Wednesday, July 28, 2010

Mystery Diagnosis

I heard about an interesting case the other day... interesting enough to share. A young woman presented to her clinic provider with fever and chills. She became ill about a day prior to coming in, and her associated symptoms were headache, nausea, diarrhea, neck pain, and low back pain. She was not employed, having recently finished her service with the Army, and had no ill contacts as far as she knew. She was, drum roll please, sent to the ER based on her symptoms. Basic labs were drawn and the had a slight leukocytosis (13k) with a left shift and no immature forms. Her platelet count was 55k. She was seen and treated and released from the ER. Her diagnosis was missed, but it was made on her next visit to the ER, three days later (for recurrent symptoms as above). I know this is a new one for us, but go ahead and give it a shot. All relevant questions answered when I can. Old school y'all.


  1. Hgb? MCV? Retic?

  2. Retics nl. Mcv nl. Hgb 12.

  3. Malaria until otherwise proven if she was deployed overseas in an endemic area. Flu like illness, fever, chills, low platelets : dead giveaway. The mildly elevated WBC is a red herring, treatment is antimalarials, not antibiotics...

  4. And if not malaria, consider brucellosis if she was deployed in the Middle East :-)

  5. further testing was performed.

  6. Nope, but read your blog regularly. Canadian ER doc, but originally from South Africa. Worked in Saudi for 4 years, and United Arab Emirates for 1 year on tax free contracts. Unfair advantage in tropical diseases :-) I'd be very surprised if it wasn't malaria or brucella ;-) C'mon, fess up...

  7. you don't even want an LP on a chick with fever, headache, back pain. not even an lp? and you are correct sir, it was malaria. looks like i'd be lousy in grand rounds. going to stick to the dick jokes. have a good one dr Afrikaner-Canuck. sorry gang, smart guy from the peanut gallery.

  8. and OBTW, seven months after returning to the states.

  9. Heh heh, no, I'd want a malaria smear, not an LP ;-) Mantra, repeat after me : overseas, flu like illness = malaria until excluded. Low platelets : start the antimalarials, almost certain. Low platelets and other signs of hemolysis such as lowish Hb / jaundice : absolutely certain - don't trust your lab tech if he says the smear is negative, he probably just hasn't seen enough cases, and is missing it. And btw, cerebral malaria sucks - LP does have a place, but only if meningism and confused, and start the IV quinine without waiting for results. Rounds over ;-)

  10. I really like these type of posts. Congrats to Canada for nailing it.

  11. Not terribly hard, but still a great case. I was thinking that Malaria had a big left shift with lots of immature forms, but with the deployment history it had to be in the top 3 and NONE of my residents would have missed it!OF

  12. Good Pickup,
    Malaria, the reason God invented the Sickle Cell...
    Yout Christian God that is, really, what useful purposes do Mosquitos Serve???
    I mean, I know the "OFF!" company employs thousands of Americans in high paying jobs, but wouldnt they be better used figuring out Nuclear Fusion or the cure to Cancer??
    Thanks for leaving out the part where she gets killed when the Med-evac helo crashes...

  13. dear Canuck MD,
    i hope i did not come of as denigrating you. in all honesty i thought you were one of the few i told about this and that you were simply pulling a fast one on me. i was amazed that you nailed it with as little info as i gave. kudos, and i will always think of the IV quinine pending smear.

  14. Awwwwww, shucks, 911 - don't go all touchy feely on me... I told you, unfair advantage : *every* fever with a low platelet count in Africa is malaria ;-) If it makes you feel better, I probably wouldn't recognise a West Nile Virus case if it bit me in the ass. Congo fever / Ebola and similar nasties, yeah, but not North American varieties. P.S. Frank - yeah, it's true : all Canucks have useless nubbins :-)

  15. IV quinine? So last millennium....

    Artesunate my man - superior drug, minimal/no side effects....

    Surely ED folks in the US know about this????

    And... this presentation could have been a lot of other infections (dengue, meningococcal etc etc....)

    Just sayin...

    A drive by ID doc.

