Resolved question:
What is the probable cause? What management do you suggest?
For either an Infectious Disease Specialist, a Tropical Medicine Specialist or Clinical Virologist.
Patient History:
1. Pyrexia of unknown origin, started 6 days ago and continuing, from 99-103.5 F., with chills every 4-6 hours and sweating
2. Myalgia. Severe myalgia for first 4 days, then abated
3. Tender nodules. Painful neck and upper back lumps for first 4 days, then receded
4. Head pains. Severe headache for first 4 days, then mainly in eye area for 1 days and then shooting temple pains, on left side as well as generally tender scalp. Palpation of temporal area precipitates shooting pain. (similar to giant cell arteritis)
5. Fatique. Complete prostration for first 4 days, then decreasing to moderate
6. Hypotension. (Patient is hypertensive but bp readings are as low as 114/65mmHg)
7. Dyspnoea. Malaise. Severe for first 4 days, then moderating.
Clinical Notes
1. Absence of Kernig's Response for meningeal irritation
2. Absence of Influenza A and B test response
3. No abdominal signs.
4. Clear urine
Submitted:
4 Days
Category:
Infectious Disease Specialist
Hello,
Thank you for choosing DoctorSpring.
Dr.Steve Morris has forwarded this consult to me as you have requested Tropical Medicine Expertise.
Thank you for providing a concise and informative medical history. Just to be sure I would like to know some additional information from you so than I can provide my best and learned opinion.
Any history of loose stools, ear ache or discharge , swellings, bone pain, sore throat, cough, back pain, shoulder pain , decreased urine out out ?
Any blood /urine/imaging investigation carried out ? If so are the results normal ?
Any history of valvular heart disease ?
You can reply as a followup.
Thank you
Dear Dr. Morris, In reply:
1. There is earache but no discharge. It seems almost "referred" but worsened by head shaking.
2. Only during first 4 days was there general myalgia, including the back and shoulders.
3. Urine was somewhat decreased and darker during days 1-4 but now normal colour.
4. There was shoulder pain on days 1 to 4, including a tender nodule located above the right scapular spine.
5. There were two submandibular neck lumps both painful. Only 1 remains and is not tender.
6. Urinalysis on 12/29 was normal with 2 wbc/HPF, 2 rbc/HPF, 0 epithelial, 0 hyaline cast. No bilirubin, no glucose, no ketones, no nitrites. SG 1.017, pH 6, urobilinogen 1 E.U.
7. Lipase 127; Comp Meta Panel all normal except Glucose 138 mg/dl, Creatinine 0.68 mg/dl, Calcium 8.3 mg/dl, Albumin 3.1 mg/dl, Anion Gap 6 MMOL/L, Alb/Glob ratio 0.7, Calc Osmolarity 274 MOSM/KG
8. CBC with Differential: WBC 12.49k/uL, RBC 4.51M/uL, Hemoglobin 13.4 g/dl, Hematocrit 40.6%, Monocytes 14.7%, Immature granulocyes 0.8%, Neutrophils 8.51k/dl, Monocytes 1.84k/dl, Eosinophils 0.55k/dl, Immature Granulocytes 0.1k/dl; all other parameters in normal range
9. No history of valvular disease.
Thank you.
Hello,
This Dr.Sebastian here (The first reply is also mine). Not sure what name they are showing in the dashboard.
Please allow me to list down my opinion :
1. Symptamatology wise there are no direct pointers for infection. Available blood investigations are not suggestive either.
2. I would suspect the following - n intrabdominal infection (small bowel), cholangitis, pyleonephritis, endocarditis, tropical infection - Malaria ( rare possibility)
3. The patient needs antibiotic coverage. I hope is already on this. A gram negative coverage is essential since he has hypotension.
4. He will need a Blood culture (3 samples) , urine culture , ultrasound followed by a CECT of abdomen for sure. And investigations aimed at the above mentioned diagnostic possibilities.
5. Your local Infectious Disease surveillance unit can help with information on Malaria (prevalence, any recently reported cases etc). If the suspicion is justified it need to be tested - QBC + Peripheral Smear would be the best way to go.
*Periodicity, Hypotension, Chills, duration are more suggestive of a bacterial infection
I would like to know his current status / medications . I hope a thorough physical examination has been done.
Hope this help
Thank you
Dr.DSS