Aa
female with recurring symptoms
Hello,
I would appreciate your advice regarding a 52-year-old female patient who has been experiencing some concerning symptoms. A month ago, she began to suffer from weakness, sweating, and intermittent fever with temperatures reaching up to 104°F (40°C), but no other symptoms or pain were reported. Some of her blood test results showed elevated levels: White Blood Cells (WBC) - 78.9, Erythrocyte Sedimentation Rate (ESR) - 120, C-reactive protein (CRP) - 150, Alkaline phosphatase (ALP) - 659, Aspartate aminotransferase (AST) - 42.8, and Alanine aminotransferase (ALT) - 122.4.
She was hospitalized for two weeks, during which she underwent several examinations: a chest CT scan without any abnormalities, an abdominal CT scan that revealed a hyperdense formation (13x12x10 mm) with a round and smooth shape and clear, even contours (calcified lymph node) but was otherwise reported as "no abnormalities", a transabdominal ultrasound of the uterus and adnexa which showed signs of uterine fibroids (a long-standing issue for her), and tests for hepatitis and coronavirus, which were negative. During her hospital stay, she was treated with antibiotics. Upon discharge, her blood and urine tests were within normal limits, and her fever subsided.
However, 12 days after being discharged, she started feeling unwell again, with a fever intermittently reaching 103.1°F (39.5°C) and occasionally subsiding without antipyretics. New tests were conducted:
Blood test:
CRP - 190 mg/L; Bilirubin - 14.5 µmol/L; AST - 31.2 U/L; ALT - 40 U/L; ESR - 50; WBC - 12.3, Red Cell Distribution Width (RDW) - 15.4%.
Urine test (previous urine tests were normal):
Color - Amber; pH - 5.0; Protein - 1.11 g/L; Ketone bodies - 1.5 mmol/L; Erythrocytes - 181 cells/µL; Leukocytes - 220 cells/µL; Bacteria - significantly present in the field of view. Other parameters of the general urine test were within normal limits.
Given her history and test results, what should be the primary focus of our investigation?
What examinations should be prioritized to determine the cause of her recurring symptoms?
Thank you for your assistance.
I would appreciate your advice regarding a 52-year-old female patient who has been experiencing some concerning symptoms. A month ago, she began to suffer from weakness, sweating, and intermittent fever with temperatures reaching up to 104°F (40°C), but no other symptoms or pain were reported. Some of her blood test results showed elevated levels: White Blood Cells (WBC) - 78.9, Erythrocyte Sedimentation Rate (ESR) - 120, C-reactive protein (CRP) - 150, Alkaline phosphatase (ALP) - 659, Aspartate aminotransferase (AST) - 42.8, and Alanine aminotransferase (ALT) - 122.4.
She was hospitalized for two weeks, during which she underwent several examinations: a chest CT scan without any abnormalities, an abdominal CT scan that revealed a hyperdense formation (13x12x10 mm) with a round and smooth shape and clear, even contours (calcified lymph node) but was otherwise reported as "no abnormalities", a transabdominal ultrasound of the uterus and adnexa which showed signs of uterine fibroids (a long-standing issue for her), and tests for hepatitis and coronavirus, which were negative. During her hospital stay, she was treated with antibiotics. Upon discharge, her blood and urine tests were within normal limits, and her fever subsided.
However, 12 days after being discharged, she started feeling unwell again, with a fever intermittently reaching 103.1°F (39.5°C) and occasionally subsiding without antipyretics. New tests were conducted:
Blood test:
CRP - 190 mg/L; Bilirubin - 14.5 µmol/L; AST - 31.2 U/L; ALT - 40 U/L; ESR - 50; WBC - 12.3, Red Cell Distribution Width (RDW) - 15.4%.
Urine test (previous urine tests were normal):
Color - Amber; pH - 5.0; Protein - 1.11 g/L; Ketone bodies - 1.5 mmol/L; Erythrocytes - 181 cells/µL; Leukocytes - 220 cells/µL; Bacteria - significantly present in the field of view. Other parameters of the general urine test were within normal limits.
Given her history and test results, what should be the primary focus of our investigation?
What examinations should be prioritized to determine the cause of her recurring symptoms?
Thank you for your assistance.
I'd be on guard for signs of sepsis, which can be very very severe. Then straight to Emergency Dept. Also watch for lower back pain and similar signs of any infection getting upstream to the kidneys. Also regularly taking her temperature, of course. Good luck.
Hi, some quick brainstorming:
She either had a wicked pathogen or else a hyper immune reaction. Her lab numbers were pretty darn high.
What are the abs numbers for neuts and lymphocytes? The WBC is just the catchall.
Noteworhty: that node is *very* rounded, almost spherical; if it really is a node. They can further scan it to see the internal 'architecture', maybe using HRCT /w contrast; unless it's near the surface then you'd want ultrasound, and then the Doppler to see blood flow. I wouldn't just forget that it's there, because it might be driving the all around problems. But if it was the only odd thing, I wouldn't fixate on it. That's called clinical context.
