18 years old girl with recurrent fever

Patient name :   DIOSCOREA462HISPIDA

History uploaded by Ms Anamika Sharma, PCMS Medicine, Research Lab, Bhopal, Winter-Spring 2014"

Patient Particulars - Age-18 year, hight - 5,weight - 48,sex -female

History of Illness-last month me mujhe fever aaya the tab mujhe thand lag kar fever aaya the.to mene docter ko dhikhaya to investigation me kuch bhi nahi nikala sari report normal aai.lekin meri family ko laga ki maleria hai.to meri family ne mujhe maleria ka doj diya. 10-12 din .fir me teek ho gai.uske baad mujhe bas weakness bas lagti hai.or bhukha bhi nahi lag rahi thi.

abhi 2014 jan. me mujhe fir se thand lag kar fever aaya.or vomitting ,chakkar.haeadache problum ho rahi hai.sir me bharipan or aankho me dhundhlapan aana. or jab me medicine leti hu tab tak teek rehti hu.uske bad mujhe fir se fever jese lagne lagta hai.

history upload by interns dr.ruchika and dr.sadaf, interns, PCMS, Medicine

a 18 yr young female,presents with complaints of fever for 2 months,initially for 15 days fever was high grade and associated with chills and rigor for which antimalarial treatment and monocef was given for 8 days.after 10 days she also complained of low backache which was more in the left buttock (pain localized by us to sacro-iliac joints.

Online clinical decision support:

Rakesh Biswas Update: This girl eventually failed to respond to chloroquine and was admitted with us for further fever charting which showed this:http://www.udhc.co.in/ViewImage?file_id=2250&scale=800
Rakesh Biswas We began ceftriaxone intravenously and sent a blood culture and meanwhile she also complained of a pain in her left buttocks suggestive of sacroiliietis. This is one of the CT images of of her sacroiliac joint: http://www.udhc.co.in/ViewImage?file_id=2248&scale=800
Rakesh Biswas The blood culture grew this organism much to our relief as we now had a solid diagnosis for her fever:http://www.udhc.co.in/ViewImage?file_id=2246&scale=800
Rakesh Biswas The culture sensitivity revealed the usual muti-drug resistant avatar which is so very common in India:http://www.udhc.co.in/ViewImage?file_id=2247&scale=800
Rakesh Biswas Her fever started coming down in the same step ladder pattern commonly described in text books (subsiding by lysis instead of crisis?): http://www.udhc.co.in/ViewImage?file_id=2315&scale=800
Rakesh Biswas This organizm is known to cause sacroilietis or reactive arthritis but any reference to it happening in the acute phase when the organism is still active? Michele MeltzerAble LawrenceAmit Taneja,Priyank Jain?
Rakesh Biswas Michele Meltzer inputs: Very instructive and interesting case. Here is a reference: http://www.josonline.org/pdf/v19i2p244.pdf that should be helpful. I know malaria is common but it is important to develop a differential diagnosis!!
Rakesh Biswas Thanks Michele. Malaria and Typhoid are the commonest pillars in India that feed a medical industry producing antibiotics and anti-protozoals dealing with fevers where the commonest cause is often viral. smile emoticonWe have in the past tried to optimize their usage utilizing low cost diagnostic tools but we still have a long way to go. frown emoticon
Amit Taneja Great case. I haven't seen sacroilietis happen from typhoid, certainly not in acute bacteremic phase.
Rakesh Biswas Me neither. This was a first although subsequently we found it well described in case reports as in the link from AIIMS shared by Micheleas well as these here:Paper 1: This paper highlights a patient's bone scan (99mTc-MDP) 10 days after onset of symptoms showing increased uptake of the radioisotope in bilateral sacroiliac joint:http://jidc.org/index.php/journal/article/viewFile/476/275

Paper 2: While no pathology was found in the direct sacroiliac radiography of the patient, her sacroiliac diffusion-weighted magnetic resonance imaging (MRI) examination revealed signal changes consistent with edema in the bones adjacent to the left sacroiliac joint and inflammation in the adjacent paraspinal muscles, corresponding to left sacroiliitis (Fig. 1). On the three-phased and whole body bone scintigraphy, on the late static images, activity retention which increased in focal terms in the left sacroiliac joint region, consistent with sacroiliitis, was reportedhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3354413/

Paper 3: http://www.kfshrc.edu.sa/annals/Old/173/96-202.pdf...
Rakesh Biswas We didn't find anything in her CT (from BMHRC) here:http://www.udhc.co.in/ViewImage?file_id=2248&scale=800

We may have been able to pin point the sacro ilieitis better with sacroiliac diffusion-weighted magnetic resonance imaging (MRI) and/or Three-phasic whole body bone scintigraphy (Tc99m MDP).

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