2. 22 years old man with fever

3. BRIEAF HISTORY A 22 years old man has been admitted in emergency department due to malaise and nausea,vomitting.he had a history of diabetus from 6 years ago and was under treatment by insulin(NPH and REGULAR) and has discontinued his insulin from 3 month ago intentionally.

4. (continued) BRIEAF HISTORY 2weeks before admission(26/8/93) he has had an episode of rhinorrhea and malaise which he thought that, it is a common cold.2 days before admission he has had nausea and vomitting.

5. PH/EX At admission time: An episode of abdominal pain 2 days ago At present:without abdominal pain Seems ill but not toxic Bp:120/70 PR:112 RR:14 T(orally):38.3 He complains of cough Other PH/EX:normal

6. Lab data Bs:373 VBG: PH:7.4 HCO3:22.8 PCO2:31.5 WBC:3400 HB:15.5 PLAT:87000 UREA:16 CR:0.8 NA:130 K:4.5 Ca+:4 Mg:5.9 P:3.8 MCV:79.3 MCH:28.1 MCHC:35.4

7. INTERNAL MEDICINE CONSULT Routine lab test u/a patient was hydrated by N/S Insulin CXR ESR and CRP PBS AND hematology consult Can transfer to internal medicine emergency

8. BUT the patient had been transferd to endocrinology ward by emergency department.

9. Lab data(27/8/93) Wbc:3000 Hb:13.3 Plat:77000 Mcv:80 MCHC:35.4 BILL:Total:1.1 D:0.5 PT:15 PTT:33 INR:1.3 U/A:KETON 1+ ERS:6 CRP:12 POSITIVE

10. PBS: atypical lymphocytes:10% Plat:75000

11. Workup and TX The patient had been under treatment by ceftriaxon and azithromycin because of respiratory compliants and fever Insulin(lantus and novarapid) for high BS during BS charts And pantazol,acetaminophen PRN

12. PULMUNOLOGY CONSULT Signs and symptoms of patient are compatible with atypical pneumonia Consolidation was seen in LLL Antibiotic regimen is suitable If fever unresolved another CXR would be done Because of neutropenia and thrombocytopenia other causes should be R/O

13. CARDIOLOGY CONSULT ECHOCARDIOGRAPHY was normal Preserved right and left function NOT any evidence of endocarditis If symptoms unresolved after 7 days TEE should be done

14. Infection speciallity consult B/C *2 U/A and U/C ESR and CRP Wright and coombs wright Pbs for malaria*3 Maliglancy and collagen vascular disease should be R/O

15. ABDOMINAL SONOGRAPHY MILD splenomegaly Others were normal

29. HEMATOLOGY CONSULT BMA and biopsy was done The response should be followed

30. Gastroenterology consult Autoimmune hepatitis panel Anti TTG antibody The patient is candidate for endoscopy Endoscopy was done for him and was normal

31. TEMPERATURE 39.5 38.2 40 40 38.6 and usually over 38 during admission in endocrinology ward Blood sugers were in goal range

32. Lab data Blood culture 2 times:negative Malaria:not seen Anti HIV ab:negative HBS Ag:negative HBC ab:total: 0.99 >1 non reactive 0- 0.9:reactive 0.9-1 border line HCV ab:negative Hbv DNA PCR was requested for him

33. Lab data (continued) procalcitonin:2.5 2 high risk HBS ag (second time): 3.17 reactive Sputum smear for BK(first time):negative Another lab test ANA, ASMA,CERULOPLASMIN,CMV PCR,ANTI LKM was requested

34. BMA&BMB RBC morphology: mild hypochromia Wbc morphology:decreased count with following diff: poly 52%,lymph36%,monocyt12% Platelet:adequate count Aspiration findings:dysplastic changes in erythroid series with following diff: Myeloid 49%,erythroid37%,lymphoid10% blast:10% plasmacell3% Iron storage is 2+ Diagnosis :cellular marrow with increased megacaryocytes

36. HEMATOLOGY CONSULT Patient's bycytopenia is due to peripheral destruction B12 & Folic acid prescribed

37. INFECTIOUS CONSULT IF PATIENT is dischargable from endocrinology ward can be transfered to infectious ward

38. Prolonged fever commonly see patients with prolonged fever many different possible etiologies Infectious, neoplastic and inflammatory or autoimmune disorders diagnostic approach should be based on any potential clues in the patient's history, physical examination, and routine screening blood tests and cultures

39. Splenomegaly and fever infectious causes: such as bacterial (typhoid fever, Mycobacterium tuberculosis, or AIDS with M. avium complex) fungal agents (histoplasmosis) more commonly splenomegaly results from parasitic diseases such as malaria and leishmaniasis. Viruses such asEpstein-Barr virus (EBV) and cytomegalovirus (CMV), or hepatitis viruses rarely cause this degree of organomegaly.

40. 15.910.98.96.94.92.928.827.826.8 15001300150010001200220027003000Wbc:3400 9.49.213.212.112.612.713.213.3HB:15.5 83000101000720006100085000660007200077000PLT:87000 1428521381AST 1188386401ALT 14751141ALKP 5.82.1BILL T

41. DIAGNOSIS? The previous history of complete health, and the abrupt onset of high fever all argue for an acute rather than a chronic smoldering disease :such as an infiltrative, or a chronic hematologic neoplastic disease

44. DIFF DIAGNOSIS LEUKEMIA,LYMPHOMA ENDOCARDITIS TB LESHMANIASIS MALARIA

45. ORDER HBv DNA PCR CMV PCR GCSF/daily ANTI LKM1,ANTI smAB CERULOPLASMIN URINE COPPER 24 HR

46. Lab data(15/9) AST:1428 ALT:1188 ALKP:1475 BILL T:5.8 D:2.9

47. LAB DATA(20/9) AST:608 ALT:614 ALKP:1549 BILL T:3.3 D:1.8

48. Ophthalmology consult KF ring: was not seen Cotton wool spot on retina Sever NPDR is present

49. Visceral leshmaniosis in bone marrow aspiration

50. .visceral leshmaniosis in bone marrow aspiration Hellal M, and Kundu S Blood 2013;122:627 ©2013 by American Society of Hematology

51. Journal of Thi-Qar University No.1 Vol.4 June/2008 The effect of visceral leishmaniasis on some liver enzyme and blood parameter

52. RESULTS Alanine amino transferase (ALT) was increase in some sever cases reached to 170 IU/L, while Aspartate aminotransferase (AST) so increase and reached to 97 IU/L.

53. Medical journal of the Islamic Republic of Iran Volume 8 Number 2 Summer 1373 August 1994 VISCERAL LEISHMANIASIS AS FEVER Of UNKNOWN ORIGIN GH. R. OMRANI, A. FARHADl, A. PARHlZGAR, S. ARDEHALl*,M.HAGHSHENAS From the Department OF Internal Medicine and Microbiology, Medical School/ Shiraz medical uni

54. ABSTRACT Visceral leishmaniasis is the second most common cause of fever of unknown origin in our study The majority of the affected individuals were young. High grade spiking fever, chills and splenomegaly were unique findings common findings were neutropenia, anemia, abnormal liver function tests