MDG5207: You are Required to arrive at a possible Diagnosis for the Patient, by Assessing and Evaluating the Significance of the Pathology: Clinical Immunology and Immunotherapeutics Case Study, NUS, Singapore

The assessment for this module consists of a portfolio of two case studies, over these two case studies your understanding of the following module learning outcomes will be assessed.

Students should be able to discuss:

1.The role of the immune system in infection.

2.The immunological basis of a range of disorders including primary and secondary immunodeficiencies, hypersensitivity states, tumours, autoimmune disorders.

3. Methods and evaluate results from laboratory investigations of immunological disorders.

4, The immunological basis of transplantation and graft rejection, including GvH disease in grafting of immunocompetent tissue.

In the following pages the clinical findings of two case studies are outlined, the first is of infectious disease and the second is of an autoimmune disorder. The case studies include a range of presenting symptoms with any relevant previous history, or family history if appropriate. Also included is a range of results from recently performed laboratory investigations, carried out on either the patient or biological samples from the patient.

a) You are required to arrive at a possible diagnosis for the patient, by assessing and evaluating the significance of the pathology results, in light of the history of the patient. All presenting signs and symptoms need to be fully explained.

b) You need to explain the significance or the results of the laboratory investigations,

in order to justify your conclusions and diagnoses.

c) You should outline any further investigations (if any) which should, in your opinion, be performed to confirm the diagnosis.

d) You should discuss the potential therapies for the treatment of the condition(s) you conclude to be present in this case.

Case study #1

Mr. Gray, a 19-year-old male presented with a sore throat. The sore throat had become painful and the patient reported having a mild fever that had developed during the previous few days. The patient reported feeling lethargic and “run down” which he attributed to returning from a football tournament a month previously and studying hard to catch up on work he had missed for his degree. Whilst is currently healthy Mr. Grayhad previously received a living donor kidney transplant four years previously following polycystic kidney disease.

The transplant was successful and Mr. Gray was compliant in his use of a low maintenance dose of cyclosporine. On examination, the patient’s tonsils appeared very swollen and exudate was seen, the patient was given amoxicillin for suspected streptococcal pharyngitis, and a swab taken for analysis.

7 days later the patient returned to the clinic reporting a worsening of symptoms including the inability to eat solid food due to severe soreness and swelling of the throat, extreme lethargy, abdominal discomfort, nausea but no vomiting, general pruritus, and an itchy rash on his trunk.

On examination the patient seemed very ill with a dry red throat, the tonsils had enlarged further and exudate was still present. Anterior and posterior lymphadenopathy was detected, palpitation of the abdomen revealed an enlarged liver and spleen with the tip easily palpable. The patient had a temperature of 38.2oC with pulse and blood pressure within normal ranges. A maculopapular rash was seen mainly on the trunk with a lesser presentation on the arms. A urine dipstick test detected bilirubin.

At this time the throat culture had returned with no streptococci detected and the antibiotics were discontinued. A further throat swab was taken for culture and blood was taken for analysis.