(From Dr. Tweeddale, 27 Oct 2000, by Brian Buschman)
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The patient had granulomas that would be either TB, Brucella or deep fungi.
The patient had swollen testicles which can be seen in young men with Brucella or Mumps.
The confirm Brucella you need an AB test. You can observe either a 1/16 acute titer or you can look for a change of 4x in the titer between before and after blood samples.
Brucella must be intracellular if it causes granulomas. All granulomas are caused by such intercellulars.
This is a case of cat-scratch disease caused by Bartonella. Cat scratch disease does not appear for a few week after infection which allows the scratch time to heal before the patient presents.
Bartonella is one of three things that causes satellite granulomas. Other two are Yersinia enterocolitica and the lymphogranulomas caused by Chlamydia.
Cryptosporidium is an acid fast yeast. The acid fast organisms include Mycobacterium, Nocardia and Cryptosporidium. Being immunocomponent this child would have Cryptosporidium.
Creeping eruption is caused by larva from worms that are found in dog feces that get into the skin and migrate subcutaneously. When they are invading the lungs you will see eosinophilia when you look at the CBC. This lung invasion is classified as Loeffer’s pneumonia. Loeffer’s syndromes is a primary pulmonary eosinophilia.
Echinococcosis is a tapeworm from wolves or dogs. The eggs from the feces find their way in. It causes abscesses like this one in Old Crusty’s abdomen. When you open the abscess Echinococcosis will have a sand like appearance. In performing the procedure you want ultrasound guidance because if you don’t hit the right spot you can spill the contents and cause a systemic anaphylaxis.
Cystacercosis comes from the pig and is similar to Echinococcosis. It may also be confused with cutaneous miasisis from flies.
People that work with cattle like this butcher are at risk of infection with Erysipelothrix. (Brucella also comes from cattle.)
The site of the scrape revealed what would appear as necrotizing fasciitis. Necrotizing fasciitis is usually caused by group-A b-hemolytic strep. It is the most common cause of cutaneous infection without a given method of entry. In this case he cut his hand giving Erysipelothrix a way to get in.
Clostridium can also infect skin if there is a traumatic injury.
Erysipelothrix must also be differentiated from H. influenzae. Both are able to form the non-puss forming (non-suppurating) violet legion. In the peds age range it’s more likely to be H. influenzae and in old (or grown ups) it’s more likely to be Erysipelothrix.
If there is seawater associated then think about the idea of V. vulnificans.
This girl got her ringworms from her cat. Getting the cutaneous infection from the cat shows that it is either Microsporum or Trichophyton. It has a target like appearance as it grows out from a central point. You must give this careful attention so that you don’t get it mixed up with lyme disease which has the true target like appearance.
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