Yesterday was the 3rd combined US Navy medical meeting with our institution.
The session started off with one of our excellent English speaking first year resident's, Dr Tsunoda., who presented a case of a young patient with a history of what appeared to be consistent with meningitis. The case took a twist as the patient had an additional problem of an abnormality in the left frontal lobe on CT scanning which was considered by some to be a contusion and by other to be an abscess or even a lymphoma.
This was a so-called 'Grey Case' as there was no definite answer, but it provided an excellent opportunity to raise discussion on the possibilities that existed for generation of a differential diagnosis and work-up of the patient.
Following on in the second half, a US Navy resident, Dr Suzuki, presented a case of a patient with diffuse arthralgia & tenosynovitis and skin lesions on the hands and feet. The case took on a whole new slant when a sexual history was enquired about and the diagnosis unravelled nicely just based on this set of questions. The patient had had risky sexual encounters. The senior members of our institution got the diagnosis just based on the history, but particularly the new element of a strong sexual history, and a few photos of the skin lesions. I was very proud to hear them say-- disseminated neisseria gonorrhoea and the diagnosis was later confirmed as this.
By grouping together the significant parts of the history such as sexual exposure, arthralgia & tenosynovitis and skin lesions made the diagnosis relatively straight forwards.
It was interesting to hear that the rate of gonorrhoea infection in Japan may in fact be higher in prevalence than in the USA ! Moreover, cultures to try and identify the organism are usually negative! Hence, a high suspicion of this infection needs to be borne in mind.
The evening went very well and the cases presented made us all think and they provided a great forum for discussion.
As I emphasize on many occasions, take a sexual history. Being married is not the beginning and the end of a sexual history. Probing deeper about sexual partners, foreign travel for sex, types of sexual encounter e.g. bisexual, types of sex e.g. oral, anal, are very important and should be pursued in your questioning especially if you think that the problem is a sexually transmitted infection. In knowing the answers to the above allows one to consider which places to examine and where to obtain cultures.
Moreover, contact tracing for partners is essential as part of a well organised public health programme because stopping the spread of sexual infections such as HIV, gonorrhoea, syphilis and chlamydia and education on safer sexual practices will hopefully reduce some of these most devastating infections known to mankind.