FW: Advice on a patient

From: Jason, Janine (jmj1@CDC.GOV)
Date: Fri Mar 24 2000 - 11:51:23 EST


> I wonder if I could get ideas on a patient.
>
> Patient is a 9 mo Indian girl presenting with 4 weeks of documented fevers
> to 104, persisting through most of the day, without any obvious pattern.
> Past history is remarkable only for a visit to India in January and
> positive throat FA or culture (not clear which) for adenovirus on her  and
> for Group A strep on her 3 year old brother.  At admission, the child
> looked quite well, playing through her fevers, though she does not look
> good now.  PE was unremarkable, with no cough, clear lungs, no tenderness
> or organomegaly or rash.  Thick and thin smears X7 have been negative for
> malaria.  Also negative (bacteria, mycobacteria, etc.) are   blood
> cultures, stool cultures, urine cultures.   Eye exam and cardiac echo were
> negative.  All serology was negative, including CMV, EBV, parvovirus,
> febrile agglutinins, toxo.  (Brucella, leishmania, HAV, HBV, HCV pending).
> Albumin 2.8, total protein 7.2 ;  IGG 1260, IGM 128; tetanus titers
> pending (was vaccinated).   Bone marrow aspirate and culture of aspirate
> were negative for organisms, including salmonella and AFB and for viral
> inclusions/multinucleated cells.   Red cell precursors were absent and
> there were minimal white cell precursors, except for a plethora of
> eosinophils.  Hematology read it as without hemophagocytosis and without
> malignancy; pathology thought they saw rare hemophagocytizing cells.   CT
> of chest, abdomen and pelvis showed normal sized liver and spleen but
> diffuse uptake in liver.  Now we come to the bizarre parts.  Liver biopsy
> shows large areas of necrosis and inclusions strongly suggesting
> adenovirus.  (FAs are being done as I write.)    A flow panel on
> peripheral blood showed the following:    WC 1.3 with 60% lymphocytes
> (780).  11.3% CD3+, 5.2% CD4+, 1.2% CD8,  18.2% CD3-CD56+, CD3-CD16+
> 19.2%, 64.6% CD19+.
>
> The adeno comes as quite a surprise.  We had not even known about the
> throat culture until today.  It is odd that it is just in the liver.
> Also, the LFTs were not really abnormal, at least 4 days ago, which is
> also odd, given the amount of necrosis.
>
> We cannot help but  suspect some underlying malignancy or
> immunodeficiency, but there is no evidence of previous health problems.
> Does anyone have any ideas re the possibility of underlying disease or
> suggestions on how/whether to work this up further?  Our therapeutic
> options are poor, so any advice would be much appreciated.
> Janine Jason, M.D.
> Mailstop A25
> Assistant Branch Chief, Clinical Studies
> HIV Immunology and Diagnostic Serology Branch
> Division of AIDS, STDs, and Tuberculosis Laboratory Research
> National Center for Infectious Diseases
> Centers for Disease Control and Prevention
> Telephone 404-639-3919
> FAX 404-639-2108
> E-mail JMJ1@CDC.gov
>



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