Case of the Month -January 2017

Dr Ryan Aylward and Dr John Black

A 59 year old male from a residential area in Port Elizabeth was assessed in A&E with a short history of haematemesis and rash. He used alcohol regularly and was treated for pulmonary tuberculosis a few years prior, but was otherwise well. There was no significant travel or exposure history from the limited details available.

Pulse 125 bpm, BP 97/62mmHg and axillary temperature, 36.1°C. He had peripheral stigmata of chronic liver disease, a tender epigastrium, no ascites and the abdomen was not peritonitic. Purpura of the tip of the nose, trunk and digits were noted (figure 1). He had no features of infective endocarditis or meningitis.


Admission laboratory results
Haemoglobin 10g/dL13.0 – 17.0
Lactate dehydrogenase 3505 U/L 208 - 378
Reticulocyte Production Index 0.3
International Normalized Ratio 1.37
Conjugated Bilirubin 89 umol/ L 0 - 3
Haptoglobin 0.88 g/L 0.30 – 2.00
Platelets 7 x 109 171 - 388
White cell count 46 x 109 3.92 – 10.40
Neutrophil absolute count 39 x 109
Creatinine 1216 64 - 104

Chest x-ray revealed diffuse peri-hilar infiltrates and a right upper zone infiltrate (figure 3). There was no free air under the diaphragm. The peripheral smear showed intra- and extra-cellular bacilli (figure 2). The peripheral smear and laboratory results indicate a micro-angiopathic haemolytic anaemia (fragment count of 4.3%) with renal impairment. ADAMTS13 activity was normal (72%) and thrombotic thrombocytopenic purpura was therefore excluded. He was admitted to the ICU for acute haemodialysis and vasopressor support and was started on ceftriaxone. CT abdomen revealed renal cortical infarcts (figure 4) as well as an infarcted spleen of normal size.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Question 1: What infections are commonly associated with alcoholic liver disease?

Continue to Answer 1