I'm not feeling well

[ERDoc]

Holy crap, Batman! This lady has a fever/sepsis, spontaneous bruising and recently returned from Uganda. This is not going to end well. What has she done to break the fever?

[Just Plain Ruff]

Hello,

First, I think it is safe to say this lady is septic because of the history and the fact that she meets two of the Sepsis/SIRS criteria. A HR above 100 and a resp rate of 20. Now, a temperature would be nice. If not, is the skin hot? Cool? Also, her BP is low. More importantly, her DBP is only 40.

As for the cause. Not sure. The petechia and the blood shot eyes are worrying.

As for treatment. Lets get this lady in to the ambulance. Start an IV, a 500cc bolus to start. Do an EKG and get her in to a hospital gown. See anything new?

Any photophobia?

Stiff neck?

Pain when she flexes her legs?

Travel immunizations?

N+V?

Diarrhea?

Cheers

12 lead is unremarkable

IV is started

NO photophobia

Some mild pain when flexing knees

All travel immunizations are current

Mild nausea but 2 episodes of vomiting with blood in the emesis

Diarrhea yes, per patient it also had blood in it.

Holy crap, Batman! This lady has a fever/sepsis, spontaneous bruising and recently returned from Uganda. This is not going to end well. What has she done to break the fever?

She has no fever right now Doc. She had a febrile illness that ended about a week after she returned from Uganda.

She relates to you that there was some sort of outbreak in Uganda but it wasn't Ebola.

You have given the fluid bolus and the lady says in broken english that she is feeling better.

You are now at the ER.

What are you going to want to do with her now.

Remember, your ER and hospital have all the newest lab tests and evaluation tools. They do not have ever have to send out labs. Due to the breakdown of the population with many of those people in your community being from Africa there are lab tests that the lab can do that most communities cannot.

So far someone has said Ebola but there are other illnesses that mimic Ebola out there.

[DartmouthDave]

Hello,

Well, if we are in the ED I figure we would start with the Sepsis of unknown source protocol (whatever the abx may be for this) plus blood cultures, urine cultures and sptum cultures. Plus, lytes, LFT, coags, and BUN/Cr.

If there ID consult them as well.

Get a CXR, ABG an arterial line and central line (once coags are check).

More fluid as well.

As for the cause, I need to dig on this some. Dengur fever (DHF) maybe. Just a mad guess.

Cheers

[Just Plain Ruff]

On physical examination, she is alert and apparently well developed and well nourished. The patient has a regular pulse of 90 bpm and a respiratory rate of 14 breaths/min. Her temperature is 98.2° F (36.8° C) and blood pressure is 90/70 mm Hg. The cardiac examination reveals a normal S1 and S2, with no murmur, gallop, or rub Per physician. Auscultation of the lungs is normal, and no palpable organomegaly or tenderness is found on abdominal examination.

Examination of the extremities reveals large bruises and a petechial rash across both forearms and lower extremities Conjunctival hemorrhages are noted bilaterally. Bruises are also apparent on her soft palate, and minor trauma from oral examination results in gingival hemorrhage.

The laboratory investigation reveals a hemoglobin of 8 g/dL (80 g/L), platelet count of 11 × 103/µL (11 × 109/L), and a white blood cell count of 1.8 × 103/µL (1.8 × 109/L). Her serum blood urea nitrogen, creatinine, liver function tests, albumin, and electrolytes are normal. Coagulation studies, including a prothrombin time, activated partial thromboplastin time, fibrin degradation products, and serum fibrinogen, are normal. Blood cultures do not show any growth. Urine analysis and urine culture result negative. Posteroanterior and lateral chest radiographs, as well as abdominal ultrasonography, are unrevealing.

EMS Has given 500ml of normal saline.

Is this a critical patient or is she stable?

Dave, you got the diagnosis right. She has Dengue Hemmorhagic Fever - sort of an oxymoron because she has no fever but she did.

What do you think her hospital course is going to be?

I'll post in a few where this scenario came from and what the site I got it from has to say about Dengue.

[Just Plain Ruff]

The scenario was pulled from the medscape cme site. The website is http://cme.medscape.com/viewarticle/722659_2 But you need a user name and password to see the info so sign up if you want quality education for Free. I was able to use the CME's that I got from this site to relicense in Missouri.

Here is the info I promised on Dengue Hemorrhagic Fever - definately a nasty one but not like Ebola or Marburg.

This patient was diagnosed with dengue hemorrhagic fever (DHF), which is a complication of dengue fever (DF). The diagnosis was eventually confirmed by paired immunoglobulin M samples demonstrating an acute rise in antibodies.

