Case 48

Published on 18/02/2015 by admin

Filed under Allergy and Immunology

Last modified 22/04/2025

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CASE 48

RG is 45 years old and has recently returned from a trip to China. While there he visited several small local markets, as well as a number of other typical tourist sites, including the Great Wall near Beijing. Two weeks after his return he developed a fever, which seemed only to defervesce intermittently with acetaminophen. During the past 2 days he has complained to his family of feeling more short of breath than usual and has had a crushing headache. Finally, tonight his overall condition worsens and he comes to the emergency department.

This is a worrisome presentation (particularly in view of recent evidence for infection by a number of transmissible emerging viruses, including severe acute respiratory syndrome [SARS], swine flu, avian flu, West Nile virus, and so on). He should be quarantined during workup! What should you do as part of the workup? What are the treatment options?

QUESTIONS FOR GROUP DISCUSSION

RECOMMENDED APPROACH

Implications/Analysis of Laboratory Investigation

Routine blood work was ordered (e.g., complete blood cell count, electrolytes) as well as a chest radiograph. To determine the cause of the headaches, a CT scan was requested, as was a lumbar puncture to obtain cerebrospinal fluid (CSF) for culturing to determine if RG was infected with Neisseria meningitidis.

ETIOLOGY: WEST NILE VIRUS

West Nile virus is a mosquito-borne virus that belongs to the family of flaviviruses, as do the yellow fever and dengue viruses. Individuals infected with West Nile virus may have no symptoms, whereas others may have fever and headache, become comatose, and have long-lasting neurologic damage, including muscle paralysis. Generally, most people make a complete recovery. A few will have longer-term neurologic dysfunction, probably reflecting cross-reactivity between immune response to virus and common neuronal antigens (see Cases 28 and 30).

Attempts to understand why there is such a discrepancy in response to West Nile virus infection have led to a search for susceptibility genes in murine models. A team of French scientists found a direct correlation between mortality and mutations in the gene encoding the enzyme “oligoadenylate synthetase.” The activated form of this enzyme converts the latent endonuclease, RNase L, to its active form. West Nile virus has a single-stranded RNA genome, which is a substrate for RNase L. As yet, this mutation’s association with West Nile virus has not been identified in humans.

SARS is a coronavirus that has caused significant morbidity/mortality worldwide (Fig. 48-1). A large effort is being made to develop a protective vaccine effective before and after exposure. In addition, better diagnostic and prognostic indicators are needed. Recent data suggest evidence for overexpression of the novel prothrombinase fibroleukin in the lungs of sick patients (a phenomenon seen also in the case of other single stranded RNA viruses (e.g., fulminant hepatitis C infection). Procoagulants and prothrombinases play an important role in triggering fibrin deposition and thrombosis in small vessels. Thus, measures to prevent fibroleukin overexpression are another important therapeutic avenue of approach.

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FIGURE 48-1 A, Negative-stain electron micrograph of a coronavirus such as SARS. B, Portable upright chest radiograph of a previously healthy female with viral pneumonia (in this case after adenovirus infection), showing consolidation of the left lower lobe and lingual segment, along with a left-sided pleural effusion. This would not be an atypical picture in SARS (in this case after coronavirus infection).

(A, From Hart CA, Shears P: Color Atlas of Medical Microbiology, 2nd ed. St. Louis, Mosby, 2004; B, From Klinger JR, Sanchez MP, Curtin LA, et al: Multiple cases of life-threatening adenovirus pneumonia in a mental health care center. Am J Respir Crit Care Med 157:645–649, 1991.)

Note that the incidence of disease in, and severity of infection in, immunocompromised individuals is extremely enhanced relative to healthy control populations (see Transplantation, Section V). Remember that, in fact, AIDS was recognized for what it was (an acquired immunodeficiency disease) because we had already gained experience with many of the presentations (Kaposi’s sarcoma, Pneumocystic carinii (jiroveci) pneumonia) from looking after oncology patients and transplant survivors.

FURTHER READING

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