The start of case 16 can be found by scrolling down or by clicking a link to the right hand side.

Things aren’t looking good for our patient.  He continues to have temperatures despite broad spectrum antibiotics.  He is getting worse rather than getting better.  Amylase is normal.  No growth on cultures so far.  His blood count is worsening:

Hb 82g/L

Neutrophils 0.8×10*9/L

Platelets 76×10*9/L

A CT is obtained and reveals hepatosplenomegaly, with no other size significant lymohadenopathy, although there are some mesenteric and inguinal nodes which are less than 1cm.  Normal flow in abdominal vessels.  Bowels appear normal and no collections.  CT of the chest reveals bibasal atalectasis but no mediastinal lymphadenopathy.

As #teamhaem have suggested, the ward team will obtain an echocardiogram to look for vegetations.

Haematology and infectious diseases are requested to review in order to try and obtain a diagnosis.

Questions

• It is sometimes useful to revisit the history and examination at this point.  Is there anything we’re overlooking?
• What is the differential diagnosis of hepatosplenomegaly?