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Download Intern Case Report - Emergency Medicine
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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.