SYNDROMES
MASQUERADING AS
INFECTIONS
Syndromes that masquerade as infections
• We will tackle questions and cases
• Fever is often a presenting symptom
• Or can present in a way that is similar to an infectious
syndrome like pneumonia, cellulitis, wound infection, or
septic arthritis
• There are many; we will cover a few today
Question
• A 25 yo M is referred to you for recurrent fevers lasting 2-3 days.
• Fevers are sometimes accompanied by arthralgias of the ankles
•
•
•
•
or other joints
Recurrent bouts of testicular and abdominal pain that last 24 to
48 hours. Surgery for hydrocele did not improve the pain.
No pleuritis, genital ulcers, rash history of STI. Occasional oral
ulcers
Exam normal vital signs, no rashes, several oral aphthous
ulcerations, plantar tenderness and mildly swollen knees
Labs CRP of 3.0 mg/dl (normal 0–0.8) and neg RF. UA
showed trace proteinuria. Ferritin 300 (normal 40-200)
Question
• The most likely diagnosis is
• A. Familial Mediterranean Fever
• B. Adult Still’s Disease
• C. Kikuchi’s Disease
• D. Behcet’s disease
Question
• The most likely diagnosis is
• A. Familial Mediterranean Fever
• B. Adult Still’s Disease
• C. Kikuchi’s Disease
• D. Behcet’s disease
Familial Mediterranean Fever
• Autosomal recessive
• Occurs primarily in Jews, Armenians, Turks, Arabs in the
Mediterranean basin, central Asia, and Japan
• Can occur at any age, but 80% of cases occur before age
of 20
• M:F  1.5-2
• Episodic attacks
• last from 24-72 hours
• Moderate to high fever
• Painful serositis including abdominal pain
• Mutation in MEFV gene leading to alteration in pyrin
protein
• Treatment: colchicine
Recurrent Ulcers
• 40 yo Caribbean
woman referred for
refractory oral ulcers.
• No response to
valacyclovir
• Low grade fevers at
home, poor appetite,
weight loss
• Then developed ulcers
pictured at right
© THE STANFORD PROGRAM ON INTERNATIONAL AND CROSS-CULTURAL EDUCATION
Fever
Question
• A 68 yo man presented with several months of fevers
followed by precordial chest pain for 1 week. He also
reported generalized fatigue, weight loss, and night
sweats.
• PE: T 101.7°F. His physical examination results were
unremarkable. No murmur or rub was noted on cardiac
examination.
• Labs: WBC 8.3 K/mm3, Plt 301 K/mm3. ESR 99, CRP
161.9. Cr: 2.1. u/a: 3+ protein
• EKG showed pericarditis. Transthoracic and
transesophageal echocardiograms showed a moderate
pericardial effusion, but no vegetations
Question
• The most likely diagnosis is:
• A. Myocardial infarction
• B. Coxsackievirus infection
• C. Purulent pericarditis with S. aures
• D. Systemic lupus erythematosus
Question
• The most likely diagnosis is:
• A. Myocardial infarction
• B. Coxsackievirus infection
• C. Purulent pericarditis with S. aureus
• D. Systemic lupus erythematosus
Antinuclear antibody titer was 1:340 (n = <1:40) and an
anti–double-stranded DNA titer was 1:640
SLE – Dx Criteria
• Malar rash
• Discoid rash
• Photosensitivity
• Oral ulcers
• Arthritis (non-erosive)
• Serositis
• Renal disorder
• Neurologic disorder (sz,
psychosis)
• Hematologic disorder
• Immunologic disorder
• Anti-DNA, anti-Sm, APLA
• ANA+
From: A Comprehensive Evidence-Based Approach to Fever of Unknown Origin
Arch Intern Med. 2003;163(5):545-551. doi:10.1001/archinte.163.5.545
Figure Legend:
The percentage of patients with fever of unknown origin by cause over the past 40 years.
Copyright © 2012 American Medical
Association. All rights reserved.
