Case of a 33 year old male

This is a case of a 33-year-old male, resident of Kolkata. This de-identified blog was created after taking informed consent from the patient.

CHIEF COMPLAINTS 

  • Pain abdomen since 6 years 
  • Burning sensation in the stomach and mouth since 6 years 
  • Pain in the anal canal since 6 years 
  • Irregular bowel habits since 6 years 

History of Presenting Illness

The patient was apparently asymptomatic 6 years ago. 

6 years ago, the patient started having 

Severe pain in the abdomen, Involving the area above the umbilicus. The pain is localised, a dragging type of pain, experienced especially when the patient has not consumed food. It is relieved when the patient ingests food. The pain aggravates when the patient inhales and is relieved when the patient exhales. The pain is also reduced when the patient applies pressure on the area.The pain does not change during defecation.  

The patient also describes pain observed in the anal canal during defecation. That lasts 2 to 3 hours after defecation. The pain is sharp in character. Experienced 3 times a week. At that time the patient had a black stool, once a day, sticky in consistency, and no blood or mucous was observed in the stool. The patient also complains of constipation occurring irregularly in between. The colour of the stools is no longer black but the consistency is the same. 

The patient complains of nausea and vomiting. The patient complains of a burning sensation in the throat and in stomach. The burning sensation started in the morning at around 5 o'clock. The vomitus was non-bilious and occurred every time the patient consumed food. 

Associated symptoms like reduced appetite, early satiety, tenesmus, bloating, burning sensation in the stomach and hiccups (that begin 10 minutes after eating food) are present. 
Hiccups: Start after eating food, not relieved by drinking water. The patient has to wait for 5 to 10 minutes for the hiccups to resolve on their own and then continue eating. 

5 years ago, the patient visited a hospital in his city. On examination, he was told that everything was normal. He was given Pantop 40 and sucral syrup. The patient consumed sucrol syrup for 1 month every morning before breakfast and still continues to take pantop 40 before breakfast. The patient found a little relief in symptoms. 

13 Months ago, the patient had an increase in the intensity of these symptoms, for which he visited a doctor who suggested an endoscopy - 


He was prescribed the following medication, He found relief in symptoms since then. 


1 year ago, the patient had reduced appetite, non-bilious vomiting(when he did not consume food) and increased weight of 4 KG and abdominal pain. he visited a doctor who suggested USG abdomen. He was diagnosed with fatty liver and was prescribed medication. 

5 months ago he experienced a dry cough, and he could not sleep. The cough has reduced in the last 2- 3 months but is still present. 

3 months ago, the patient had excessive pain in the left lumbar region, localised, and sharp in character. He also complained of weakness and pain abdomen. He visited a doctor. It was found that he had nephrolithiasis and was treated symptomatically. 



Patient's Diet 
- Breakfast: Biscuits 
-Lunch rice/roti, banana and curry, fish 3 times a week 
-Dinner: Mostly roti 

Past History: 

Not a known case of DM, TB, HTN, or Epilepsy. 

Family History:
 
Father had similar complaints 

Personal History : 

Diet - mixed 
Appetite - Reduced
Bowel- Constipation present on and off for 6 years 
Bladder movements - 2-3 times a day 
Addictions - Consumption of 1 cigarette, occasionally- for example meeting a friend 
Alcohol consumption, one peg during Durga pooja. 
Both since the age of 16 


General Examination : 
 
The patient is conscious, coherent, oriented to time place and person 
The patient is well-built and well-nourished. 

Pallor, Icterus, cyanosis, lymphadenopathy, koilonychia, oedema, clubbing, cyanosis absent 

Clinical Images - 












Investigations 





Dermatology Refferal 


Endoscopy 



Orthopedic consult 



Discussion 

Question 1: 

👆How would you confirm this diagnosis(tinea corporis )  


1. Skin scrapings from active margin of lesion Followed by KOH mount . 

If positive there will be septate branching long hyphae.  

2. SDA agar culture

Question 2 

How common or pragmatic or evidence based is it to prescribe empirical antifungals without isolating the organism? 
This patient is having a non invasive cutaneous tinea corporis and it appears to be common practice among dermatologists in not making efforts to isolate the organism. Is it because of low sensitivity of the scrapings ⁩ ?

Answer 2 

"The diagnosis of tinea corporis is most often clinical, especially if the lesion is typical.A well-demarcated, sharply circumscribed, erythematous, annular, scaly plaque with a raised leading edge, and scaling and central clearing on the body is characteristic."


"In one recent study of 2,427 patients, the sensitivity and specificity of KOH examination of tinea pedis were found to be 95.7% and 69.6%, respectively, relative to a culture gold standard [5]. Interestingly, the study found that the percentage of patients presenting with a clinical diagnosis of tinea pedis that had skin cultures positive for fungus were only 36.6%, raising a question as to whether culture is the optimal gold standard by which to evaluate diagnostic tests for tinea pedis."


"Examples of how culture may miss a diagnosis of tinea pedis include sampling error from the affected foot, using defective culture medium, and mishandling of the culture medium."

 "In the clinic, we accept positivity of culture or KOH smear as indicative of infection because, even in the event of a false positive, harm from topical treatment is nil. Negative tests may not deter therapy on the basis of clinical suspicion since the tests are imperfect, and again, risks of topical therapy are nil. If the disease did not improve after a 1-week trial of topical antifungals, other diagnoses, such as plantar psoriasis, might be entertained and treated with, say, a topical steroid. What is occurring is that treatment is being chosen on the basis of a positive clinical diagnosis, albeit that culture and KOH smears may be supportive of that decision when positive. That is, clinical diagnosis—albeit imperfect and subjective—is the gold standard in practice."

:
Well shared 👏

Yes the above few articles more or less wraps it up. 

Majorly tinea is diagnosed clinically due to poor sensitivity as suspected. 

Question 4
However what is the impact on antifungal resistance in the community due to this current approach of convenience?

Answer 4


: From the above recent article :

With 20–25% of the world’s population afected by cutaneous fungal infections,reports of increasing treatment failure and acquisition of drug resistance are alarming.

It is generally believed that the epidemic of cutaneous fungal infections has emerged in India because of suboptimal and irrational regimens of prescribed topical and oral antifungals, inexpensive brands that often do not have satisfactory efficacy.
: “diagnosis of fungal infections is shifting toward laboratory identifcation of the pathogen(s) and MIC testing to tailor treatments for optimal success.”

“The key to selecting an efective antifungal therapy for a recalcitrant infection is identifcation of the infectious organisms(s) and testing susceptibility of the organism(s) to antifungal drugs. Combination and sequential therapy regimens are options.”

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