Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
CLINICAL CASE REVIEW
MANAGEMENT PROBLEMS IN GENERAL PRACTICE
A 30-year-old man with fatigue
and red eyes
Here we prsneni a clinical
problem encountered
in general practice together
with a commentary from an
expert in the field. If you meet
an interesting or puzzling case
you would like considered in
this series, please send it to us.
Commentary
•
My immediate impression is
that this patient has a systemic illness of recent onset affecting several organ systems. I see some
urgency in establishing the diagnosis, since several of the candidate diseases need prompt therapy to obtain control and to limit
the degree of damage. Further
investigations would be guided by
two priorities: firstly, to determine
the extent and pattern of involvement of other organ systems, and,
secondly, to identify the underlying disease process. These two
goals would be pursued pari
passu.
The kidney is commonly affected in many systemic illnesses;
therefore, I would first examine
the urine for red blood cells, casts
and proteinuria, measurements of
serum electrolytes, urea and creatinine would suggest whether substantial renal dysfiinction was present. Liver function tests would
establish whether the patient had
hepatitis, which would have a
bearing on determining the underlying cause. Measurement of the
Commentary by Professor Ronald S Walls,
DPt)il(Oxon), FRACP, FRCPA, associate
professor in medicine, University of
Sydney, and t)ead, immunology
department, Concord Hospital, Sydney,
New South Wales, Australia. This article
was written specially for h/looERN I\AEDICINE.
Clinical problem
A 30-year-oId male high school sports master presents
with a two-week history of fatigue, malaise, myalgia
and uncomfortable red eyes. On examination he is
found to have obvious iritis end a few palpable cervical
lymph nodes. His full blood count is normal but his erythrocyte sedimentation rate is 65mm/h. What further
investigations should be undertaken in this patient?
serum creatine kinase level would
shed light on his muscular symptoms and should be performed if
the myalgia is judged on clinical
grounds to be any more than a
nonspecific symptom of an acute
illness. A chest X-ray is a simple
procedure that should be performed to detect the presence of
mediastinal lymphadenopathy or
any parenchymal involvement.
I find serum protein electrophoresis a useful investigation
in circumstances such as this. I
would look for the clinical picture
of an acute phase reaction, or
there may be a polyclonal increase
in gammaglobulin, which would
infer the presence of a longstanding inflammatory disease that had
been silent until recently.
The underlying disease process
is most likely to be inflammatory
(although not necessarily infective). Neoplastic disease is always
possible, even in a young man, and
should be considered down the
track if the diagnosis is not forthcoming. Infective causes are less
likely in view of the normal
peripheral blood haematology, but
I wovdd still perform serology for
infective mononucleosis and seek
the patient's permission to perform an HIV antibody test.
Sarcoidosis and tuberculosis may
be suggested by the appearance of
the chest X-ray. However, to pursue the possibility of sarcoidosis
further, I would measure serum
5 6 I^ODERN IVIEDICINE OF SOUTH AFRICA /IVIARCH1998
calcium,
phosphate
and
angiotensin converting enzyme,
and perform a Multitest CMI. This
is a commercial multiantigen
intradermal device for determining delayed hypersensitivity reactions to tuberculin and six other
antigens simultaneously.
The advantage of this test over
a tuberculin test is that a negative
result can be interpreted as a true
negative (in which case other antigens will elicit reactions), or as
being due to anergy, which is of
significance in the context of sarcoidosis.
Any suggestion of lower back
pain, colonic symptoms or urethritis would raise the possibility of
Reiter's syndrome and other
seronegative arthropathies. X-rays
of the sacro-iliac joints and spine,
and measurement of HLA-B27
antigen covdd be justified if such
symptoms were present.
I would also be concerned about
the possibility of a systemic necrotizing vasculitis or auto-immune
disorder and I would look for
immunological markers of these
disieases. Such markers include
ANCA (antineutrophil cytoplasmic
antibody), rheumatoid factor and
ANA (antinuclear antibody). Ethe
patient was found to be positive
for any of these markers, further
tests would be indicated, such
as for antibodies to doublestranded DNA, extractable
nuclear antigen (ENA), comple-
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
CLINICAL CASE REVIEW
MANAGEMENT PROBLEMS IN GENERAL PRACTICE
ment components and cardiolipin.
With a bit of luck the diagnosis
should be apparent by this stage.