• What is the workup for FUO?
Obligatory tests: ESR or CRP, CBC with diff, CMP, SPEP, LDH, CK, ANA,
RF, blood cultures (x3), urine Cx, chest X-ray, abdominal ultrasonography
(or CT), PPD or IGRA
2nd Level: BM biopsy, temporal artery biopsy in patients older than 55
years, funduscopy, abdominal CT, and chest CT.
Question
• 64 yo man has had repeated
bouts of tenderness of the
cartilaginous part of both ears
that typically last for one to two
weeks.
• No SOB, chest pain, dyspnea,
or any eye complaints during
these episodes. He had
symptoms of degenerative
arthritis but did not have
evidence of joint effusions
Am Fam Physician. 2002 Jul 1;66(1):141-142.
Question
• Which one of the following is the
most likely diagnosis?
• A. Cellulitis of the ear.
• B. Allergic contact dermatitis.
• C. Chronic cutaneous (discoid)
lupus.
• D. Superficial basal cell
carcinoma.
• E. Relapsing polychondritis.
Am Fam Physician. 2002 Jul 1;66(1):141-142.
Question
• Which one of the following is the
most likely diagnosis?
• A. Cellulitis of the ear.
• B. Allergic contact dermatitis.
• C. Chronic cutaneous (discoid)
lupus.
• D. Superficial basal cell
carcinoma.
• E. Relapsing polychondritis.
Am Fam Physician. 2002 Jul 1;66(1):141-142.
www.uptodate.com
www.nejm.org
Relapsing Polychondritis
• Systemic inflammatory process that affects cartilage
• Can involve
• Ears (auricular chondritis)
• Joints (nonerosive, seronegative inflammatory polyarthritis)
• Nose (nasal chondritis)
• Eyes (conjunctivitis, keratitis, scleritis/episcleritis, uveitis)
• Respiratory tract chondritis (laryngeal and/or tracheal cartilages)
• Ears/vestibular system (neurosensory hearing loss, tinnitus, and/or
vertigo)
• Heart (valvular disease)
• Clinical diagnostic criteria
• Occurs in all races and groups, male = female
• Treated with glucocorticoids, other immunosuppressants
Saddle Nose Deformity
• Syphilis
• Lepromatous leprosy
• Relapsing polychondritis
• Granulomatosis with polyangiitis (Wegner’s
granlulomatosis)
• Cocaine abuse
Question
• A 54 yo man with a history of laryngeal cancer was
admitted to the hospital for evaluation of fever and of a
painful, erythematous eruption on back and chest. The
patient denied any recent trauma, travel, gardening, or
exposure to animals. No recent chemotherapy or radiation
treatments.
• PE T 101.4, well demarcated, ecchymotic, tender,
plaques were noted on back and chest, neck.
• Labs  WBC 13k (86% PMN), Plt 404, Cr 1.3.
• The patient was given broad-spectrum antibiotics, but his
condition did not improve.
Néstor P. Sánchez. Atlas of
Dermatology in Internal Medicine
Question
• The most likely diagnosis is:
• A. Sweet’s syndrome
• B. Drug eruption
• C. Dermatomyositis
• D. HSV
Question
• The most likely diagnosis is:
• A. Sweet’s syndrome
• B. Drug eruption
• C. Dermatomyositis
• D. HSV
Sweet’s Syndrome
• Acute febrile neutrophilic dermatosis
• Characterized by
• Painful erythematous or eccymotic plaques, papules or nodules
• Fever
• Leukocytosis
• Typical histologic features
• Can be associated with infection (URI or GI infection -
Yersinia), malignancy (esp heme malignancies), drugs
(including GCSF)
• Lesions are more commonly on face, neck, UE
• Path – edema, dense neutrophilic infiltrate in dermis
• Treatment: glucocorticoids
Néstor P. Sánchez. Atlas of
Dermatology in Internal Medicine
Dermatomyositis
http://dermatlas.med.jhmi.edu
Am Fam Physician. 2002 Oct 1;66(7):1285-1286.