Dengue virus belongs to the family Flaviviridae (genus Flavivirus) and has emerged as the most common arboviral disease in the world. The disease is endemic to tropical and subtropical areas of the world, with about 2.5 billion people (40% of the world's population) at risk of acquiring the infection.[1] Dengue virus is transmitted to humans through the bites of infective female Aedes mosquitoes (particularly A aegypti and A albopictus). Mosquitoes generally acquire the virus while feeding on the blood of an infected person. After an incubation period of 8-10 days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus to susceptible individuals for the rest of its life.[2] Unlike malaria, which is more prevalent in rural areas, DF is spread via mosquitoes that thrive in highly populated urban environments.[3]

Four distinct, but closely related, viruses (termed dengue virus types 1-4 [DENV 1-4]) cause DF. Humans are the main amplifying host of the virus.[4] Infection with 1 of the 4 serotypes of dengue virus causes a wide spectrum of clinical disease, including asymptomatic infection, undifferentiated fever, DF, and DHF. DHF occurs in a minority of patients and is characterized by bleeding and plasma leakage, which may lead to shock.[5] The major risk factor for DHF is prior immunity to a single dengue virus serotype. Infection with one dengue serotype confers lifelong homotypic immunity and a very brief period of partial heterotypic immunity (~6 months), but an individual can eventually be infected by more than one serotype. An individual could therefore experience a case of DENV-1 fever in one year, followed by a case of DENV-2 fever in the following year. Third infections are, however, very rare, and fourth infections have never been reported.[6] Several serotypes can be in circulation during a particular epidemic.[7]

Some people infected with DF are asymptomatic. Young children often have a fever with a rash, but other symptoms are minor. Older children and adults may also have mild symptoms; however, they are more likely to experience classic DF.[2] Symptoms of DF include a high fever (up to 105° F [40.5° C]), severe headache, retro-orbital pain, severe muscle and joint pain, swollen lymph nodes, general malaise, nausea, and vomiting; a macular erythematous rash with petechiae may also be observed.[7] The differential diagnosis for DF and DHF is broad and includes meningococcal meningitis, septicemia and disseminated intravascular coagulation, other hemorrhagic fevers (Crimean Congo hemorrhagic fever, Ebola, etc.), thrombotic thrombocytopenic purpura, falciparum malaria, leptospirosis, aplastic anemia, acute leukemia, and yellow fever.

Direct person-to-person transmission of dengue virus has not been documented. A few case reports have been published of transmission of DENV through exposure to dengue-infected blood, organs, or other tissues from blood transfusions; solid organ or bone marrow transplants; needle stick injuries; and mucous membrane contact with dengue-infected blood.[8]

Dengue or dengue-like epidemics were reported throughout the nineteenth and early twentieth centuries in America, Southern Europe, North Africa, the east Mediterranean, Asia, Australia, and on various islands in the Indian Ocean, the south and Central Pacific, and the Caribbean. DHF has increased both in incidence and distribution over the past 40 years, and, in 1996, 2.5-3.0 billion people lived in areas potentially at risk for dengue virus transmission. It is estimated that there are 20 million cases of dengue infection annually, resulting in around 24,000 deaths.[9] The geographic distribution of dengue viruses and their mosquito vectors has expanded, and DHF has emerged in the Pacific region and the Americas. In Southeast Asia, epidemic DHF first appeared in the 1950s, but by 1975 it had become a leading cause of hospitalization and death among children in many countries in that region.[10] In Europe, the last dengue epidemic dates from 1927-1928 in Greece, with high mortality. However, there continues to be imported cases of DF in travelers returning to Europe from endemic areas.[11]

In the 1980s, DHF began a second expansion into Asia when Sri Lanka, India, and the Maldives Islands had their first major DHF epidemics; Pakistan first reported an epidemic of DF in 1994. The recent epidemics in Sri Lanka and India were associated with multiple dengue virus serotypes. After an absence of 35 years, epidemic DF occurred in both Taiwan and the People's Republic of China in the 1980s. The People's Republic of China had a series of epidemics caused by all 4 serotypes, and its first major epidemic of DHF, caused by DENV-2, was reported on Hainan Island in 1985. Singapore also had a resurgence of DF/DHF from 1990 to 1994 after a successful control program had prevented significant transmission for over 20 years. In other countries in Asia where DHF is endemic, the epidemics have become progressively larger in the last 15 years.[10]