If not, I would organize histology
of the lymph nodes, by either fineneedle aspiration biopsy or excision biopsy. I would also consider
the possibility of inflammatory
bowel disease, especially Crohn's
disease, which may necessitate
endoscopy. I would also be reaching the stage of considering a CT
scan of the abdomen, looking for
(among other things) lymphadenopathy or masses that may
be amenable to biopsy.
While these investigations were
in progress, the patient would be
being treated for his iritis. If the
diagnosis was stiU not established,
one would expect the disease to
resolve or evolve, presenting clues
as to the best way to proceed. This
might be to defer further investigation but maintain carefial medical supervision, or to proceed
immediately with further investigations — especially to seek out
any affected tissue that would be
amenable to biopsy. •
..FOR YOUR INFORMATION...FOR YOUR INFORMATION...FOR YOUR INFORMATION.
N*w clinic treatnwnt for hirsutism: ^minimal' thermal Injury to the skin
A new rtafr rsmova/ system: sixxassas like rte one Iw^p (he patients commg OacA.
The FOA has granled ESC
Medical Systems clearance to
market its EpIUght Hair Removal
System lo clinics in the US. For
moat patients, the system allows
a doctor to salely remove hair
with a single pulsed-light treatment
In en le-month multicentre
study, dermatologists administered a single treatment to more
ttian 100 men and women al more
than 200 anatomic sites. Three
months after treatmenl, the average clearance rate tor all sites and
tor all hair coburs and skin types
was 52%. For black hair on light
skin, the rate was 62%,
The EpiUght ts not a laser. Its
intense pulsed light is converted
into heal when It is absorbed by
melanin. According to ESC, the
heat destroys the near-by hair
with only 'minimal' thermal injury
lo the skin.
Seeking, treating
H pytori Is cost-effective
Chances are that a new palleni
who presents to a primary care
physician with dyspepsia will have
Helicobacter
alprazolam
ri*!
^ U m g
he W n M U u
h e ito JOrtirW)!
mmmm^
pylori
infection,
according to Scottish researchers.
In iheir study, 63% of those who
agreed to be tested had (he ulcercauaing bacteria.
Dr Ann-Marie Mclntyre and colleagues In lhe UK compared lhe
cost-etlectiveness of H pylori testing and sradicalion with conventional empiric treaimenl in 57
patients. They concluded that the
former strategy is cosi-effaclive.
'More than halt lhe patents in the
sludy... were cured, the majonty of
them the first time,' The Reuters
News Service reports that this
study appears in the July/August
Issue of the Intamationsf
of Clinicat Practice.
Journal
MARCH 1998 / MODERN MEDICINE OF SOUTH AFRICA
57
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
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T
iTolab^lidaide 80
r
A
B
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X
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I Newer 2nd generation sulphonylurea<^>
I Affordability and quality
I Preferred in the elderly Type II diabetic'^)
I Dosage: initially 40 mg to 80 mg daily
Dexfln 500,8S01SOO FC, 8S0 K
T
A
B
L
E
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• Biguanide type oral blood glucose lowering agent
• Useful in management of the obese Type II diabetic®
• Dosage: 500 mg t.d.s. or 850 mg b.d. with meals
Glyben #5 t a b
• Widely used in the treatment of NIDDM
• Effective in Type II diabetes not responding satisfactorily
to dietary regulation
• Dosage: initially half a tablet (2,5 mg) daily
References;
1.
Gibbon CJ, Swanepoel CR, eds. South African Medicines Formulary 4ed. Cape Town: Medical Association of South Africa, 1997: 59.
2.
Gibbon CJ, Swanepoel CR, eds. South African Medicines Formulary 4ed. Cape Town: Medical Association of South Africa, 1997: 58.
] Rolab-Gliciazide 80 Tablets. Each tablet contains 80 mg giiclazide. Reg. No. Z/21.2/197.
] Dextin 500 and 850 Tablets. Each tablet contains 500 mg or 850 mg of metfomnin hydrochloride. Reg. Nos. Q/21.2/290. Q/21.2/291.
Dextin 500 FC and 850 FC Tablets. Each tablet contains 500 mg or 850 mg of metformin hydrochloride. Reg. Nos. 28/21.2/0046. 28/21.2/0047.
J Glyben 5 Tablets, Each tablet contains 5 mg giibenciamide. Reg. No. T/21.2/150.
THE
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providing
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A sector of Novartls South Africa (Pty) Ltd.
72 Steel Road
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Telephone: (Oil) 929-9000
Fax: (011) 929-9001
E-mail: [email protected]
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