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Old 06-27-2011
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Question painful jaw case

A 32-year-old woman presents to her physician with chilly sensations all over her body. She reports pain localized to both sides of her jaw and abdominal discomfort for the past 4 days. She states her appetite has been poor for the past 3 days. Upon physical examination, both sides of her lower face extending from the tempromandibular joint to the mid-mandibular region are enlarged and slightly tender to touch. Pain can also be elicited upon deep palpation in the lower abdominal quadrants. The patient has a social history of three packs of cigarettes per day and three beers per day. Which laboratory test helps to confirm the diagnosis quickly?

Temperature: 39.4°C (103°F)
Pulse rate: 82/min
Hemoglobin: 13%
Hematocrit: 40%
White blood cells: 9000 with 40% segmented PMNs, 8% monocytes, 52% lymphs

Answer Choices
A. Blood cell count
B. Blood culture
C. Serum amylase
D. Single blood sample for a specific immunoglobulin G
E. Single blood test for a specific immunoglobulin M
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Old 06-27-2011
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Blood cell count? I think its a case of temporal arteritis.. ESR?
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Old 06-27-2011
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I have absolutely no idea what it is but heres what i understand
1) theres an infection
2) It probably viral cause as theres an increase in lymphocytes
3) the area they are indicating is the parotid gland

for some reason im thinking EBV but its just a random hunch no logic that i can think of

anyway i would choose D- blood for IgG
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Old 06-27-2011
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Is it Parotitis? Mumps?

Answer would be E.
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Old 06-28-2011
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i m with parotitis also...igm to show acute infection so
e
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Old 06-28-2011
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The diagnosis is definitely mumps, with the lower abdominal pain possibly due to oophoritis.

IgM antibody titres would be a good diagnostic test. But serum amylase is also raised, and combined with the clinical picture, is highly suggestive of mumps. And serum amylase can perhaps be performed more quickly as asked in the question.

I'm confused between these two options. Let's see what miss patho has to say
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Old 06-29-2011
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Option E (Single blood test for a specific immunoglobulin M) is correct. This patient has mumps. Pain extending from the temporomandibular joint to the mid-maxillary region, in conjunction with a white blood cell (WBC) count with predominant by lymphocytes points to a viral etiology. Mumps is an enveloped virus belonging to the paramyxovirus group. It is an acute, communicable infection with localized swelling of one or more salivary glands. The virus is transmitted in saliva. It has also been found in urine specimens. At times, gonads, meninges, pancreas and other organs can be involved. In males, inflammation of the testes usually occurs 3-4 days after parotitis (orchitis does not occur after the common cold, influenza or whooping cough) and if it is bilateral, then sterility can occur. The virus can spread hematogeneously to the meninges, via viremia or infected mononuclear cells, where it may invade the Purkinje cells and provoke glial cell proliferation, and meningeal and perivascular mononuclear cell infiltration. A single test revealing a specific immunoglobulin M (IgM) directed towards the mumps virus can be used to confirm the disease.

Option A (Blood cell count) is incorrect. Blood cell count by itself is a nonspecific test to arrive at a quick and specific diagnosis of mumps. As a rule, blood cell count by itself only guides a clinician to rule in or rule out infections and other disease states. For example, pneumoccocal pneumonia and other causes of “typical bacteria pneumonias” have leukocytosis associated with a left shift.

Option B (Blood culture) is incorrect. This patient has a viral infection of the parotid glands. Blood cultures are specific tests that are predominantly useful for diagnosing various bacterial pneumonias. Urine samples and throat swabs can also be taken to grow the mumps virus in the laboratory. Throat swabs are quickly and easily obtained from patients and would eventually lead to the diagnosis; however, they are not the quickest way to confirm the presence of the mumps virus.

Option C (Serum amylase) is incorrect. Serum amylase levels can be elevated in various disease states, and this test is not specific for mumps. Many diseases can increase the amylase concentration, including various gland tumors, tubal pregnancy, acute pancreatitis, Hodgkin’s disease, Sjögren syndrome and lupus erythematosus.

Option D (Single blood sample for a specific immunoglobulin G) is incorrect. Acute and convalescent titers of specific immunoglobulin G (IgG) antibodies can be used to confirm the diagnosis of mumps, but two different samples at different time intervals are needed. A quicker method is to take one sample and make a single IgM measurement to arrive at the diagnosis.

High-yield Hit 1
WORKUP
Diagnosis based on history of exposure and physical finding of parotid tenderness with mild to moderate constitutional symptoms.
Diagnosis is confirmed by a variety of serologic tests or isolation of the virus.
LABORATORY TESTS
Diagnosis is confirmed by fourfold rise between acute and convalescent sera by CF, ELISA, or neutralization tests.
Virus can be isolated from the saliva, usually from 2 to 3 days before to 4 to 5 days after the onset of parotitis.
Virus can be isolated from CSF in patients with meningitis during the first 3 days of meningeal findings. More rapid confirmation of mumps in the CSF is IgM antibody capture Immunoassay and nested PCR assay.
Virus can be detected in urine during the first 2 wk of infection.
WBC
May be normal
Possible mild leucopenia with a relative lymphocytosis
Leucocytosis with left shift with extra salivary gland involvement, such as meningitis, orchitis, or pancreatitis
Serum amylase:
Elevated in the presence of parotitis
May remain elevated for 2 to 3 wk
May be differentiated from mumps and parotids by isoenzyme analysis or serum pancreatic lipase
Mumps meningitis:
CSF WBCs from 10 to 2000 WBC/mm3 with a predominance of lymphocytes
In 20% to 25% of patients, predominance of polymorphonuclear cells
CSF protein normal or mildly elevated
CSF glucose low, <40mg/100ml, in 6% to 30% of patients
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The above post was thanked by:
bassatom (06-29-2011), Sadalssud (06-29-2011)



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Infectious-Diseases, Internal-Medicine-, Step-2-Questions

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