12-09-2009, 08:08 PM
A 46-year-old veterinary researcher who frequently operates on rats presents to the emergency room with jaundice and scant hemoptysis. She recalls having a fairly deep cut on her hand during an operation about 14 days prior. She has had no recent travel or other animal exposures. Her illness started ~9 days prior with fever, chills, severe headache, intense myalgias, and nausea. She also noted bilateral conjunctival injection. Thinking that she had influenza infection, she stayed home from work and started to feel better 5 days into the illness. However, within a day her symptoms had returned with worsening headache, and soon thereafter she developed jaundice. On initial evaluation, her temperature is 38.6°C, pulse is 105 beats per minute, and blood pressure is 156/89 mmHg with O2 saturations of 92% on room air. She appears acutely ill and is both icteric and profoundly jaundiced.
Her liver is enlarged and tender, but there are no palpable masses and she has no splenomegaly. Laboratory results are notable for a BUN of 64, creatinine of 3.6, total bilirubin of 64.8 (direct 59.2), AST = 84, ALT = 103, alkaline phosphatase = 384, white blood cell (WBC) count is 11,000 with 13% bands and 80% polymorphonuclear forms, hematocrit of 33%, and platelets = 142. Urinalysis reveals 20 WBCs/hpf, 3+ protein, and granular casts. Coagulation
studies are within normal limits. Lumbar puncture reveals a sterile pleocytosis. CT scan of the chest shows diffuse flamelike infiltrates consistent with pulmonary hemorrhage.
What is the likely diagnosis?
A. Acute interstitial pneumonitis
B. Acute myeloid leukemia
C. Polyarteritis nodosum
D. Rat bite fever (Streptobacillus moniliformis infection)
E. Weil™s syndrome (Leptospira interrogans infection)
Her liver is enlarged and tender, but there are no palpable masses and she has no splenomegaly. Laboratory results are notable for a BUN of 64, creatinine of 3.6, total bilirubin of 64.8 (direct 59.2), AST = 84, ALT = 103, alkaline phosphatase = 384, white blood cell (WBC) count is 11,000 with 13% bands and 80% polymorphonuclear forms, hematocrit of 33%, and platelets = 142. Urinalysis reveals 20 WBCs/hpf, 3+ protein, and granular casts. Coagulation
studies are within normal limits. Lumbar puncture reveals a sterile pleocytosis. CT scan of the chest shows diffuse flamelike infiltrates consistent with pulmonary hemorrhage.
What is the likely diagnosis?
A. Acute interstitial pneumonitis
B. Acute myeloid leukemia
C. Polyarteritis nodosum
D. Rat bite fever (Streptobacillus moniliformis infection)
E. Weil™s syndrome (Leptospira interrogans infection)