CLINIC CASE

A three year-old African American female child presented with complaints of

fever, irritability and lethargy for the past 6 days. She had decreased energy
associated with fatigue, decreased appetite, respiratory symptoms, and cough.
Mother noticed pallor.
The child was givenibuprofenwhich provided temporary relief to fever. She
also developed painful oral lesions on buccal mucosa. The patient was taken to
urgent care and found to have inflamed tonsils andanemia.

He had no significant past medical history. Physical examination revealed a

febrile pale and acutely ill-looking girl with clear rhinorrhea. She had
hemorrhagic painful blisters on lips and buccal mucosa, pharyngeal erythema
with enlarged inflamed tonsils without exudates, and shotty non tender
bilateral anterior cervical lymphadenopathy. She was tachycardic, the liver and
spleen were not palpable. There was left hip ecchymosis with no restriction in
range of motion.
Initial lab results showed
WBC: 3.5 (neutrophils 7, lymphocytes 91, mono 1, eosino 1)
Hb: 3.3 g/dL
Hct: 9.4 %
Platelets: 6/L
RBC: 0.96 million/L, MCV: 97.8
Serum ferritin 198 (10-291 ng/ml)
Serum iron 85 (50-170 g/dL)
TIBC 192 (261-478)
Iron saturation 44 % (21-42%)
Serum folate and B12 were both elevated >24

Pertinent viral studies showed: positive EBV VCA IgG and negative IgM. Blood EBV
DNA quantitation showed 8,613copies/ml.The patient received IV antibiotics.

DX: EBV Infection Resulting in Aplastic Anemia

 CLINIC CASE
We report the case of a 70-year-old North African man who, two months prior to
medical examination, presented with mild laryngeal respiratory distress that
worsened until he ultimately required a tracheotomy. A direct laryngoscopy had
been performed, revealing a subglottic, submucosal lump. A biopsy revealed a
mantle cell type B NHL with the following antigen constellation: cluster of
differentiation (CD5+, CD20+, CD23-, cyclin D1+. Importantly, a physical
examination and computed tomography (CT) scans showed a lack of lymph node
involvement, establishing the larynx as the primary site of the neoplastic lesion.

The patient did not present any B symptoms and had a performance status 3 as
measured using the World Health Organization performance scale. During a follow-
up four weeks after his initial admission, a physical examination found laterocervical
lymph nodes. An investigation into possible tumoral extension by cervical,
thoracoabdominal and pelvic CT scans showed a subglottic tumor and cervical
lymph nodes.
 CLINIC CASE
A 56-year-old man sought treatment at the Unidade de Diagnstico por
Imagem Hospital (a tertiary hospital within the municipal district of Sao
Lus). He reported high fever, headache, myalgia, arthralgia, retro-
orbital pain, and nausea that began two days earlier. He came to the
hospital with an axillary temperature of 39C and petechia in the lower
limbs. His total leukocyte count decreased from 7,400 to 2,200
cells/mm3 , his lymphocyte count decreased from 2,590 to 946
cells/mm3 , and his platelet count decreased from 232,000 to 13,700
cells/mm3 . His hematocrit ranged between 38% and 45.1%. Serum
albumin levels decreased from 4.9 to 3.1 g/dL. He remained in the
hospital for five days and had a fever for three days. His only
hemorrhagic manifestation was petechia in the lower limbs.

Dengue-specific IgM was detected by an antibody capture enzyme-

linked immunosorbent assay seven days after the onset of symptoms.
DENGUE HEMORRHAGIC
 CLINIC CASE

A 29 year-old man was admitted to the hospital because of fatigue, anorexia, malaise,
occipital headache, fever and difficulty concentrating.

On physical examination he appeared tired and thin. His temperature was 40 C. The liver
edge was tender and palpated 3 cm below the right costal margin, with diffuse abdominal
tenderness. An abdominal computed tomographyc scan showed thickening of the terminal
ileum wall and clumped-enlarged mesenteric lymph nodes in the right lower quadrant.
Laboratory test: white cells count, 4,600/mm3; aspartate- aminotransferase, 790 U/L;
lactate-dehydrogenase, 1,562 U/L. He also had roseola spots distributed on the trunk.
Repeated blood cultures were negative. Microscopy of a liver biopsy showed lobular
aggregates of Kupffers cells (typhoid nodules). Bacterial cultures of the livers tissue and
roseola spots biopsy were positive for Salmonella typhi.
The fecal culture of the patients wife was also positive for S. typhi and the molecular
typing of the bacterial DNA showed the wife was a silent carrier and main source of the
typhoidic infection. Since the isolated Salmonella was sensitive in vitro to
fluoroquinolones, this drug was administered and the patient was egressed as cured.