Male patient, 42 years old, with a history of chronic renal failure of unknown etiology, diagnosed in 1993, without further control, chronic alcoholism and mild mental retardation.
She presented with a three-week history of decay, malaise, anorexia, vomiting, abdominal and lumbar pain, with fever subsequently added.
He was admitted with fever (38o C axillary), without tachycardia, blood pressure 161/96 mmHg.
Dehydrated, thin and pale.
He had a right malar ulcer (diameter of 2 cm), with increased volume, erythema and induration of the area and purulent secretion in the right eye.
The liver was projected to be 2 cm below the costal margin, without stenosis.
No lymphadenopathies were detected.
Laboratory revealed a 16% haematocrit, hemoglobin 5.5 g/dL, 8,000 leukocytes/mm3 with left shift of 5%, erythrocyte sedimentation rate ESR 28 mm/h, CRP: 82 mg/L, creatinine nitrogen: 21 mg/dL alkaline
The culture of malar ulcer was positive for Staphylococcus aureus sensitive.
Blood cultures, urine culture, HIV serology (ELISA), HBsAg, HCV (ELISA), VDRL, PPD, sputum smears (two) and urine (se) were negative.
A normal chest X-ray and abdominal ultrasound showed evidence of moderate chronic liver damage, hepatomegaly, spleen of 13 cm, gallstones and symmetric small kidneys.
No ascites.
Parenteral hydration, acid-base and electrolyte status correction were performed, which showed a significant improvement in nitrogen parameters and empirical antimicrobial therapy with ceftriaxone 1 g / day (ev) and 10 g / day (ev) hacil ulcer was indicated.
The etiology was persistent fever with diarrhea without pathological elements. A coprocultive showed abundant development of Candida albicans.
Progressive leucopenia was added to this reaching 2,900 leukocytes so it was decided to perform a spinal biopsy which was reported as "eosinophilic hyperplasia" and the myelocultive Candida albicans.
With these elements the diagnosis of disseminated candidiasis was proposed and treatment with fluconazole 150 mg/day oral (dose adjusted according to renal function) was initiated.
On the tenth day the fever persisted and she was switched to amphotericin B deoxycholate 40 mg/day (ev) together with starting hemodialysis.
A week later, fever still persists, liver function tests abnormal alkaline phosphatase, alkaline phosphatase, gamma-glutamyltransferase, Uineptidase, transaminase increased
Hepatosplenic hydroureter was suspected. An abdominal CAT scan showed homogeneous hepatomegaly, with focal nonspecific candidiasis ecchymosis isolated in liver and spleen, left gallbladder, kidneys a
No visible liquid, lymphadenopathy or free.
culture results showed no response to amphotericin B (700 mg total), and a transparietal liver biopsy was performed. Histological study revealed the presence of scarce hepatic granulomatosis with acid-fast bacilli resistant (BA).
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With the hypothesis of TB, specific therapy was performed with isoniazid, pyrazinamide, et rifampicin and rifampicin, adjusting the drugs according to the patient's weight and renal function up to 7 months.
The fever curve dropped on the second day of treatment, with a concomitant improvement in the general condition and in the liver laboratory.
At the time of this report the patient is asymptomatic, remains on hemodialysis and completed anti-cracking therapy.
