36

CASE 36


A 41-year-old white man was brought to the emergency department with a 3-day history of shaking chills, high fever, headache, abdominal pain, and generalized weakness. Mild diarrhea had started 2 days earlier and had been improving when the fever began.


The patient had returned to the United States 10 days earlier, after a 3-week visit to India. He recalls eating a variety of local foods, particularly from street vendors. He had not received any travel-related vaccines. Past medical history was unremarkable.



PHYSICAL EXAMINATION



VS: T 39.5°C, P 82/min, R 18/min, BP 94/58 mmHg

PE: On examination, the patient appeared ill and confused. His abdomen was diffusely tender, and his liver and spleen were enlarged, although there was no evident jaundice. Erythematous maculopapular lesions (“rose spots”) were noted on his chest (Fig. 36-1).

image

FIGURE 36-1 Maculopapular rash (“rose spots”) on the chest of this patient.


(Courtesy of Dr. Paul Southern, Departments of Pathology and Medicine, University of Texas Southwestern Medical Center, Dallas, TX.)



LABORATORY STUDIES



Blood



Hematocrit: 36%

WBC: 3700/μL

Differential: 30% PMNs, 28% lymphs, 38% monos

Platelet: 76,000/μL

Serum chemistries: ALT 344 U/L, AST 268 U/L


Imaging


Abdominal CT scan was remarkable for enlarged liver and spleen with no focal lesions.



Diagnostic Work-Up


Table 36-1 lists the likely causes of illness (differential diagnosis). A clinical diagnosis of sepsis was considered. Investigational approach may include


• Cultures of blood or bone marrow and stool (when diarrhea is present)

• Failing above, the additional tests are
• Cultures of stool on selective media for Salmonella (if diarrhea is present)

• Viral serology for dengue fever

• Peripheral blood smears for malaria parasites

TABLE 36-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Amebic hepatic abscesses

Brucellosis

Dengue fever

Leishmaniasis

Malaria

Tuberculosis

Typhoid (enteric) fever
Salmonella paratyphi types A, B, and C

Salmonella typhi

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 36

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