Educational Case

[ERMudPhud]

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Let the interns and students have a chance before everyone else jumps in.

It is late June in suburban Denver and you are seeing the following 35 yo male.

CC: Fever
HPI: 35 yo male complains of 5 days of fever, chills, low grade headache, diffuse myalgia, nausea, and severe weakness. He has basically felt too crappy for the last 5 days to even get out of bed. Prior to this he has been totally healthy. He denies sick contacts. He denies vomiting or diarrhea. Denies dysuria or hematuria. He denies rash.

PMH: none
PSH: appendectomy 5 years ago
Social: No ETOH, tobacco, drugs. Works as accountant. Married
Travel: No overseas travel in last year
ROS: Full ROS in chart but essentially as above.
Meds: He's been taking aleve and tylenol

Vitals HR 110 BP 110/70 RR 22 T 102.5 02sat:normal for Denver
Gen: Young male lying in bed looks "wiped out" but not critically ill or septic
HEENT: NC/AT, anicteric, TM's clear, oropharynx: dry but no lesions
Neck:no adenopathy, no meningismus
Chest: CTA
Heart:tachycardic otherwise normal
Abd: Perhaps a bit of RUQ tenderness but otherwise pretty normal
Back: no CVAT
Derm: No petechia,purpura,rash
Extr: no c/c/e
Neuro: normal

So, what else do you want to know, order, do?

 

[hornste]

alright, i get first cracks at this case.

History/Physical:
- what brings him into the ED after 5 days of sx?
- cough, rhinorrhea, sore throat, SOB, CP?
- photophobia/phonophobia?
- arthritis, radiculopathy?
- was the patient completely undressed for the derm exam? any recent rashes?
- Can you specify what is included in a normal neuro exam?
- When is the last time he's taken tylenol or ibuprofen? How much and how often?
- calf swelling?
- Who took this RR of 22? Was it the nurse or physician? Are we to believe it?
- With a temp of 39 degrees C, it should raise his HR by 8.5, so a HR of 110 seems appropriate for his temp. Am I correct in this interpretation?

Ddx:
- acute viral illness (influenza, EBV, CMV, adeno, HIV, etc)
- acute abdominal process (cholecystitis/cholangitis, pancreatitis although he isn't vomiting, abscess, etc.)
- Lyme disease or one of the other tick borne illnesses
- RMSF (although the patient should be bradycardic, not tachycardic)
- Meningitis
- PE (the patient is tachycardic, tachypneic, febrile, with presumably a low O2 sat)
- tylenol/ibuprofen toxicity (it's a reach, but maybe he's overdosing on tylenol and is in phase 1 or 2, he does have RUQ pain afterall, or maybe he's OD'ing on ibuprofen and he's having sx of uremia from ARF)

Prelim Orders:
- CBC-D/chem7
- heplock
- 0.9 NS bolus 500 cc, then 125cc/hr (he's been sick, febrile, mouth is dry, I'm guessing he's a bit dehydrated. I'd bolus him, reassess, and prob bolus him again since he isn't CHF or elderly, or any condition leading to decreased cardiac function)
- tylenol 1g PO x 1 or ibuprofen 600mg PO x 1 (depending on last administration of drug)
- abdominal labs (amylase, lipase, LFT's, PT, PTT)
- reassess

intern.

 

[RxnMan]

Before looking at hornste's post, these are what I wanted to know/test. RR looked high, may/may not be accurate. I thought a viral infection (EBV) or cholecystitis. I'd want a CBC and electrolytes. MS2.

 

[ERMudPhud]

History/Physical:
- what brings him into the ED after 5 days of sx?
- cough, rhinorrhea, sore throat, SOB, CP?
- photophobia/phonophobia?
- arthritis, radiculopathy?
- was the patient completely undressed for the derm exam? any recent rashes?
- Can you specify what is included in a normal neuro exam?
- When is the last time he's taken tylenol or ibuprofen? How much and how often?
- calf swelling?
- Who took this RR of 22? Was it the nurse or physician? Are we to believe it?
- With a temp of 39 degrees C, it should raise his HR by 8.5, so a HR of 110 seems appropriate for his temp. Am I correct in this interpretation?

intern.

Finally came in because he was sick of being sick.
no cough, rhinorrhea, ST, SOB, photophobia, phonophobia, radiculopathy
Whatever chest pain he had seemed indistinguishable from his general myalgias
I find pt's have a hard time distinquishing arthralgias from myalgia, they just hurt all over. He had no obvious synovitis or arthritis on exam
Completely undressed and no recent rashes either
My basic neuro includes CNII-XII(actually I probably don't really test IX,X very well except to look at their palate and listen to their voice), pronator drift, light touch, reflexes, finger to nose, heel-shin, gait.
aleve 2 hours ago
no calf swelling
RR done by triage nurse but mine are pretty good about not cheating
I thought is HR was reasonable for his temp and degree of dehydration.

I'll save the studies for after a few more people have had a chance to weigh in.

 

[Flopotomist]

MS2 here, so not good at this game yet, but with the RUQ tenderness, can we add an acute hepatitis to hornste's ddx? Also, what about his diet, anything unusual there? What is the patient's general body habitus? (Is this a potential steroid user?)

 

[SolidGold]

Recent time spent outdoors during the Denver summer?

 

[ERMudPhud]

MS2 here, so not good at this game yet, but with the RUQ tenderness, can we add an acute hepatitis to hornste's ddx? Also, what about his diet, anything unusual there? What is the patient's general body habitus? (Is this a potential steroid user?)

Good thought given the possible association of supplements with L-tryptophan and eosinophillic myalgia syndrome. I routinely ask about supplements, otcs, herbals, etc... but none in this case.

 

[ERMudPhud]

Recent time spent outdoors during the Denver summer?

Of course😀

 

[SolidGold]

Does this guy have a lot of hair? Pets?

 

[It'sElectric]

I, too, am a lowly MS2, but I was curious if Murphy's sign was elicited, since some of us are throwing cholecystitis in the ddx.

This is a pleasure reading through, so thanks in advance!

 

[Flopotomist]

Other tests to add maybe:

Rapid HIV (very cheap, even if very unlikely)
Ultrasound (if available) of calves (dvt?) and you can also look to see if there is sludge / stones in gallbladder. (cheap, easy and fast test)

 

[RxnMan]

Recent time spent outdoors during the Denver summer?

Of course😀

Add West Nile to Ddx.

 

[EM_Rebuilder]

Add West Nile to Ddx.

I ditto that. Wait seven days (or is it fourteen?... cant recall for sure) and then send titers... after you spent thousands and ruled everything else first, of course.

EDIT: Looks like its 14. Eight new cases this past week in MS (108 for the year).

 

[SolidGold]

West Nile is definitely on the differential. I'm going to throw out a real zebra: early tick paralysis (associated with the toxins of certain ticks, not an infection like lyme disease as mentioned before). Which is why I want to know about pets and if there is a possibility that there is a hidden tick somewhere on this dude's scalp.

 

[Dr. Will]

West Nile is definitely on the differential. I'm going to throw out a real zebra: early tick paralysis (associated with the toxins of certain ticks, not an infection like lyme disease as mentioned before). Which is why I want to know about pets and if there is a possibility that there is a hidden tick somewhere on this dude's scalp.

Dude...you're on vacation. Go do something besides posting on SDN!

 

[southerndoc]

Add West Nile to Ddx.

Don't forget, anytime you consider WNV you should also consider Eastern Equine Encephalitits (EEE) and St. Louis Encephalitis. California Encephalitis is also one to consider.

However, none of these have definitive treatments, so it's more academic fodder than anything else.

 

[SolidGold]

Dude...you're on vacation. Go do something besides posting on SDN!

I'm just being a couch potato (I missed a whole month of football on ortho) until the girl and I spend some time in a cabin down at Red River Gorge for a bit. I've been strong though and resisted buying a 360 for Halo 3. A flat screen comes first, hopefully with enough time left in the football season.

 

[Hard24Get]

interesting case, thanks.

would want to know if he had shaking chills or just regular feeling cold, if he has been unable to take POs with all this, if there is any proximal muscle weakness, if the fever was even higher at home before taking the aleve, whether the aleve was actually helping with the pain, if he was able to ambulate in (since he was too weak to get out of bed for 5 days). Would want to clarify whether he ever actually had abd pain since he is tender there (ie, biliary colic story?).

My ddx would include viral syndromes, lyme dz, meningitis, PE, maybe hepatitis as mentioned above. Would worry about a myositis/rhabdo with the myalgias and weakness. Also, since he is tachypneic with fever, would think of a PNA, PE, or less likely TB. Perhaps less likely but also a worry would be a blast crisis of some sort from leukemia/lymphoma that his age group likes to develop. Other thoughts include endocarditis/myocarditis, HIV

In addition to previously mentioned cbc w/ diff, chem panel (with Ca/Mg), lfts, lipase, rapid HIV if available (always good to be screened, right?), would send lyme titer, d-dimer and EKG since PE was mentioned would check CK and UA to r/o a myositis or rhabdo. CXR to address PNA possibility, blood cultures. EKG would also help with looking for myocarditis. Unless this gave me something to work with I would probably do a LP at some point.


In the interim, would give him a 1L NS fluid bolus and some tylenol for the fever (I guess it could be an overdose but he doesn't give that kind of history). Would leave him on monitor for a bit until his hemodynamics and resp status was sorted out. ms4 on break from ACEP 😀

 

[hyperbaric]

Could you expand upon the RUQ pain/tenderness?

Outdoor activities/exposures/hobbies?

Addition to DDx: amebiasis

 

[ERMudPhud]

Does this guy have a lot of hair? Pets?

Not that I recall.

 

[ERMudPhud]

I ditto that. Wait seven days (or is it fourteen?... cant recall for sure) and then send titers... after you spent thousands and ruled everything else first, of course.

EDIT: Looks like its 14. Eight new cases this past week in MS (108 for the year).

Thats part of what I thought was interesting about this case. We've had several years of WNV in Colorado. I usually send titers on cases early in the year just to establish when the epidemic is starting. After that I usually just tell people that they probably have it and they'll probably do ok. The ones who end up hospitalized usually get titers, the rest don't. Our blood bank does a good job of tracking the scope of the disease by testing donors.

He could have very easily been just another WNV case that I sent home with instructions to come back if he gets worse. In this case I asked one specific question that I ask most people with summer time febrile illnesses and got a very specific interesting answer.

Sometimes what looks for all the world like a systemic viral syndrome isn't a viral syndrome

 

[Febrifuge]

I'm at approximately midterm of my first quarter with the medical stuff (Summer was all Anatomy all the time). So I'll wait on the other guys' labs for now... I definitely want to know what's up with his liver.

If nobody said a manual CBC, I'll say that... I'd like to know what the MT thinks about this guy's RBCs and how young they look (why, yes, I am doing the hematology part of my lab class now). Mostly I'm curious about liver and thyroid, just because my gut says so.

I kind of want to give him some Celebrex and see what happens, too. He's been chowing COX-1's all week and they're doing bupkus for him.

EDIT TO ADD:

In this case I asked one specific question that I ask most people with summer time febrile illnesses and got a very specific interesting answer.

Hmmm... do we get to take turns guessing what that question was?

 

[ERMudPhud]

West Nile is definitely on the differential. I'm going to throw out a real zebra: early tick paralysis (associated with the toxins of certain ticks, not an infection like lyme disease as mentioned before). Which is why I want to know about pets and if there is a possibility that there is a hidden tick somewhere on this dude's scalp.

Good thought but tick paralysis is usually afebrile without much in the way of other systemic symptom, just ascending paralysis like GB.

The interesting thing about tick born illness in Colorado is that most of it is exogenous. Even though the disease is called RMSF most of the cases in our part of the Rockies were acquired on trips elsewhere. Same with Lyme disease. All the cases I've seen were acquired elsewhere.

 

[ERMudPhud]

His CXR, UA, and EKG were all normal. CBC was interesting with a WBC of 3.0 and platelet count of 70 or so. His HCT, HGB, MCV were all normal. I don't remember anything interesting standing out from his differential. His LFT's showed both transaminases around 200 or so. I can't remember which was higher. All the rest of his LFT's along with his lipase, and electrolytes were normal. Monospot was negative. Didn't bother with WNV titers. Pt denied HIV risks and I believed him😱 I really wasn't impressed with abdominal pain as a component of the story nor was I impressed by his RUQ tenderness. I think the mild transaminits probably explains it.

 

[Febrifuge]

I'm trying to do this without looking stuff up, but I think I'm just testing how far I am in school, instead of testing knowledge... so his white cells and platelets are disappearing, and the liver is working hard, making it the prime suspect.

Dude doesn't drink, you say? Okay... here's one: does he hunt?

 

[southerndoc]

I think I know it. Let's see if I'm right.

 

[BADMD]

His CXR, UA, and EKG were all normal. CBC was interesting with a WBC of 3.0 and platelet count of 70 or so. His HCT, HGB, MCV were all normal. I don't remember anything interesting standing out from his differential. His LFT's showed both transaminases around 200 or so. I can't remember which was higher. All the rest of his LFT's along with his lipase, and electrolytes were normal. Monospot was negative. Didn't bother with WNV titers. Pt denied HIV risks and I believed him😱 I really wasn't impressed with abdominal pain as a component of the story nor was I impressed by his RUQ tenderness. I think the mild transaminits probably explains it.

Did anyone do microscopy on the granulocytes?

 

[ERMudPhud]

Did anyone do microscopy on the granulocytes?

Eventually😀

 

[Febrifuge]

Did anyone do microscopy on the granulocytes?

Um, yeah... that's what I meant to say with the 'manual differential.'

 

[ERMudPhud]

I routinely ask patients with viral like febrile illnesses during the summer and fall about tick exposure. I usually get a shrug, and "I don't know maybe." The deer ticks that can carry lyme are easy to miss but for most patients if they have a bug with its head embedded in their skin for a day or two they'll remember it😱. In this case he said, " Wow, you know what. I went hiking around Chesapeake Bay about two weeks ago and the next day I found a tick stuck in my skin." He got fluids, tylenol, and doxycycline and went home after a few hours to follow up with ID the next day. His buffy coat microscopy and titers eventually confirmed ehrlichiosis, sometimes called "rocky mountain spotless fever" for its lack of rash and somewhat milder course. I thought it was pretty cool that that one question kept me from lumping him in with all the WNV cases I was seeing. Ehrlichiosis and RMSF are treatable, potentially lethal, and present so non-specifically that you will miss them if you don't ask.

 

[BADMD]

Um, yeah... that's what I meant to say with the 'manual differential.'

I don't mean count the granulocytes...I mean look at the granulocytes.

 

[Febrifuge]

Yes -- I'm doing a lousy job of explaining what I mean. My lab sciences teacher is a PA who was a lab tech for fifteen million years, and he's making us aware of all the ways the automated tests are great, and all the ways they totally suck. A human who knows what they're doing can get a lot more information than just the counts, in the process of doing the counts.

(My "um, yeah" was not sarcasm; it was me trying to cover for not being clear the first time. This'll teach me to try to think on a day off from school...) 😉

 

[BADMD]

Yes -- I'm doing a lousy job of explaining what I mean. My lab sciences teacher is a PA who was a lab tech for fifteen million years, and he's making us aware of all the ways the automated tests are great, and all the ways they totally suck. A human who knows what they're doing can get a lot more information than just the counts, in the process of doing the counts.

(My "um, yeah" was not sarcasm; it was me trying to cover for not being clear the first time. This'll teach me to try to think on a day off from school...) 😉

At all the hospitals I've been at, the differentials are manual. If the WBC count is abnormal then a trained technician counts 100 cells and gives you the breakdown on the cells types.

If this diagnosis is what I think it is, in order to make the definative diagnosis, you have to make a special request to have either a pathologist or a hematologist examine multiple granulocytes. It will likely be missed on a standard manual differential.

 

[Seaglass]

Yes -- I'm doing a lousy job of explaining what I mean. My lab sciences teacher is a PA who was a lab tech for fifteen million years, and he's making us aware of all the ways the automated tests are great, and all the ways they totally suck. A human who knows what they're doing can get a lot more information than just the counts, in the process of doing the counts.

(My "um, yeah" was not sarcasm; it was me trying to cover for not being clear the first time. This'll teach me to try to think on a day off from school...) 😉

It's true that you can get a lot more info from looking at the cells but that extra info isn't usually reported. If you want inclusion bodies etc. you usually either need to look at it yourself or order a smear.

PS. Having fun at ACEP!

 

[Dr. Will]

I think this type of case was presented in morning report in early July of this year where I'm at, and I'm trying to remember what it was exactly. Grrr...alzheimers kicking in.

 

[ERMudPhud]

His buffy coat microscopy and titers eventually confirmed ehrlichiosis

I guess I should have highlighted this part

 

[kungfufishing]

strangely enough, our golden retriever just finished a course of doxy for ehrlichiosis. Not chaffeensis, another one.

 

[Hard24Get]

I guess I should have highlighted this part

Thanks, cool case. Of course, I'm still looking forward to seeing my first pt with WNV. 🙂

 

[southerndoc]

Thanks, cool case. Of course, I'm still looking forward to seeing my first pt with WNV. 🙂

I've seen a few cases. One of them died from encephalitis, rhabdomyolysis, and severe myocarditis (with an EF of 20%; prior documented EF was 65% only a year prior). She developed AV block (2nd degree 2:1 with periods of 3rd degree). Ultimately, the family decided to withdraw care. There really isn't much you can do for viral encephalitis. Acyclovir and other meds don't work. However, there is some recent investigation using ARB's and ACE-inhibitors. The most promising research seems to be with the use of alpha-interferon.

 

[SolidGold]

Nice case. I've seen a patient (not of my own) get discharged home with doxy with a presumptive diagnosis of a tick borne illness where ehrlichiosis was considered but never heard what the guy had with his follow up.

 

[Febrifuge]

Thanks, ERMudPhud! Bawk Bawk!

(For those too young to get the reference, here ya go.)

 

[Chronic Student]

At all the hospitals I've been at, the differentials are manual. If the WBC count is abnormal then a trained technician counts 100 cells and gives you the breakdown on the cells types.

If this diagnosis is what I think it is, in order to make the definative diagnosis, you have to make a special request to have either a pathologist or a hematologist examine multiple granulocytes. It will likely be missed on a standard manual differential.

There is an automated diff machine out there, we were using it down at UTMB and the heme techs caught a lot of things on the differential besides just a breakdown of the cell types (malaria, Alder-Reiley, hypersegmentation, blasts, schistocytes, target cells, spherocytes, NRBC's, atypical lymphs, etc) and then flagged them for pathologist review. Although the differential is certainly no substitute for a formal path consultation.

I spent a week on the five-headed microscope learning from the hematologist while I was getting my undergrad. I learned an incredible amount and it took me several weeks to recover from the scope sickness. The dramamine really helped.

-Mike

 

[RxnMan]

Don't forget, anytime you consider WNV you should also consider Eastern Equine Encephalitits (EEE) and St. Louis Encephalitis. California Encephalitis is also one to consider.

However, none of these have definitive treatments, so it's more academic fodder than anything else.

I'll remember for next time. With essentially one year under my belt, I'm just glad I was on the right track.

 

[Apollyon]

strangely enough, our golden retriever just finished a course of doxy for ehrlichiosis. Not chaffeensis, another one.

Ehrlichia canis, maybe?

Where did the name "chaffeensis" come from? Ft. Chaffee, Arkansas.