A 40 YEAR OLD LADY WITH DYSPHAGIA, FEVER AND COUGH

A 40 year old lady who works in cotton fields came to the hospital with the chief complaints of :

  • DIFFICULT IN SWALLOWING,FEVER AND COUGH, SINCE 2 MONTHS
HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back when she presented with :
  • Fever since 2 months which is sudden in onset, intermittent and high grade (on and off associated with chills and rigor).
  • Cough since 2 months on taking food and liquids which was initially non productive then associated with sputum which is white in color , moderate in quantity and non foul smelling
  • difficulty in swallowing since 2 month . It was initially difficult only with solids but then followed by liquids also.
H/O weight loss of 10 Kgs since 2 months, hoarseness of voice, inadequate sleep since 2 months. 
No H/O nausea, vomiting, difficult in breathing.

PAST HISTORY:
 

Not a K/C/O Diabetes, Hyper Tension , Asthma ,TB ,CAD.

As patient was diagnosed with RVD positive in 2012, she is on ART since 2 months (CD4-420).But on 18/05/2021, 10.45am she is TB positive.

Biomass fuel exposure - positive.

FAMILY HISTORY:

Her husband died in 2012 due to RVD. She has 2 kids with him

PERSONAL HISTORY:

Diet - mixed
Appetite - normal
Sleep - inadequate (since 2 months)
Bowel and Bladder movements - regular
No habits like consumption of alcohol or smoking.
No history of blood transfusion.

OBSTETRIC HISTORY:

Age of marriage - 18 years
Age of 1st child birth - 20 years
Gravida - 2, Para - 2 (1 Caesarian section)
No of kids - 2 
No family planning methods are used.

GENERAL EXAMINATION:

The patient was conscious, coherent, cooperative, sitting comfortably on bed .
Well oriented to time, place and person.
Thinly built and malnourished.

Pallor - positive
No Icterus 
No Clubbing
No Lymphadenopathy
No Edema

VITALS:

(13/05/2021, 8 AM):

Temperature - Afebrile
Pulse Rate - 108bpm
Respiratory Rate - 14cpm
BP - 90/70 mm/Hg, left arm (sitting position) 
SPO2 at room air - 96%

(22/05/2021):

S- no temp spikes, SOB decreased
O-96% on RA ,HR decreased from 150 bpm to 66 BPM
BP 90/60 mm HG
R.S - wheeze present in bilateral mammary areas.

ENT EXAMINATION:(17/05/2021)

ORAL CAVITY AND OROPHARYNX: 

Normal on examination

NECK EXAMINATION:

Bilateral no palpable lymph nodes
laryngeal crepitus- positive(aspiration? TE Fistula?)
bilateral vocal cords movements- normal, No growth is seen.

SYSTEMIC EXAMINATION:

CVS: 

S1 and S2 heart sounds - heard
no murmurs

RESPIRATORY SYSTEM: 

Elliptical  and bilaterally symmetrical chest
Both sides moving equally with respiration
Bilateral air entry- present
Normal vesicular breath sounds

CNS:

No abnormal defects
Reflexes can be elicited

PER ABDOMEN: 

Soft and bowel sounds can be heard

INVESTIGATIONS:

  • CBP, LFT, RFT, Urine analysis

Decrease in HEMOGLOBIN, Raise in CRP. 


  •  ECG



  • BARIUM SWALLOW  


  • (ON 17/05/2021,12PM) OTHER INVESTIGATIONS:ENT opinion taken I/V/of dysphagia
RTPCR REPORT for COVID 19
PLAN for FLP 
MTB PROFILE



  • ENDOSCOPY (19/05/2021):




  • CECT(contrast-enhanced computed tomography),21/05/2021:
It was done to know the origin, extent and surrounding structures of the lesion we found on endoscopy and plan for biopsy accordingly





Procedure was uneventful and patient was shifted to ward.
20-30 min later patient suddenly developed SOB 

O/E : 
PR: 102 bpm
BP: 100/60 mm/Hg
SpO2: 85% on RA & 96% on 8 lit O2
RR: 36/min

RS: Diffuse crepts & wheeze + in B/L lung fields
CVS: S1 S2 + no murmurs
P/A: soft , NT
CNS: NFND

Patient was shifted to ICU
  • X-ray:
17/05/2021


21/05/2021


  • 2D ECHO:
24/05/2021




DIAGNOSIS:

14/05/2021:

40/female with RVD since 2 months on ART with dysphagia secondary to Esophageal Candidiasis ?Tracheoesophageal fistula ? Stricture

It can be any of the above diagnosis

22/05/2021:

40/female with RVD with DISSEMINATED TB with TEF 2° to ? TV/MALIGNANCY with ANAPHYLAXIS 2° to radio contrast (resolving)

TREATMENT:

RT FEEDING MILK + PROTEIN POWDER 200ml - 2nd HRLY
                        WATER - 100ml - HRLY
TAB PANTOP 40mg RT/OD
TAB FLUCANAZOLE 100mg RT/OD
TAB DOLOTGRAVIR(50mg), LAMIVUDINE(300mg),TENOFOVIR(350mg) RT/OD
CANDID MOUTH PAINT LA
BP/RR/PR/TEMP/4th HRLY
GRBS- 6th HRLY
18/05/21-TB POSITIVE with RIFAMPICIN SENSITIVE and started on ATT
24/05/2021-LOMOH(ENOXAPARIN) 40mg once daily starting low(going slow to address her thromboembolism differential)

DISCUSSION:

24/05/2021- she had sudden bout of tachypnoea with tachycardia along with hypoxia closely resembling what she had post CT contrast on Friday and now the expanding differentials appear to include recurrent aspiration (happened shortly after her RT feeds) as well as recurrent pulmonary thromboembolism (she has some in her HRCT pulmonary angiography images).This the reason she was given Enoxaparin (anticoagulant).

  • TPR GRAPHIC CHART
Patient had one episode of sudden onset of SOB with tachypnoea and tachycardia
PR-136bpm
Fever spikes of 101F
SPO2-89% with RA

Inj Avil 2cc iv stat given
Oxygen supplementation to maintain SPO2-95%
Symptoms subsided within 1/2nd hour
Blood transfusion is started
Monitored her during transfusion
And also vitals are stable during transfusion.




IN THIS LINK WE CAN SEE SIMILAR CASES LIKE THIS WHERE THEY BROADLY EXPLAINED CAUSES AND MANAGEMENT

ANTI RETRO VIRAL TREATMENT:

At present there are no vaccine or cure for treatment of HIV Infections. But these ART suppress HIV infection before complications can be occur and proved to be useful in prolonging life of several ill patients.

Classification of drugs used for ART:




WHO recommended ARV treatment schedule:










Post-exposure prophylaxis:





Monitoring the efficacy of ART:



 



 

 









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