Case of the Month - May 2018
Dr Evan Shoul, Prof Lucille Blumberg, Prof John Frean
A 52 year old man was flown to a Johannesburg hospital from Zambia on 10 January 2018. He had been on holiday in the South Luangwa National Park, having arrived there 2 weeks prior to his transfer to South Africa.
6 January 2018:
He developed frontal headaches and reduced appetite in the evening.
By the next morning, his headaches had worsened. He now complained of fever, rigors and backache. He had lost his appetite but had no nausea, vomiting or diarrhoea.
He developed diarrhoea which was watery with no blood. His right foot became swollen and purple. A local doctor assessed this as cellulitis and prescribed flucloxacillin. A rapid malaria test was negative according to the patient.
He now noted jaundice with dark urine. The doctor was again consulted, tested his urine and noted ‘bilirubin in the urine’. The patient had generalised myalgia, worsening headaches and further episodes of diarrhoea. A repeat rapid malaria test was negative.
His headaches continued to worsen along with persistent fever. Myalgias worsened, especially involving his lower back. He also noted bilateral knee pain. He was then transferred via medical evacuation to South Africa.
Central nervous system – headaches, no neck-stiffness, paraesthesiae over right knee and photophobia noted on day of transfer
Eyes – vision normal, no conjunctivitis noted.
Ear, nose, throat – recent sore throat one week before. No cervical nodes noted. No other ENT issues.
Chest – no cough, mild shortness of breath on moderate exertion. No chest pain.
Abdomen – no nausea/vomiting. No abdominal pain/cramps. Diarrhoea as noted. Appetite reduced since onset of symptoms.
Genito-urinary – no dysuria/no haematuria. Dark urine for 3–4 days despite adequate oral fluid intake.
Musculo-skeletal - bilateral knee and right foot pain 3 days prior to presentation.
Skin - macular rash noted over abdomen over preceding few days.
Surgical history: nil
Medical history: hypercholesterolaemia – on atorvastatin 20mg daily x 25 years
Also, on sertraline 100mg daily.
No diabetes mellitus/hypertension/epilepsy/asthma.
Social: lives with his wife and 4 children in Melbourne, Australia. Works as managing director of a safety equipment company. Smokes <5 cigarettes a day and drinks at least 4 units of alcohol per day.
Travel history: current trip – family holiday in Zambia, visiting national parks. Staying in upmarket lodges, drinking bottled water, eating prepared food. Reports being bitten by many mosquitoes, flies, “other bugs”. He also travels annually to rural China for business.
On admission, awake and alert but acutely ill, uncomfortable and agitated.
Vital signs: heart rate – 120 beats/min, BP 100/60mmHg, Temp 39.5°C, oxygen saturation 94% on nasal prong oxygen at 2L/min. Weight 100kg.
On general examination, he was markedly jaundiced. No nodes, oedema, pallor, cyanosis or clubbing. He was not clinically dehydrated. He had a fine macular rash over his abdomen. He also had numerous small raised erythematous reactions likely secondary to insect bites – mostly over his back, trunk, legs.
Chest exam: no distress, resonant, clear
Cardiac exam: pulse regular, good volume. Normal cardiac auscultation.
Abdomen: no distension, soft, non-tender. No organomegaly.
Neuro: GCS 15/15, no focal deficit.
Figure 1: Lesions from bites noted on lower limbs.
Admission: 10 January 2018
White cell count 3.28 x 109 cells/L
Haemoglobin 12.9 g/dL
Platelets 78 x 109/L
Malaria thick and thin smear – negative
Malaria common antigen – negative
Malaria falciparum antigen – negative
Sodium 132 mmol/L
Potassium 3.0 mmol/L
Urea 7.6 mmol/L
Creatinine 201 µmol/L
Bilirubin (total) 138 µmol/L
Bilirubin (conjugated) 97 µmol/L
Alkaline phosphatase 355 U/L
Gamma GT 436 U/L
ALT 270 U/L
AST 457 U/L
C-reactive protein 376 mg/dL
International normalised ratio 1.3
Question 1: What is the differential diagnosis of fever and thrombocytopenia in a returning traveller?
Continue to Answer 1