PGY3 Paul Yang presented a case of a 34 year old female with history of chronic migraines, bipolar disorder an fibromyalgia who presents with 8 days of abdominal cramping, nausea and diarrhea. The patient was in her usual state of health until 1 day after returning from vacation in El Salvador when she started having frequent episodes of diarrhea associated with mild subjective fevers (at home, 103F). Diarrhea was initially watery and non-bloody but became bloody a few days later. Diarrhea improved with Imodium. Patient went to OSH 4 days prior to presentation and was prescribed ciprofloxacin for gastroenteritis. After taking ciprofloxacin, she developed new diffuse rash and pruritus on her bilateral upper and lower extremities. Rash improved slightly with Benadryl but persisted. She also reports severe occipital headache associated with photophobia. In addition, patient had diffuse joint pain in her knees, elbows and fingers at the time of onset of the rash and headaches.
Social history is pertinent for recent travel to France 1 month prior with exposure to ill patients and also recent travel to El Savador. In El Salvador, she was in a more rural area with jungle exposure. No direct freshwater exposures but did experience rain there. She ate local foods, including lots of diary products. Did not use malaria prophylaxis.
Vitals stable. Exam with no conjunctive injection, no nuchal rigidity, neuro exam intact, skin with diffuse erythema with macular rash in BUE/BLE sparing head/hands/feet.
CBC: WBC 2.91 > Hb 14.5/Hct 44.5 <Plt 98
Differential: 69.2% Neutrophils, 17.5% Lymphocytes, 7% Monocytes, 6% others (increased circulating plasma cells and immunoblasts per path read).
Na 140/K 4.1/Cl 103/HCO3 24/BUN 4/Cr 0.64 <Glucose 91
ALP 70>T.protein 7.5/Albumin 4.5/AST 36/ALT 50/Tbili 0.3
Coags:PT 14, INR 1, PTT 34.1
CTH performed with no intracranial bleed, mass effect or midline shift.
- BCx negative x2
- UA negative
- Lactate 1
- Fungal BCx with no growth
- HIV non-reactive
- RPR non-reactive
- Acute hepatitis panel negative
- CMV DNA PCR not detected
- Lumbar Puncture:
- Cell count: RBC 1, WBC 0, Glucose 53, Protein 17
- CSF Culture negative
- CSF Cocci Ab not detected
- CSF Crypto Ag not detected
- CSF MTB not detected
- CSF HSV 1/2 not detected
- CSF VZV not detected
- Rickesttsia typhi IgM and IgG not detected
- Strongyloides IgG negative
- Malaria smear negative
- West Nile IgM 0.07, IgG 3.65 (H)
- Chikungunya not detected
- Trypanosoma cruzi IgM 1:16
- Dengue Virus IgM 1.84 (1.65-2.84 equivocal), IgG 7.73 (<1.65 normal)
- ANA 1:80, speckled
- dsDNA negative
- C3 146 (normal: 90-180)
- C4 16.1 (normal: 10-40)
Treatment: ID was consulted and recommended supportive care in setting of likely arthropod-borne viral illness. Patient was feeling well by hospital day 3 for discharge.
Diagram obtained from Dengue WHO 2009, https://www.who.int/tdr/publications/documents/dengue-diagnosis.pdf?ua=1.
Take home points:
- Dengue fever is a mosquito born viral disease. Incubation can range from 3-14 days. There are 3 phases of presentation:
- Febrile phase: sudden high grade fever, HA, vomiting, myalgia, arthralgia (“Back Breaking Fever”), transient macular rash
- Critical phase: characterized by increase in capillary permeability leading to hypovolemic shock
- Recovery phase
- Lab findings for Dengue Fever: Leukopenia, thrombocytopenia, elevated liver enzymes. Direct detection by PCR.
- Increasingly, co-infections of dengue occurs with leptospirosis, malaria, HIV/AIDS and Chikungunya. Differential diagnosis: other viral hemorrhagic fevers (Ebola, yellow fever, hantavirus), Chikungunya, Zika virus, Malaria, Typhoid, Leptospirosis, Parvovirus B19, Acute HIV, Viral hepatitis, Rickettsial infection
- Management is supportive with intravascular repletion, blood transfusions if patient develop hemorrhagic features of severe infection