The Gorgas Courses in Clinical Tropical Medicine

Selected Cases Seen by 2009 Course Participants

The Gorgas Courses in Clinical Tropical Medicine are given at the Tropical Medicine Institute at Cayetano Heredia University in Lima, Perú.  Each August we run one of our 2-week refresher courses for those with previous training in tropical medicine; currently running is the Gorgas Advanced Course.  For the past 9 years, we have been pleased to share interesting cases seen by the participants during the weeks of the year one of our courses is in session; there will be one more case next week to complete the 2009 case series.  Each case includes a brief history and digital images pertinent to the case.  A link to the actual diagnosis and a brief discussion follow.

History:  39 yo female patient admitted with a four-month history of diarrhea, significant weight loss and subjective ongoing fever.  The patient complains of 5-10 loose stools every day with blood, diffuse abdominal pain, and tenesmus.  One year earlier the patient had a chronic diarrheal illness lasting many months, which lacked the tenesmus and bloody diarrhea seen at this presentation.  The patient states that she was diagnosed at another hospital with strongyloidiasis, which had a variable response to a number of medications, including at least one course of ivermectin before the diarrhea resolved.  No history of travel, no known TB contacts, no HIV risk factors.

Epidemiology:  Born and lives in Pucará, Chanchamayo in the high jungle of Perú.  Agricultural worker who spends significant time in very rural jungle areas.

Physical Examination:  T: 38.1°C (oral), pulse 92, respiration 20, BP 90/60.  Chronically ill appearing, wasted, pallor.  HEENT: normal oral mucosa, few small non-tender cervical lymph nodes.  Normal chest and cardiovascular examinations.  Abdomen: diffusely tender, no visceromegaly, normal neurologic exam.  Skin and mucosal surfaces without rash or lesions.

Laboratory Examination:  Hematocrit, 30, WBC 6.8 (normal differential count), creatinine 0.5, marked hypo albuminemia (1.6 mg/dl ), Normal ALT and AST.  Normal urinalysis.  Blood and pus cells were noted on direct stool exam but multiple stool examinations for ova and parasites (including parasite coproculture) were negative as was bacterial stool culture.  HIV negative.  Chest X-Ray showed mild interstitial infiltrates in the lower lung fields and a small cavity on the left [Image A].  CT scan of the chest [Image B] also demonstrated cavitary and intersticial disease.  Sputum culture for bacteria, AFB and fungi were negative.  Abdominal CT: no visceromegaly, small amount of ascites, diffuse edema of the colon wall, no lymphadenopathy.  Upper endoscopy was negative.  Colonoscopy, multiple colonic ulcers scattered throughout the colon [Image C].

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