Download Intern Case Report - Emergency Medicine

Intern Case Report
Nick Robell
Goals & Objectives
• Challenge the Audience
• Presenting a novel case
• Review a common infectious disease test
• Educate
• Epidemiology
• Disease pathogenesis
• Diagnosis and classification
• Management and treatment
• Entertain
• No Disclaimers
Weekday in September
CAT 2 West
34 yo m c/o fever
“Pt to prelim desk c/o fever, possible tooth
infection. Pt had tooth extraction 1 week ago.
Now having fever. AOx3. Resp even and
unlabored. Skin w/d. MAE x4.”
“Sent from Wayne State Campus for fever of
unknown origin. Wearing mask.”
T 39.5
HR 119
BP 99/65
RR 20
SpO2 98%
History
Fever, headache and myalgia
Vietnam for 1 mo, returned
yesterday
Tooth extracted 1 week ago
Past Medical History
No Past Medical History
No Past Surgical History
No Family History
Review of Systems
Negative for eye pain.
Negative for rash.
Positive for headache.
Positive for myalgias.
Negative for Neck stiffness.
Negative for any GI, Resp or CV
complaints
Physical Exam
Diaphoretic
Oropharyneal exudates
No meningismus
No rash
No focal neurologic deficits
Initial Testing
ED Blood Panel
Imaging
Other Testing
Lumbar Puncture
ID tests
132
99
15
3.5
22
1.15
14.1
3.4
140
3.4
Differential
Neutro (T/%): 2.6/ 77
Lymphs (T/%): 0.50/ 15
Mono (T/%): 0.30/8
Baso (T/%): 0/0
Eos (T/%): 0/0
Bands (T/%): 0/0
111
85
0.6
0.1
49
100
Rapid Strep Negative
Back
SPOILER ALERT:
NOT HELPFUL
FINDINGS:
There is a metallic fixation rod in the midportion of the right
scapula. Cardiomediastinal contours are normal. Lungs and pleural
spaces are clear
IMPRESSION:
No pneumonia. No other significant finding
FINDINGS:
There are multiple prominent bilateral lymph nodes,
which are likely reactive.
IMPRESSION:
1. Absent left posterior mandibular molar level without
surrounding inflammatory changes. However, cannot
exclude an infected socket. No abscess.
Back
2. May have an oro-antral fistula. Correlate clinically.
Meanwhile…
Patient remained tachycardic, 90-120s
Spiked fevers multiple times despite antipyretics
Blood pressures ranged from 100-120s/ 60-70s
received 1 L of normal saline
Normal respiratory rate
Back
FINDINGS:
Ventricles are normal in size and midline in location. No
intra-axial or extra-axial fluid collections . Gray white
differentiation is well maintained. Mucosal thickening right maxillary
sinus and ethmoid air cells.
IMPRESSION:
No acute intracranial process
Lumbar Puncture
-Opening pressure 19.2 cm H2O
-4 tubes of clear fluid
-Cryptococcus
-West Nile Virus
-Mononucleosis
HIV Positive
Admit to F6/ Infectious Disease
• Screening- ELISA
HIV Testing
• Confirmatory- WB
• Based on antibody testing
• Based on viral protein
• Misses window period
• False-positive in healthy population,
0.06%-0.12%
• False Positive- Rheumatic, EtOH,
Syphilis, IVIG, Dengue, Malaria & Hep B
HIV Testing
• Confirmatory
• Western Blot
• Based on viral protein
• Scored as negative, positive or
indeterminate
• Indeterminate- Elevated
bilirubin, SLE, hemolysis, RF,
Polyclonal gammopathy, HD, HLA
ab, HTLV-1, Schistosomiasis,
Heterophile Ab, massive
proteinuria
Hosp. Day 1
• Leukopenia, Lymphopenia, Elevated
LFTs, thrombocytopenia and febrile
Hosp. Day 2-5
• Negative HIV WB, cyclical fevers, +
cryptococcus CSF, antibiotics & antifungals given
Hosp. Day 6, Discharge
• Antibiotics and anti-fungals
discontinued, Dx confirmed, LFTs
downtrended, Plts uptrending
The Febrile Traveler
34 yo male with no pmhx presents with
fever and headache after being in
Vietnam for 1 month with leukopenia,
thrombocytopenia, transaminitis and
positive HIV ELISA.
CDC Tropical Diseases in Travelers
A.
B.
C.
D.
E.
F.
G.
Malaria
Typhoid Fever
Leptospirosis
Chikungunya
West Nile Virus
Measles
Rubella
H. Acute HIV
conversion disease
I. EBV
J. Dengue
K. Viral Hemorrhagic
Fevers
L. Rickettsial Diseases
M. SARS
• Dengue Serology
sent on Hospital
Day 5
• Performed Salt
Lake City, UT
• Elevated IgM and
IgG
• All antibiotics
discontinued
• Follow-up with
DMC providers
500
450
400
350
300
ALT
AST
Plts
250
200
150
100
50
0
1
2
3
4
5
Day of Hospitalization
6
“Most rapidly spreading mosquito-borne viral
disease in the world…”
Dengue Pandemic
• “Imperils” 2-5 billion people living in Tropical and sub-tropical countries
• 50-100 Million infected every year, 500,000 admitted to hospital, 25,000 deaths/
year
• 100 Countries world-wide
• 796 Cases in North America from 2001-2007
• Outbreaks in Texas 2006, Hawaii 2002, Cuba 1977, Singapore 2006 and Florida today
• 16% of febrile travelers may have Dengue
Dengue
• RNA genome Flavivirus with Aedes
vector
• Viral Syndrome
• Partial-immunity leads to more severe
reactions to second infection (DHF/DSS)
• Hemorrhage, Third spacing and organ
failure
• Shock-state due to venous pooling
• Serologic diagnosis with IgM and IgG
• Infants
DENV-1
Cytokines
T-cells
Immune
System
DENV-2,3
and 4
Complements
Antibodies
Dengue
Fever
•Viral
Syndrome
Hemorrhagic
Fever
•Bleeding
tendencies
Shock
Syndrome
•Circulatory
collapse
WHO criteria dengue fever
1. Fever
2. Two or more of the
following clinical symptoms
3. Positive serology or
occurrence with same time
and place as other
confirmed cases of dengue.