A recent outbreak of DF in Karachi occurred in 2005 when Aga Khan University reported 30 positive cases out of 100. A recent trend of DF in southeastern countries is that it has become endemic, causing cyclical epidemics every 2-3 years.[12]

A major challenge for public health officials in all tropical areas of the world is the development and implementation of sustainable prevention and control programs that will reverse the trend of emergent DHF.[13] Environmental controls, including solid waste management, decreasing vector breeding sites by eliminating standing water, improvement in public awareness by media, and the use of household insecticides and mosquito repellants can help prevent the spread of dengue virus. Active case surveillance is important for early detection and implementation of control programs in the setting of acute epidemics.[11] Unfortunately, there is no commercially available vaccine to prevent dengue.[14] Tetravalent vaccines are currently being studied.

Clinically, the diagnosis of DF is suggested by the presence of fever, severe headache, maculopapular skin rash, and myalgias associated with either the isolation or identification of DENV from either serum, plasma, or tissue specimens, or by demonstration of a 4-fold increase of DENV antibodies in paired serum samples. The diagnosis of DHF is based on similar clinical features associated with a bleeding diathesis and/or thrombocytopenia. In some patients, a shock syndrome (dengue shock syndrome) may be observed.

The treatment of DF and DHF is essentially supportive. Antipyretics as well as fluid resuscitation, monitoring, and support are often necessary. Monitoring of laboratory parameters and replenishment with blood products as necessary are indicated in severe cases of DHF. The World Health Organization has created a useful guide (Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control; available at the WHO Website[9]) that delineates recommended approaches to the identification and management of DHF patients.

The patient presented in this case was admitted to an inpatient medical ward for 10 days and managed with intravenous fluids as well as repeated platelet and packed red blood cell transfusions. She was discharged when her platelet count reached 60 × 103/µL (60 × 109/L). She returned to the outpatient department after 3 weeks for follow-up, at which time her bleeding, rash, and other symptoms had improved.

CME/CE Test

[DartmouthDave]

On physical examination, she is alert and apparently well developed and well nourished. The patient has a regular pulse of 90 bpm and a respiratory rate of 14 breaths/min. Her temperature is 98.2° F (36.8° C) and blood pressure is 90/70 mm Hg. The cardiac examination reveals a normal S1 and S2, with no murmur, gallop, or rub Per physician. Auscultation of the lungs is normal, and no palpable organomegaly or tenderness is found on abdominal examination.

Examination of the extremities reveals large bruises and a petechial rash across both forearms and lower extremities Conjunctival hemorrhages are noted bilaterally. Bruises are also apparent on her soft palate, and minor trauma from oral examination results in gingival hemorrhage.

The laboratory investigation reveals a hemoglobin of 8 g/dL (80 g/L), platelet count of 11 × 103/µL (11 × 109/L), and a white blood cell count of 1.8 × 103/µL (1.8 × 109/L). Her serum blood urea nitrogen, creatinine, liver function tests, albumin, and electrolytes are normal. Coagulation studies, including a prothrombin time, activated partial thromboplastin time, fibrin degradation products, and serum fibrinogen, are normal. Blood cultures do not show any growth. Urine analysis and urine culture result negative. Posteroanterior and lateral chest radiographs, as well as abdominal ultrasonography, are unrevealing.

EMS Has given 500ml of normal saline.

Is this a critical patient or is she stable?

Dave, you got the diagnosis right. She has Dengue Hemmorhagic Fever - sort of an oxymoron because she has no fever but she did.

What do you think her hospital course is going to be?

I'll post in a few where this scenario came from and what the site I got it from has to say about Dengue.

Hello,

I would say unstable due to a low BP, very low Hgb, and an obliterated white count.

With such a low white count I think reverse isolation may be a good idea. Plus, isolation gowns for staff as well.

With such a low BP she need her tank filled with NSS and PRBC until her CVP is elevated. Then if need be a pressor.

This is a viral illness. I am not sure if an anti-viral (Acyclovir?) may be benifical or not. I have never seen DHF myself.

Prognosis. Not too bad. I have seen some really bad septic patients walk out of the hospital with good care.

Cheers

PS....I appears that I was typing this when your were doing an update. LOL!

Edited June 23, 2010 by DartmouthDave

[zippyRN]

given the presentation and history , the worst case scenario has to be assumed

sepsis of unknown origin possibly viral haemorhagic fever ...

which means the full three ring circus and a retrieval by an appropriately trained crew and a high security infectious diseases team

http://www.royalfree.org.uk/default.aspx?top_nav_id=5&tab_id=453