감염 내과 R2 박소영 / Prof. 이미숙

 C.C) delusion o/s) 내원 2 개월 전  P. I.) 47 세 남자 환자 10 년전 당뇨병 진단 받고 경구 혈당 강하제 불규 칙하게 복용 중인 자로 내원 1 년전 부터 이혼후 혼자서 생활하였 으며 2 개월 전부터 혼잣말 하고, 환시 증상 보호자에 의해 발견되 어 내원 6 일전 개인병원에서 정신분열증 의심하에 입원. - 개인 병원 의료진에 의하여 피부 궤양 발견되어 망상 증상과 피 부 궤양에 대한 자세한 검사 위해 응급실 통해 신경 정신과로 입 원함.  PMHx) HTN /DM /Tbc /Hepatitis (-/+/-/-) DM : 10 년 전 진단, 불규칙하게 경구혈당강하제 복용.  PHx) alcohol (+) : social smoking (+) : 3 pack-years

 General fever(-), chill(-), fatigue(-), general weakness(-)  Skin pruritus (-), ulcer (+)  Head and Neck headache(-), dizziness(-), rhinorrhea(-), sore throat (-)  Respiratory system cough(-), sputum(-), dyspnea(-)  Gastrointestinal system anorexia(-), vomiting(-), nausea(-), diarrhea(-), constipation(-) abd. pain(-), melena(-), hematochezia(-), hematemesis(-)

 Genitourinary system dysuria(-), hematuria(-)  Musculoskeletal system arthralgia(-), myalgia(-)  Neurologic and Psychologic system sensory disturbance(-), motor problem (-) delusion (+) visual hallucination (+) : “ 몸 속에서 벌레가 기어 나온다.”

 V/S 120/80mmHg – 64 회 /min- 18 회 /min- 36.0°C Height -168cm BW -58.5kg BMI  General Alert consciousness Chronically ill looking appearance  Skin ulcer with crust formation – both forearm and lower legs  Head and Neck Isocoric pupil c pupil light reflex (++/++) Normocephaly, pharyngeal injection(-) palatine tonsil hypertrophy(-/-), whitish sclera, pinkish conjuctiva No neck vein engorement No cervical lymph node enlargemnet Neck stiffness(-)

 Thorax symmetric chest expansion clear breathing soung without rale, wheezing regular heart beat sound without murmur  Abdomen soft and flat abdomen normoactive bowel sound tenderness (-) / rebound tenderness(-)  Back and extremities costovertebral andgle tenderness (-/-) pretibial pitting edema (-/-)  Neurology & mental status

 General appearance ◦ 자주 위협, 질문에 지리멸렬하게 대답하고, 지남력 유지, 위생상태 불량, eye contact (+)  Mood and affect ◦ somewhat elated, not anxious  Perceptual disturbance ◦ auditory hallucination (-) ◦ visual hallucination (+) – “ 몸 속에서 벌레가 기어나온다.” ◦ derealization(-), depersonalization (-)  Sensorium and cognition ◦ consciousness : alert ◦ orientation : time/ person/ place (+/+/+) ◦ concentration : intact ◦ memory : somewhat impaired

 CBC/DC 6,690/mm g/dl – 34.3% - 430K (seg : 80.3%) aPTT 39.8 sec PT(INR) % (0.97)  Chemistry TB 0.38 mg/Dl AST/ALT11/16 U/L Protein/alb 6.8/3.9 g/dL BUN/Cr17/0.8 mg/dL Ca/P/Mg 8.9/3.8/2.1 mg/dL ALP/rGT84/14 U/L Na/K/Cl 136/4.5/95 mmol/LChol130 mg/dL Uric acid 3.7 mg/dL TG69 mg/dL LD/CK 308/ 71 U/LGlucose 380mg/dL  UA RBC 2~4/HPF WBC 2~4/HPF blood (-) protein (+/-) pH 5.5 SG 1.019

 Viral marker anti – HCV Ab(-) Hbs Ag/ anti – HBs Ab (-) /(+) anti – HIV Ab(-) RPR weakly positive (1:64)  HbA1C10.6 %

 1. Delusion Visual hallucination  2. skin ulcer  3. uncontrolled DM  4. RPR positive

 1. Schizophrenia, paranoid type r/o neurosyphilis  2. Skin ulcer r/o gumma  3. Known type 2 DM

 1. Schizophrenia, paranoid type r/o neurosyphilis ◦ Psychologic test ◦ Neurologic exam ◦ Serum TPHA ◦ CSF exam : VDRL, TPHA, cell count, protein, glucose ◦ Ophthalmologic exam ◦ Antipsychotic drugs ◦ Penicillin

 2. Skin ulcer d/t r/o gumma ◦ Skin biopsy ◦ Daily dressing  3. Known type 2 DM ◦ Insulin(MDI) ◦ DM complication test

CSF11/13 WBC count14 lymphocyte90% monocyte10% Protein71.2 mg/dL Glucose198 mg/dL VDRL(+) SERUM11/13 TPHA(+) Glucose380 Protein6.8

 Serum TPHA (+), CSF VDRL(+) 로 신경 매독 진단 되어 신경 매독의 집중적인 치료 위하여 신경정신과에서 감염 내과로 전과됨.

 1. Neuropsychologic test ◦ attention 과 visual memory 를 제외한 모든 항목 의 기능저하

H-E stain X40 H-E stain X200he

CSF11/1311/26 WBC count140 Lymphocyte90% Monocyte10% Protein71.2 mg/dL53.4 mg/dL Glucose198 mg/dL87 mg/dL VDRL(+) TPHA

 1. Neurosyphilis with gumma 2. DM with retinopathy