"HARMS" Headache
Hemolytic tendencies
(Ecchymoses, purpura)
Arthralgia
Retro orbital pain
Rash
Myalgia
Serology for dengue
WHO criteria for dengue
hemorrhagic fever
1. Thrombocytopenia
(Platelets < 100,000/cu mm)
2. Evidence of plasma leakage
(> 20% rise in hematocrit
>20% drop following fluids
Signs like pleural effusion, ascites,
hypoproteinaema)
3. Signs of hemorrhagic
tendencies
(Positive tourniquet test
Petechie, ecchymoses, purpura
Bleeding from gums
Hematemesis, melena)
4. Fever (Lasting for 2-7 days)
WHO criteria for
dengue shock
syndrome
• All 4 for DHF signs of
circulatory failure.
• The mnemonic is,
"CHIRP" • C: Cold clammy skin
H: Hypotension
R: Restlessness
Rapid and weak pulse
P: Narrow pulse
pressure
Dengue without
warning signs
Dengue with
warning signs
-Abdominal pain or tenderness
-Nausea, vomiting
-Rash
-Aches and pains
-Leukopenia
-Positive tourniquet test
-Persistent vomiting
-Clinical fluid accumulation
(ascites, pleural effusion)
Severe Dengue
Severe Plasma Leakage
leading to:
– Shock (DSS)
– Fluid accumulation with
respiratory distress
-Mucosal bleeding
-Lethargy, restlessness
-Liver enlargement >2 cm
-Laboratory: increase in HCT
concurrent with rapid decrease
in platelet count
**requires strict observation
and medical intervention
Severe Bleeding as
evaluated by clinician
Severe organ involvement
– Liver: AST or ALT ≥ 1000
– CNS: impaired
consciousness
– Failure of heart and other
organs
Treatment
• Death from acute liver failure,
hemorrhage, renal failure, brain
edema and pulmonary edema
• No specific treatment available
• Supportive Measures (antipyretics,
Oxygen, colloids > crystalloids, blood
products)
• Monitor vitals, Monitor CBC and
Fluid balance (avoid over hydration)
• WHO Guidelines available for fluid
management
• Antivirals are being investigated
• CDC Indications for hospitalization
•
•
•
•
•
•
•
Tachycardia
Increased cap refill
Cool Mottled or pale skin
Decreased peripheral pulses
Mental status changes
Oliguria
Sudden increase in hematocrit despite
fluids
• Narrowing of pulse pressure (<20
mmHg)
• Hypotension
Summary
• Aedes vector
• Second infection is worse
• Defervescence Period
• DF/ DHF/ DSS
• Follow WHO guidelines
• Interferes with many
immunologic –based tests
• ALL LOVE for 7 warning signs of
Dengue
• Abdominal pain
Lethargy
Liver enlargement
Low platelet & high hematocrit
O – nil
Vomiting persistently
Extravasation of fluid
Sources
1.
Dengue and Dengue Hemorrhagic Fever: Information for Health Care Practicioners. 2015. Centers for Disease
Control and Prevention.
2.
Treatment. Chapter 3. Dengue Haemorrhagic Fever. Centers for Disease Control and Prevention.
3.
Laboratory Diagnosis. Chapter 4. Dengue Haemorrhagic Fever. Centers for Disease Control and Prevention
4.
Raza, Ali. Variable Impacting Dengue Surveillance in Key West Florida. University of Arizona College of
Medicine.
5.
Messenger AM, Barr KL, Weppelman TA, Barnes AN, Anderson BD, Okech BA and Focks DA. 2015. Serological
Evidence of Ongoing Transmission of Dengue Virus in Permanent Residents of Key West Florida.
6.
Watt G, Chanbancherd P, and Brown AE. 2000. Human Immunodeficiency Virus Type 1 Test Results in Patients
with Malaria and Dengue Infections. Clin Inf Dis 2000, 30: 819.
7.
Weerakkody RM, Palangasinghe DR, Dalpatadu KPC, Rankothumbura JP, Cassim MRN, and Karunanayake P.
2014. Dengue Fever in a Liver-transplanted Patient: A Case Report. Journal of Medical Case Reports 2014, 8:
378.
8.
Halstead SB. 2007. Dengue. Lancet 2007, 370: 1644-52.
9.
Wilder-Smith A and Schwartz E. 2005. Dengue in Travelers. N Engl J Med 2005, 353: 924-32.
10. Effler et al. 2005. Dengue Fever, Hawaii, 2001-2002. Emerg Inf Dis 2005, 11 (5): 742-749.
11. Guzma et al. 2010. Dengue: A Continuing Global Threat. Nat Rev Microbiol 2010, 8 (120): S7-16.