Question
• These skin lesions are associated with:
• A. Amyloidosis
• B. Ulcerative colitis
• C. Vibrio species infection
• D. Cryptococcal infection
Question
Question
• These skin lesions are associated with:
• A. Amyloidosis
• B. Ulcerative colitis
• C. Vibrio species infection
• D. Crytococcal infection
Question
• These skin lesions are associated with:
• A. Amyloidosis
• B. Ulcerative colitis
• C. Vibrio species infection
• D. Crytococcal infection
Pyoderma Gangrenosum
• Characterized by irregular, boggy, blue-red ulcers with
•
•
•
•
•
undermined borders and purulent necrotic base
Acutely, painful pustule or nodule that ulcerates
Can be associated with systemic diseases, esp UC
Histology: neutrophilic inflammation with abscess
formation and necrosis (not specific for PG)
Slight trauma (biopsy, blood draw) can initiate new PG
lesions
Treatment: immunosuppression or immune modulation
http://dermatlas.med.jhmi.edu
More PG at a Surgical Site
Question
• A 45 yo W is evaluated for a 2-month history of
fatigue, nonproductive cough, decreased appetite, intermittent
fever, RUQ pain, and a 4.5-kg (10.0-lb) weight loss.
• PE T 37.8°C (100.0°F), BP 104/68, HR 100/min, and RR 16,
BMI 28. Several erythematous 5- to 10-mm maculopapular
lesions on face. Cardiopulm normal, Hepatomegaly. B/L
inguinal LAD
• Labs:
• hgbn 12.2 g/dL; phos 4.0 mg/dL; ca 11.2 mg/dL, Cr, 2.0 mg/dL
• urinalysis, 1+ protein; 20 leukocytes/hpf
• PPD negative. Urine cx negative
• Chest radiograph shows bilateral hilar lymphadenopathy. Renal
u/s: rt kidney is 13.7 cm and lt kidney is 15.4 cm. No hydro, no
stones
Ann Intern Med. 01 May 2012;156(9):ITC5-1
http://dermatlas.med.jhmi.edu
Question
• Which of the following is the most likely diagnosis?
• A. Amyloidosis
• B. Sarcoidosis
• C. The Sjögren syndrome
• D. Systemic lupus erythematosus
Ann Intern Med. 01 May 2012;156(9):ITC5-1
Question
• Which of the following is the most likely diagnosis?
• A. Amyloidosis
• B. Sarcoidosis
• C. The Sjögren syndrome
• D. Systemic lupus erythematosus
Ann Intern Med. 01 May 2012;156(9):ITC5-1
Sarcoidosis
• Idiopathic granulomatous disease
• Can affect any organ
• In the US, more common in African Americans
• Common presenting signs and symptoms: cough, fever
and weight loss, chest pain, painful ankle swelling, painful
nodules on shins, eye pain
• Variable clinical course
• Clinical features, imaging, histopathology contribute to the
diagnosis
• Treatment: prednisone
Question
• A 21 yo man is evaluated for a 5-day history of pain and
swelling in the right ankle. 7 days ago, he developed a nodule
on the left leg. He has no history of trauma to either of these
sites.
• PE: VS are normal. The right ankle is warm and swollen, and
range of motion elicits pain. He also has a warm, firm, 2-cm
erythematous nodule over the anterior left lower extremity that
is tender to palpation and has been present for 7 days.
• A plain x-ray of the right ankle is normal.
• Arthrocentesis of the right ankle is performed, and synovial
fluid analysis reveals a leukocyte count of 3000/μL (80%
lymphocytes,12% macrophages). No crystals.
Question
• Which of the following is the most likely diagnosis?
• A. Bacterial arthritis
• B. Crystal-induced arthritis
• C. Osteoarthritis
• D. Sarcoidosis
Question
• Which of the following is the most likely
•
•
•
•
diagnosis?
