September 30th Transaminitis, Lymphadenopathy and Splenomegaly

Case Conference –epidemiological rash?Daniel LeungNo disclosures

32 yo man• 32 yo man transferred from OSH with:– Fever, chills, frontal HA x 10 days• Prior to that, was playing soccer– Rash x 5 days• Started at ankles, progressed to legs/trunk, ears– Feeling of fullness of “mouth down tostomach”– Received IVF, ceftriaxone, doxycycline

32 yo man w/fever, HA, rash•PMHx:– Child: evaluated for swelling, rash, fever,resolved spontaeneously, not hospitalized– 5 yrs ago: rash & fever, Rx TMP/SMX,resolved• Medications:– Trazodone prn insomnia

32 yo man w/fever, HA, rash• Social Hx:– Born in Brazil (Minas Gerais),– Growing up, lived on a farm with cows, horses, chickens.– Lived in Martha's Vineyard for past 11 years– Home: Lives with 2 brothers– Occupation: painter, works both outdoor & indoor.– Pets: 2 cats– Travel: last trip to Brazil 8 months ago, stayed 3 months.– Sex: last exposure 5 months ago in Brazil, with female partner(had 3 partners during that trip, all female), has multiple lifetimepartners, all female, sometimes with protection. No prostitutes.– Tob: denies EtOH: denies IVDU: denies

32 yo man w/fever, HA, rash• Exam:– Tmax: 102.9 P: 93 R: 20 BP: 120/72 , O2Sat90%– HEENT: OP w/enanthem, anicteric, noconjunctival injection– LN: Shoddy R supraclav, B inguin >2cm, noother LAD– Lungs: R base decr BS, L base crackles– Abdom: NT, ND, Splenic tip palpable

32 yo man w/fever, HA, rash• Exam Cont’d:–Skin:• Raised “dermal” erythematous infiltrate overeyebrows, nose, cheeks, ears• Several similar lesions 2-5cm on abdomen & back• Diffuse blanching erythematous rash on both legs(up to groin), and both arms (up to shoulders),including soles but not palms

32 yo man w/fever, HA, rash• Labs – OSH:–LP/CSF:• 1 wbc, 1 rbc, 100% monocytes• protein 39, glucose 79• GS: no org; Cx: NG– parasite smear negative– Babesia DNA neg– HGE DNA neg– Borellia Ab IgM neg– TSH 1.39, ESR 13– urine cx ng blood cx ng

32 yo man w/fever, HA, rash• Labs – BIDMC:– WBC 4.8 (80N, 10L, 8M)– AST 107, ALT 139– BUN 6, Cr 0.8, CK 115– ANA neg, RF 9, Ferritin 420– ESR 20, CRP 97

32 yo man w/fever, HA, rash• Imaging:–CT Chest

Enlarged lymph nodes measure 26.4 x 16.9 mm in the right axilla and 27.4 x11.4 in the left.

In the mediastinum, there are conglomerate lymph nodes seen just posterior to the leftatrium and to the right of the esophagus (2:53) whose measurement is approximately18.7 x 32.4 mm.

In the mediastinum, there are conglomerate lymph nodes seen just posterior to the leftatrium and to the right of the esophagus (2:53) whose measurement is approximately18.7 x 32.4 mm.

dependent portion of the lungs are bibasilar consolidations withassociated small-to-moderate bilateral pleural effusions

32 yo man w/fever, HA, rash• Imaging:–CT Chest– CT Abdomen/Pelvis

spleen measuring 15 cm in size

There are enlarged bilateral inguinal lymph nodes, left greater than right, withthe largest on the left measuring 2.5 x 1.7 cm in sizeALSO: Multiple enlarged left paraaortic lymph nodesprominent iliac chain lymph nodes are also seen

32 yo man w/fever, HA, rash,transaminitis, LAD, splenomegaly• DIFFERENTIAL?

32 yo man w/fever, HA, rash,transaminitis, LAD, splenomegaly• Hospital course:– Cont’d ceftriaxone, doxycycline– Acute respiratory distress -> ICU on 100% FM– Cont’d doxycycline, started Vanco, Pip/tazo,streptomycin– Cont’d nightly fever to 103F x 3 days– Rapid respiratory improvement -> floor on RA– Temp curve trended down, T 98 on discharge

32 yo man w/fever, HA, rash,transaminitis, LAD, splenomegaly• Labs:–WBC:• 4.4K (85%N) on admit• 8.3K (70%N) on d/c– ALT/AST:• 126/101 on admit• 165/149 on d/c

32 yo man w/fever, HA, rash,transaminitis, LAD, splenomegaly• Labs:– HBV, HCV neg, HAV Ab pos– ANCA neg, RF neg, ANA neg, C3/C4 wnl– HIV Ab neg, HIV-1 VL

32 yo man w/fever, HA, rash,transaminitis, LAD, splenomegaly• Skin Biopsy:– Sections show scattered superficial to deepdermal perivascular, periappendageal, andperineural granulomas. Steiner and GMSstains are negative for microorganisms. Fiteand AFB stains reveal numerous bacilli in thegranulomatous foci.

32 yo man w/fever, HA, rash,transaminitis, LAD, splenomegaly• Lymph Node Biopsy:– Flow Cytometry:• B cells comprise 20% of lymphoid gated events,are polyclonal, and do not express aberrantantigens.• T cells comprise 76% of lymphoid gated eventsand express mature lineage antigens.–“Full” of AFB