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Case of the Month - May 2011

Case 1:

A 35 year Port Elizabeth resident presented with haematemesis 4 days after the onset of fever and myalgia. He gave a history of frequent travel to the major cities in the course of his work as a pilot. He also goes hunting most weekends in the Aberdeen area of the Eastern Cape.

A gastric bleed was suspected and he was referred to the surgical unit. Blood results taken pre- gastroscopy were:

  • Hb: 11gm/L
  • WCC: 2 x 109 /L
  • Platelets: 16 x 109/L
  • Normal urea, creatinine and electrolytes
  • AST: 387 IU/L
  • ALT: 420 IU/L

Case 2:

A 19 year old university student traveled on a football tour to the Northern Cape for the past 7 days and returned last night. During the tour they stayed in hostels in various towns and also visited a farm for a farewell braai the night before the last match. On the day of his return he scored 4 goals in a match at the University.

At lunch time he complained of feeling unwell and feverish. By 16h00 he was vomiting, had a temp of 40C and seemed a b it sleepy. At 21h00 he was taken to hospital with bruising of the skin. By midnight he was hypotensive, semi-comatose and bleeding from puncture and intravenous catheter sites. At 01h00 hrs he had a cardio respiratory arrest requiring resuscitation.

Blood results on admission:

  • Hb: 13gm/L
  • WCC: 3.5 x 109 /L (absolute neutrophilia)
  • Platelets: 105 x 109/L
  • AST: 47 IU/L
  • ALT: 58 IU/L

Case 3:

A 38 year old man from Johannesburg presented with a one week history of fever and nausea and abdominal pain for which he had taken symptomatic treatment. On day 7 of his illness he was confused with a temperature of 40C, and had no skin lesions / rashes. He was previously completely well, and had a history of travel 1 month ago to the Kruger Park. Over the next 24 hours he became hypotensive, developed ARDS, was bleeding everywhere with DIC, and went into renal failure Initial blood results:

  • Hb: 11gm/L
  • WCC: 1.7 x 109 /L
  • Platelets: 25 x 109/L
  • AST: 6 000 IU/L
  • ALT: 7 100 IU/L
  • LDH: 12 000 IU/L.
  • Bilirubin (total): 56 ┬Ámol/L(total)
  • Bilirubin (direct): 39 ┬Ámol/L (direct)
  • Urea: 31 mmol/L
  • Creatinine: 536 mmol/L
  • INR: 2.8
  • PTT: 59 (control 28)

Question 1: What are the important differential diagnoses?

Continue to Answer 1