Inflammation Case Presentation

Case # 1

History A 20-year-old woman with only a one day history of : lower abdominal pain, nausea with anorexia and fever. Physical examination, there was periumbilical pain. over the next couple of hours, the pain migrated to the right lower quadrant, with rebound tenderness. Her vital signs showed T 38.5 C, P 90, R 18, and BP 110/70 mm Hg.

Question: what are the most important laboratory tests that would be helpful for the diagnosis? Answer: WBC count was 11,500 with 76% polys, 6% bands, 14% lymphs, and 4% monos. A pregnancy test was negative. A stool sample was negative for occult blood. Urinalysis was normal.

Question: What diagnosis do you suspect? Answer: Acute appendicitis.

Question: what is Acute appendicitis Answer: This is a common condition, with a lifetime risk of 7%, and though most cases occur in younger persons, the disease has a wide age range from infancy to old age. As a person ages, the appendiceal lumen often becomes obliterated, explaining the decreasing incidence with age.

Question: what further tests you may order to help you in diagnosis? Answer: Ultrasonography, Computed tomography (CT). A laparoscopic procedure. Histologic examination.

These abdominal CT scan views reveal a thickened appendix (A) with faint linear stranding (B) into the surrounding fat, typical for inflammation. A B

The gross appearance of the appendix removed at surgery The gross appearance of the appendix removed at surgery. A thickened appendix with faint linear stranding into the surrounding fat, typical for inflammation.

Question: What is seen prominently in the tissue section? Answer: There is acute inflammation with many neutrophils. The mucosa is focally eroded. The inflammation extends through the wall and appears on the serosa. The serositis accounts for much of the abdominal pain.

The low power microscopic appearance of the appendix The low power microscopic appearance of the appendix. The mucosa is focally eroded. The inflammation extends through the wall and appears on the serosa. The serositis accounts for much of the abdominal pain.

The high power microscopic appearance of the appendix The high power microscopic appearance of the appendix. There is acute inflammation with many neutrophils.

Question: What could happen if this is not promptly treated? Answer: The wall of the appendix could rupture, producing an acute peritonitis and/or abscess. The patient could become septic and die (2% mortality associated with appendiceal perforation). Rupture is more likely to occur in the very young and old, when the diagnosis is not suspected and/or is delayed.

Question: What is the differential diagnosis? Answer: Acute salpingitis Ruptured ovarian cyst Ruptured ectopic pregnancy Acute UTI Acute enteritis

A remnant of tubal epithelium is seen here surrounded and infiltrated by numerous neutrophils. This is acute salpingitis.

Ruptured ovarian cyct

Question: What is the treatment Answer: There is no medical therapy for acute appendicitis. Surgery, the patient should have an appendectomy performed.

Case # 2

- Cervical lympadenopathy, decreased breath sounds, and crackles . History A 4-year-old child with three weeks history of: - Cough, loss of appetite, night sweat and persistent fever. Physical examination, there was: - Cervical lympadenopathy, decreased breath sounds, and crackles . Vital signs showed T 38.7 C, P 120, R 28, and low BP.

WBC count was 11,500 with 49% polys,, 47% lymphs, and 4% monos. Question: what are the most important tests that would be helpful for the diagnosis? Answer: WBC count was 11,500 with 49% polys,, 47% lymphs, and 4% monos. Chest X-Ray, revealed right sided pleural effusions and ill defined consolidation on the right middle lobe with hilar lymphadenopathy. The patient was not able to provide sputum for evaluation.

Chest X-ray

Question: What diagnosis do you suspect? Answer:  - Bacterial pneumonia.

Rx: - Antibiotics and antipyretic drugs. Follow up: The child does not improve with standard antibacterial therapy. Think of atypical bacterial infection?? like TB?

Question: what further tests you may order to help you in diagnosis? Tuberculin Skin Test ( PPD test). TB PCR. ِAFB staining, on gastric lavage, bronchoalveolar lavage, pleural fluid or tissue, lung tissue, and lymph node tissue. Histological examination of: Lung or pleural tissue.

 Ziehl–Neelsen stain

Multiple caseating granulomas with giant cells and caseous necrosis with adjacent preserved alveolar spaces at the periphery.

Granulomatous inflammation A distinctive form of chronic inflammation characterized by collections of epithelioid macrophages Granuloma, in addition to epithelioid macrophages, may have one or more of the following: a surrounding rim lymphocytes & plasma cells a surrounding rim of fibroblasts & fibrosis giant cells central necrosis e.g. caseating granulomas in TB

Tuberculosis (TB). TB is a infectious disease caused by bacteria called Mycobacterium tuberculosis, that mostly often affect the lungs (air born disease). There are approximately 1.7 billion cases worldwide. Most persons infected with M. tuberculosis do not develop active disease. In healthy individuals, the lifetime risk of developing disease is 5-10%.