Surprising diagnosis

oramar · Mar 18, 2010

This is a wild guess on my part. Just because the young man never left England does not mean this disease hasn't come to England. I have heard the UK has had huge numbers of immigrants from countries where the disease still exist. Be on the look out, if there is one there will be more. Lucky it is highly treatable. By the way there is still a lot of shame associated with the disease in the countries where it is endemic and the person that infected him would be reluctant to seek treatment. PS To answer you actual question, many years ago I had this nice little old lady for a patient and they found some bizzare tropical bacteria in her spinal fluid. The doctors were flumoxed about where she got it because she never left her Pittsburgh neighborhood in her whole life. I wish I could remember what it was but it was so long ago I can't.

iNurseUK, RN · Mar 18, 2010

Yup I know that. Dapsone and rifampacin are the common treatments for m. leprae. I'm just surprised to ever encounter the disease.

I've seen the occasional case of TB pop up but never this.

oramar · Mar 18, 2010

Yup I know that. Dapsone and rifampacin are the common treatments for m. leprae. I'm just surprised to ever encounter the disease.
I've seen the occasional case of TB pop up but never this.

Yes, I figured you knew, was going to drone on and on about Hansen's disease but did not want to insult your intelligence.

classicdame, MSN, EdD · Mar 18, 2010

had a precious 4-5 yr/old girl with fever and other issues who got real sick real fast. ER doc thought she might be having appendicitis, although not typical for age. Before surgeon arrived I did assessment and found lumps under her arms. I later learned she had in fact a case of bubonic plague. Turns out it shows up in southwest Texas every now and again. Responded well to antibiotics.

Emergency RN · Mar 19, 2010

respondent classicdame is right; bubonic plague (yersinia pestis) is actually fairly common within the us southwest, with it's primary reservoir in the rodent (including prairie dog and ferret) population. it is only when their usual habitat becomes disrupted or scarce do large numbers of their carriers (fleas) make the jump to humans in a search for a new host and source of food. the buboes, or massively swollen lymph nodes, are what gives rise to the classic appearance of skin boils erupting into suppurating and dark necrotic sores. it is said that from this imagery, the name "black death" was coined.

despite the horrific appearance, at this stage, it is still highly treatable in that it had not yet spread or evolved into it's other clinical forms; that of septicemic plague (within the blood stream) or the quickly fatal pneumonic plague (within the lungs). once plague progresses to the lung, aggressive antibiotic treatment is most successful only if begun within 24 hours of onset. otherwise, untreated pneumonic plague has a mortality rate of over 90%. :eek:

thankfully, there are still several pharmaceutical agents that can be used to combat y. pestis; streptomycin, gentamicin, tetracyclines, and chloramphenicol. :up:

the last great pneumonic plague occurred in china in 1910 (manchurian plague) and killed roughly 65 thousand. it was only through international cooperation and extreme and ruthless quarantine measures that the outbreak was eradicated without further loss of life.

if anyone is interested, there are actually pictures on the web from that outbreak:

TigerGalLE, BSN, RN · Mar 19, 2010

I once took care of a guy who had an abcess in his abdomen that turn out to be TB. Who knew you could get TB in your abdomen? He stayed on our floor for 3 months. He lived and is thriving.

Emergency RN · Mar 19, 2010

i once took care of a guy who had an abcess in his abdomen that turn out to be tb. who knew you could get tb in your abdomen? he stayed on our floor for 3 months. he lived and is thriving.

yes, tb is typically presented as a pulmonary issue, but can infect just about anywhere else in the body; including the heart, brain, kidney, liver, spleen, stomach, skeletal muscles, and even the genitals. they are all loosely referred to as extrapulmonary tuberculosis.

i guess this entire thread is rather a no brainer for hand washing, eh? lol...

indigo girl · Mar 19, 2010

My unit recently had a patient referred to us by his GP with what appeared to be squamous cell carcinoma on his hands and feet.
It looked atypical for SCC and the cytology results showed no carcinoma in situ. The unit was mightily puzzled. The symptoms were odd too, no pain but widespread lack of feeling in the affected parts.
One of our older consultants had a hunch, sent off a test and dang us if this wasn't leprosy. We cannot understand it, the patient is a young man of English origin, never travelled further than Spain, no known contacts from any country where leprosy is still endemic. A mystery.
Has anyone else been similarly surprised at a diagnosis?

That is fascinating. And he thinks he is totally of English origin? The reason I ask is because the Vikings used to rape and plunder the English shores for centuries prior to year 1000. Hard to say whether the Norse brought leprosy to the English or vice versa but leprosy was endemic in Norway especially in the area of Bergen. A millenium later, the Norwegians brought the disease with them to Michigan, Minnesota, the Dakotas and Iowa with their descendants.