It's likely not Tuberculosis or Sarcoidosis. Maybe it's an atypical case of a rare-for-AU pathogen.
"has not traveled to any tropical countries recently"
That node could have been like that for a while. Rare but possible for AU is histoplasmosis, which can be dormant (look up granulomas) and then get released and active. Has she had anything to suppress her immune system lately, such as any drugs or even immense stress?
Histo would normally be in lungs first, did she have any breathing problems in times past? (Histo can later get disseminated.)
Check if the antibiotic she was given might by chance also have antifungal activity.
Lookup the DDx for histo, but for what's local to AU.
http://conditions.health.qld.gov.au/HealthCondition/condition/14/92/76/Histoplasmosis
Btw, the liver effects can possibly be downstream from infection, either (1) toxins from the pathogen or (2) massive release of immune system chemicals inevitably getting to the liver.
-------------------------------------
But you say she had no Urinary Tract problems during the initial episode in the hospital? Only 12 days after. So that's a real curiosity.
It's a possibility that her initial episode had no infection, but was all immune system (sterile inflammation) only. Any Hx or Fx of immune oddities, lupus etc? So then the UT bacteria/WBCs/blood/protein could have been coincidental, or even something hospital acquired. Maybe her Abx is one that is also anti inflammatory.
If this was a simple and plain case, her docs would have figured it all out by now. So we look at what is unlikely but possible.
She either had a wicked pathogen or else a hyper immune reaction. Her lab numbers were pretty darn high.
What are the abs numbers for neuts and lymphocytes? The WBC is just the catchall.
Noteworhty: that node is *very* rounded, almost spherical; if it really is a node. They can further scan it to see the internal 'architecture', maybe using HRCT /w contrast; unless it's near the surface then you'd want ultrasound, and then the Doppler to see blood flow. I wouldn't just forget that it's there, because it might be driving the all around problems. But if it was the only odd thing, I wouldn't fixate on it. That's called clinical context.
It's likely not Tuberculosis or Sarcoidosis. Maybe it's an atypical case of a rare-for-AU pathogen.
"has not traveled to any tropical countries recently"
That node could have been like that for a while. Rare but possible for AU is histoplasmosis, which can be dormant (look up granulomas) and then get released and active. Has she had anything to suppress her immune system lately, such as any drugs or even immense stress?
Histo would normally be in lungs first, did she have any breathing problems in times past? (Histo can later get disseminated.)
Check if the antibiotic she was given might by chance also have antifungal activity.
Lookup the DDx for histo, but for what's local to AU.
http://conditions.health.qld.gov.au/HealthCondition/condition/14/92/76/Histoplasmosis
Btw, the liver effects can possibly be downstream from infection, either (1) toxins from the pathogen or (2) massive release of immune system chemicals inevitably getting to the liver.
-------------------------------------
But you say she had no Urinary Tract problems during the initial episode in the hospital? Only 12 days after. So that's a real curiosity.
It's a possibility that her initial episode had no infection, but was all immune system (sterile inflammation) only. Any Hx or Fx of immune oddities, lupus etc? So then the UT bacteria/WBCs/blood/protein could have been coincidental, or even something hospital acquired. Maybe her Abx is one that is also anti inflammatory.
If this was a simple and plain case, her docs would have figured it all out by now. So we look at what is unlikely but possible.
By "might expose her to bacteria," of course I mean an unusual or virulent strain. (Everywhere anyone lives has the potential to expose them to bacteria.)
You're asking what the primary focus of the investigation should be. Are you on the medical team, or are you a family member? (I ask because the medical team determines the primary focus of the investigation. Having Doctor Internet come in and try to second guess them or suggest changes to what they are doing would probably irritate them a lot.)
Presumably, her doctors will take the fact that her symptoms subsided when she was on antibiotics and came back when she was not on antibiotics as a signal that her ailment is caused by bacteria. Questions they'll probably consider are whether the first round of antibiotics was given long enough or if this is simply a rebound of the first infection, or whether this might be a new bout. Does she live somewhere that might expose her to bacteria?
Presumably, her doctors will take the fact that her symptoms subsided when she was on antibiotics and came back when she was not on antibiotics as a signal that her ailment is caused by bacteria. Questions they'll probably consider are whether the first round of antibiotics was given long enough or if this is simply a rebound of the first infection, or whether this might be a new bout. Does she live somewhere that might expose her to bacteria?
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Thank you for your response. I am a family member, not part of the medical team. The reason I am asking is that the doctors have not yet been able to provide a definitive diagnosis, and I thought you might have some insight into what could be causing her symptoms or suggest additional examinations that could be performed. She has the option to undergo certain tests or blood work independently at a private hospital without a doctor's referral, which could help save time. She lives in an area without exposure to harmful bacteria and has not traveled to any tropical countries recently
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