A. Bacterial arthritis
B. Crystal-induced arthritis
C. Osteoarthritis
D. Sarcoidosis
• Lofgren syndrome: acute monoarticular
arthritis (ankles typically), erythema
nodusum, and hilar LAD.
Figure Legend:
Organ Involvement in Sarcoidosis*
Ann Intern Med. 01 May 2012;156(9):ITC5-1
Granulomatous Inflammation
• Distinct pattern of chronic inflammatory reaction in which
the predominant cell type is an activated macrophage with
a modified epithelial-like appearance
• A granuloma is a focal area of granulomatous
inflammation consisting of an aggregation of
macrophages that are transformed into epithelial-like cells
surrounded by a collar of mononuclear leukocytes
wikipedia
Sarraf Vol. 7; Issue 8; 13 May 2005
Question
• 29 yo woman originally from Puerto Rico with HIV (on
•
•
•
•
ARVs, CD4 209) admitted with fever, nausea and
vomiting.
Fever on and off for 2 years, +night sweats, 45 pound
weight loss
PE T 102, tender left sided cervial LAD, bl
supraclavicular LAD, lungs clear
Labs WBC 5.7, HCT 32, Cr 0.7, LFTs WNL
Biopsy of cervical LN showed granulomas on frozen
section.
What would you do next?
• Team started empiric TB treatment
• Final path: lymph nodes with necrotizing granulomas
• GMS stain showed small budding yeast
• Culture positive for fungi at 10 days that ultimately grew
Histoplasma capsulatum.
Granulomatous Inflammation
• Infection
• Fungi
• Histo, cocci, blasto, sporothrix,
aspergillus, crypto
• Parasites
• Toxo, Leish, schistosomiasis
• Spirochetes
• T. pallidum
• Mycobacteria
• M. tuberbulosis, M. leprae, M.
kansasii, M. marinum, M. avian
• Bacteria
• Brucella, Yersinia, Bartonella,
Nocardia, Actinomyces
• Misc
• Whipple’s disease, Kikuchi (?)
• Vasculitis
• Granulomatosis with
polyangiitis, Churg-Strauss,
GCA, SLE, polyarteritis nodosa
• Immunologic issues
• Sarcoidosis, Crohn’s, PBC,
Histiocytosis X
• Leukocyte oxidase defects
• CGD
• Hypersensitivity pneumonitis
• Farmer’s lung, bird fanciers
• Chemicals
• Talc, Silica, Zirconium
• Malignancy
• carcinoma
Granulomatous Inflammation
• Infection
• Fungi
• Histo, cocci, blasto, sporothrix,
aspergillus, crypto
• Parasites
• Toxo, Leish, schistosomiasis
• Spirochetes
• T. pallidum
• Mycobacteria
• M. tuberbulosis, M. leprae, M.
kansasii, M. marinum, M. avian
• Bacteria
• Brucella, Yersinia, Bartonella,
Nocardia, Actinomyces
• Misc
• Whipple’s disease, Kikuchi (?)
• Vasculitis
• Granulomatosis with
polyangiitis, Churg-Strauss,
GCA, SLE, polyarteritis nodosa
• Immunologic issues
• Sarcoidosis, Crohn’s, PBC,
Histiocytosis X
• Leukocyte oxidase defects
• CGD
• Hypersensitivity pneumonitis
• Farmer’s lung, bird fanciers
• Chemicals
• Talc, Silica, Zirconium
• Malignancy
• carcinoma
Many syndromes more to consider….
• Rheumatoid arthritis
• Thyroiditis
• Allergic alveolitis
• Hemophagocytic syndrome
• IBD
• Pheochromocytoma
• TTP/HUS
• Body cavity lymphoma, primary effusion lymphoma
• Multicentric Castleman’s Disease
• Drug eruption
• Lymphoma/leukemia
• Vasculitis
Descargar

Syndromes Masquerading as Infections