[Pain in the throat due to acute suppurative thyroiditis caused by Salmonella]. / Een pijnlijke hals door acute suppuratieve thyreoïditis veroorzaakt door Salmonella.

A 53-year-old woman presented with fever accompanied by chills and an extremely painful swelling of her right thyroid lobe. She was initially diagnosed as having subacute thyroiditis, but after 14 days her disease appeared to be caused by a destructive suppurative thyroiditis due to Salmonella group C. A pre-existing hyperplastic nodule in the right thyroid lobe was the predisposing factor. Antibiotics were given for several weeks and surgical drainage was performed. Finally a hemithyroidectomy was done to eliminate the predisposing factor.

[An outbreak of measles at an emergency room]. / Een uitbraak van mazelen op de Spoedeisende Hulp.

A small outbreak of measles occurred after a 33-year-old female aircrew (cabin) member presented at an emergency room with fever. Three members of the hospital staff were infected: a 42-year-old man, a 33-year-old woman, and a 26-year-old woman. The first 2 patients had not been immunised, and the third had received 2 immunisations according to the Dutch National Immunisation Programme. Vaccination of the 2 sero-negative patients within 48 h after exposure with the measles-mumps-rubella vaccine (MMR) did not prevent the development of measles. Vaccination was deemed unnecessary in the third patient. No tertiary cases occurred. The same measles virus (genotype D5) was detected by PCR and sequencing in all 4 patients. Measles remains a risk for hospital staff members who have not acquired natural immunity. The current policy of immunising patients within 72 h after exposure to measles may not be sufficient. It also appears that immunisation through the Dutch National Immunisation Programme does not always protect against nosocomial infection. Providing MMR vaccination or boosters to hospital staff in certain departments might be beneficial.

[Clinical thinking and decision making in practice. A patient with persistent fever]. / Klinisch denken en beslissen in de praktijk. Een patiënt met aanhoudende koorts.

A 20-year old man was admitted to hospital with fever and malaise after travel to India. He was soon found to have typhoid fever, caused by a multi-drug resistant Salmonella typhi. According to in-vitro resistance testing he was treated with cefotaxim, but fever and shivering were still present after 7 days of cefotaxim, with liver enzyme disturbances. The physicians caring for him started an extensive search for possible complications of typhoid fever, and they thought of the possibility of an alternative disease to explain the fever. When cefotaxim was stopped all symptoms and signs disappeared. During every medication, drug fever is a possibility. This diagnosis can only be supported by discontinuing the use and if necessary, restarting it (dechallenge and rechallenge).

[Physical diagnosis--percussion and palpation of liver]. / Fysische diagnostiek--percussie en palpatie van de lever.

Percussion and palpation of the liver can produce useful information regarding size, consistency and the surface of the lower liver edge. However, the accuracy of the physical examination of the liver is limited, especially concerning the predictive value of the absence at physical examination of hepatomegaly (> or = 15 cm liver width in the right midclavicular line) for the absence of a truly enlarged liver. Also, the inter-observer variability may be considerable. These limitations of the test may be partly due to a number of pitfalls and misconceptions concerning physical examination of the liver.