Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Adam Stern MD, PGY-2
April 14, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 45-year-old man from northern India presents
with pain, swelling and discharge from his right
foot for 15 years.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient reports that he was in his usual state of
health until 15 years ago when he noted the gradual
onset of swelling and pain in his right foot.
• He does not recall a preceding traumatic injury, but
states that he frequently walked barefoot through the
trails near his village leading to frequent skin exposure
to thorns and soil.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Initially, the patient noted the appearance of a single
nodule on the dorsum of his foot.
• Multiple additional nodules developed, grouped
closely together, which gradually grew into a mass
over time.
• He reports the lesion then started to intermittently
drain yellow and occasionally blood-tinged discharge.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• As the mass continued to grow in size, the foot
became increasingly painful.
• Prior treatment with ciprofloxacin only partially
decreased the drainage and the mass persisted.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• None
Past Surgical History
• None
Family History
• Mother: heart failure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Social History
• Lives in northern India
• Eastern Uttar Pradesh
• Sells vegetables at a market
• Married with 2 children
• Lifetime non smoker
• Denies alcohol use
• Denies illicit drug use
Medications
• Aspirin 650mg as needed for pain
• No known drug allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Thin, pleasant man in no apparent distress
Vitals: T 98.4, BP 124/78, HR 84, RR 14
Extremities:
• Right foot swelling to 1.5-2 times normal size, with
hardening of the skin.
• Yellow discharge from multiple sinus tracts.
• No associated lymphadenopathy.
The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial test results
• CBC:
• Hemoglobin 13.3 g/dL, Hematocrit 39.1%
• The remainder was within normal limits
• Basic Metabolic Panel: was within normal limits
• X-Ray of the right foot: No bony abnormalities
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
Cutaneous Leishmaniasis
Tuberculosis
Elephantiasis
Actinomycotic mycetoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Gram stain of the discharge was obtained and
demonstrated gram-positive branching filaments,
narrow and not fragmenting (0.5-1micrometer) in size.
• Acid fast staining and the Kinyoun modification with
1% sulphuric acid were performed and negative.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Actinomycotic mycetoma
• Clinical vignette based on: A case of Actinomycotic mycetoma
involving the right foot. Tilak et al. J Infect Developing Countries
2009; 3(1):71-73.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Correlations
The NYU Internal Medicine Blog
A Daily Dose of Medicine
http://clinicalcorrelations.org
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS