NEWS & EVENTS

Case of the Month - May 2014

Linda van der Westhuizen: Mediclinic Southern Africa
Briette du Toit

A previously healthy 39 year old female residing in the Western Cape was admitted to the Emergency Centre on the 5/1/2014. During the period 25 -29 December 2013 she had travelled to numerous farms in the Wepener district in the Free State and participated in farming activities that included hiking and hunting. On admission she presented with a history of severe headache, low grade fever and neck stiffness since 29/12/2013, when she was admitted and treated for meningitis in another healthcare facility until her discharge on the 1/1/2014.

Shortly after her discharge on the 1st of January, she found a tick in her navel and went to her general practitioner on the 2/1/2013 with symptoms of a persisting low grade headache and malaise. No skin rash or eschar was observed at the bite site. Doxycycline was prescribed. On 4/01/2014 a very fine rash appeared and covered her whole body. During the night of the 4th of January her condition deteriorated. She presented with diarrhoea and vomiting. Her family reported that she was confused and not able to have a meaningful conversation. At 17h00 on 5/01/2014 she vomited macroscopic blood and lost consciousness for a short period of time.

On arrival to the Emergency Centre she was awake and appeared oriented when spoken to. The triage nurse alerted the professional nurse about the patient’s condition as soon as she was told about the tick bite. An intravenous line was inserted and no excessive bleeding was observed at the puncture site. During consultation it was found that she had a severe headache and had been taking large doses of NSAID and other oral “over the counter” analgesia since the 29/1/2014. She had a small amount of blood in her sputum and her gums appeared to have a minimal amount of petichiae. No active bleeding was observed. Bloods were drawn for:

Haematology:

  • Red Cell Count 5.10
  • HB 13.8
  • Platelets 24
  • White cell count 3.1

Chemistry:

  • Sodium 128
  • Urea 12.5
  • Creatinine 177
  • MDRD (GFR Estimate) 28
  • Total bilirubin 43
  • Conjugated bilirubin 29
  • Unconjugated bilirubin 14
  • ALT 3650
  • AST 13460
  • CRP 29.4

She was admitted into the General ICU. On 6/1/2014 her left arm became oedematous and she developed a large haematoma around the intravenous puncture site, but no active bleeding was observed. At 14H00 she started with severe projectile haematemesis and was moved to an isolation room. A grand mal seizure at 17h45 caused her neurological status to fluctuate between non-responsive, extremely agitated, restless and confused with severe whining. Her skin colour changed to grey-blue and she developed melena stools.

Intra-cerebral haemorrhage was ruled out with a CT scan, but her neurological status deteriorated during the night. In the early hours of 7/1/2014 she pulled out her intravenous line and uncontrolled bleeding occurred at the puncture site. The situation deteriorated and all puncture sites made by the haemolances to obtain blood samples for HGT and HB started to bleed. The first signs of epistaxis were observed at 06h50. Her cardiovascular status became unstable with an atrial fibrillation of 210 -220 b/min, hypotension and saturation of 66% on face mask oxygen. She was intubated and ventilated at 10h10; a CVP and arterial line were inserted to assist in the cardiovascular monitoring and support.

Isolation for viral haemorrhagic fevers (VHF) was implemented on the 7/1/2014 at 13h00. On the 8/1/2014 a positive CCHF RT-PCR was received from the National Institute for Communicable Diseases (NICD). She developed all the classic signs of CCHF that included haematuria, vaginal bleeding, tachycardia, sever ecchymoses, hepatomegaly, splenomegaly and a persistent uncontrolled pyrexia of 38-43°C. On the 10/1/2014 the blood chemistry indicated a MDRD 7, creatinine of 652 and urea of 61.9. Dialysis was commenced on the 10/1/2014. Numerous blood products were administered on several occasions.

Multiple interventions done by the multidisciplinary team ensured that she gradually improved haemodynamically. Due to severe abdominal pain and discomfort surgical intervention for severe ascitis was needed. She was transferred out of the initial isolation area created in the General ICU to an isolation area in the surgical ward and discharged on the18th of February 2014.

The patient was discharged after spending 6 weeks in hospital; she was readmitted for severe peritonitis and pyrexia due to abscess formation. She is currently progressing well. No secondary cases were reported, despite the delay in the correct diagnosis and the late implementation of precautions for VHF.

Question 1: What are the important differential diagnoses?

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