Research has shown that areas that have a high summertime humidity even in Norway, tend to favor this disease. So, I wonder about his living circumstances.

Although this is a treatable disease it is also a least communciable, contagious disease but with great stigma. Often spouses never even know that their loved one is infected but being treated...There is still no vaccine.

In the US, armadillos have been used for research because their body temperature favors growth of the causative organism. They have been finding wild armadillos that are infected presumably escapees from the Gulf South Research Institute or maybe the wild ones ate the incompletely incinerated remains of infected animals from the institute. No one really knows.

I have always been fascinated by this disease since seeing the movie, Ben Hur as a child. I remember well the horrible descriptions of the leper colony in James Michener's novel, Hawaii. I don't know much about the disease and have never encountered it professionally, but I find it of great interest.

Thanks for this very interesting thread.

Jules A, MSN · Mar 19, 2010

Very interesting thread!

RhiaRN75, RN · Mar 20, 2010

I've been surprised with a few, and also some that were not diagnosed.

Carcinoid syndrome. Classic tachy and flush/rash w/ diarrhea- why is this kid having an 'allergic reaction' when using the bathroom? I was familiar w/ carcinoid, but I didn't expect to ever see it diagnosed in the ER. Further workup proved it.

Tertiary syphillis in an elderly lady. The best guess from the docs was that her hubby probably got it in WWII.

Narcolepsy without cataplexy. Every classic symptom except the cataplexy. I didn't know initially that cataplexy only occurs in ~ 70% of cases.

Several assorted trisomies, deletions, etc in kids that should be fatal before the first year. They all had a mosiac pattern.

Severe cyclic psych issues = MS with lesions predominately in the frontal lobe.

Pink disease.

A pt on a huge dose of synthroid, good compliance, and classic myxedema. All the signs- right up to CPK levels and whatnot. Pt had a ton of workup before someone finally realised it really does still happen.

Holiday heart syndrome.

I've never seen leprosy. That's just wild! Thanks for sharing.

cherrybreeze, ADN, RN · Mar 20, 2010

yes, tb is typically presented as a pulmonary issue, but can infect just about anywhere else in the body; including the heart, brain, kidney, liver, spleen, stomach, skeletal muscles, and even the genitals. they are all loosely referred to as extrapulmonary tuberculosis.
i guess this entire thread is rather a no brainer for hand washing, eh? lol...

we had a lady when i worked in the nursing home that had tb in her spine.

i can't imagine finding out a patient has leprosy. wow.

i can't think of any to share, any that aren't *that* strange, anyway. this isn't maybe as rare, but i thought it was a fascinating story...sure surpised the guy, at any rate. i took care of him quite a bit after the fact, but this was his story:

man in his mid forties, felt sick starting on a saturday. just generally tired, a little queasy, that's about all. tired enough to take a nap, which he said was unusual for him, but he figured he had a little bug. sunday he was feeling a little worse, and over the night had developed some pain in his right butt cheek. he wasn't sure why. he decided in the afternoon to go to the er, figured he could get some meds or something...his words to his wife, when leaving the house (to go by himself, he felt good enough to do that. figured he'd be in and out. he told his wife he'd call her when he was done), was that he didn't want to miss the whole superbowl. i'm not sure what meds he figured he'd get if he had the flu, but, that's another topic. :) he manages to drive himself to the hospital, and the closer he gets, the worse he feels. sweating profusely. walks in to the er and the triage nurse took him right back to a room. by now his color was gray and he was fading fast. mentioned to the er doc (who they went to get, to assess him immediately) the pain in his butt, and the doc flipped him right over on the cart to see the spot. the weird part was, the er doc had literally gone to a seminar on this the week before this patient came in! he says to the patient, straight up: "we need to get you to the or within the hour, or you are going to die." patient was just shocked. "why???" er doc was calling the on-call surgeon, and he was right: patient had necrotizing fascitis in the right ischial area. when he arrived in the er, he was in septic shock with a sbp in the 60's. how he got there in one piece is a mystery, but patient told me he believes that once he knew in his mind that he was safe and in the hands of the staff, his body could "give in" to the raging infection he had going on. he thanks god that that er doc had just been to that seminar on nf, as that may well have saved his life, what to look for was in the forefront of the mind of that doc. by the time i took care of the patient, he had just had a closure of the wound from surgery. guy was otherwise quite healthy, no idea on how he got this, other than perhaps he had an ingrown hair or scratched his butt and the strep got in there that way. felt fine one day, slightly under the next, and then just like that, he was staring death in the face.

to hear this guy tell it gave me chills. i wish i could portray all that feeling in to my typed word! i know necrotizing fascitis isn't as uncommon as other conditions out there, it was certainly not what this guy expected to be wrong with him!