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Boot camp day #4: 89 year old man with intermittent hypoglycemia

2019-12-05 | 青木語録

Boot camp day #4: 89 year old man with intermittent hypoglycemia

89 year old man with about 6 months history of cognitive problems of some aggressive nature came in with h/o intermittent hypoglycemia for the evaluation. Patient also had variety of medical illness including hypertension, hypothyroidism, etc. and was on nearly 10 medications.
On admission, he had near normal vital signs except low grade fever and respiratory rate of 16/min. Physical examination was remarkable for livedo reticularis and purpurish skin changes in the tip of left second index finger. Laboratory test were somewhat normal and abnormal including normal WBC count, low RBC, normal Platelet, low glucose of 50's, low Na, high normal K. Urinalysis:3+ Bacteria and WBC. CXR: B/L diffuse shadow. Gram stain: numerous WBC with multiple GPC, GNR, etc that would have have been typical aspiration. AFB smear:negative.

My way of approach was following. 

(By the way I had been warned that I would never guess the right name of etiologic agent.)

1)Cognitive problem in the elderly can be medical/biological problems such as TB, syphilis infection of the CNS, endocrine, nutrition etc.
2)Chronicity of about 6 months: Immune mediated pathophysiology such as TB, IE, Syphilis.
3)Near normal respiratory rate with diffuse CXR shadow ≒ slow process such as mycobacteria, fungus, or tumor. 
4)DDx of CAP should always include TB, PCP, and PE. I also mentioned possible mycoplasma infection causing CNS, adrenal, besides pulmonary problems.
5)Low Na and high normal K can be from adrenal dysfunction due to TB or CMV.

My analysis stopped here and then I was told that blood culture one out of four bottles became positive at Day#7 for mycobacteria.

M.chelonae it was.

Presenter:  Drs.Takakusaki and Yokoyama

Their warning came half true.

I would never have guessed M.chelonae right.

But I was able to mention mycobacteria at the very outset.

Dr.Shiiki told me he would give me a passing mark with relatively small margin for this case which is enough for me. 

Many staff physician, including Dr.G of NHK , Director of University of Hawaii program here  visited my room to pay homage for my analysis. What a great honor !

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