukemia . . . . . . . . . . . 157
Daniela Pellegrini
30 Elderly Man with Fever and Cough: TB or Not TB? . . . . . . . . . 161
Moira McNulty
31 Malaise, Fever, and Nausea in a Man
with Marfan Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Dima Dandachi and Vagish Hemmige