  16. ID Doc?? Oh, so your a Flea who didnt have the hand-eye coordination/grades/sense to go into something lucrative, I mean useful.
    I mean what do you really do?? Order cultures, broad spectrum antibiotics, the better to keep the bacteria on there toes(I know bacteria dont have toes, but you know wht i mean)
    and we know this could have been alot of other things, I mean Army+Female usually = Chlamydia in my experience.
    and just for shits and giggles, how much does a course of Artesunate cost??
    You dont know, do you?, and I dont mean after you look it up, like I did.
    I'd tell you but then I'd have to kill you.
    Hmmm Fever, elevated White Count, Patient looks Septic...
    "HMMM This could be an INFECTION!!!!!!!!!"
    no duh.
    Frank "Culture THIS" Drackman

  17. Damn, was going to guess Malaria. I'm a med student (in the US) and we had a lecture a few weeks ago where the professor told us that the one thing we needed to walk away with was (as he wrote in huge letters across two blackboards) "FEVER + TRAVEL = MALARIA" (until proven otherwise)

  18. tanman,
    are you effin crazy??goin into medicine in this day and age? I mean, if your into S&M thats cool, but you don't have to spend 4 yrs and god knows how much in tuition...
    and ask the professor how many actual patients with Malaria he's seen, much less treated.
    I'll bet its that number that starts with a "Z" and ends with an "O".
    "Zero" if you rode the short bus.


  19. Och aye, RJ, ye are right, of *course* it could have been a lot of other things ;-)

    Context, moi man, never forget context :-)

    Common things occur commonly. Army ? Deployed in foreign climes ? For us "common" ER docs it's malaria, moi man, it's malaria until otherwise proven - if not, THEN we call you in ;-)

    Meningococcal ? Pffffftttt, nawwwwwww. Once again, CONTEXT for the scenario given - she didn't come back DOA ;-)

    Context is EVERYTHING :-) Context says that due to where I practise, I don't need to do unnecessary CT scans on crappy MINOR head injuries :-)

    Artesunate ?

    I'm going to make a huge assumption, and postulate that you work in an academic / ivory tower / big city environment - that's where ID types congregate :-)

    Out in the real world, based on the availability / access to it in North America due to the low number of cases, IV quinine / quinidine is not previous millenium when faced with a case of severe malaria, but current reality until Artesunate is easily available.

    In Canada, it's still a special access drug, and takes time to secure.

    Mebbe not in your environment fella, but relevant to many others.

    >Eligibility criteria for IV artesunate under CDC's IND protocol: 1) severe malaria falciparum, 2) high-density parasitemia (>5%), 3) unable to take oral medications, 4) acute respiratory distress syndrome or severe anemia.

    In addition, for these patients, one of the following must be true: 1) artesunate is available more rapidly than quinidine (if the drugs are equally available, attending clinicians will decide which drug to use in consultation with CDC), 2) the patient has experienced quinidine failure or intolerance, or 3) use of quinidine is contraindicated. <

    Anonymous "Don't try to teach an African how to treat malaria, I was treating them while you were still in diapers sucking Mommies titty" MD.

    P.S. Just sayin' ;-)

  20. I love this blog, ya'll make my day!!!

  21. I had malaria, 9 months post a trip to india (while taking anti-malarials), was 9 yrs old at the time. missed x3 before finally getting a diagnosis from a family friend who's GI now but trained in india

  22. dear new friend Canuck MD,

    after leaving the american emergency-every-tenth-patient world and joining the governmental blob let me ask, how do you find EM practice under the Canadian system?

  23. Ain't half as bad as ye folks seem to think ;-)

    1. Canadian emergency-every-twentieth-patient sums it up nicely : no disincentive to go to ER as there is no user fee, on the other hand dire shortages in primary care md access, so they ain't really always got any other options depending on where you are...

    2. But think of it as EMTALA on steroids : I actually get paid for every case I see ;-)

    3. Read it and weep : my annual malpractice premiums are around $ 2 400. And I get to practice real medicine, not defensive medicine. Jaysus, I've even got lawyer FRIENDS, for chrissakes...

    4. No Press Ganey crap. If he's not sick, and has a GP, and is consuming ER resources / being obnoxious, I tell him to f**ck off outta my ER : nicely, because we're civilised ;-)

    5. Yeah, I DO actually work for "myself", and not the gubberment. In the sense that I set my hours as an independent contractor, and tell the local hospital to f**ck off and find someone else for the shift if I feel like loafing. You're right, the gubberment sets the fee I charge, but 300-400k per annum in my specific province (state) with no overhead probably goes a lot further in Canada than the US.

    6. In the US, substitute your private insurance industry for my gubberment, and we're probably talking the same thing :-) We're BOTH rationed, you in the name of profit for an insurance company, me by Stevie boy.

    7. Kinda nice knowing that our (higher) taxes cover the bills, and that my patients (or I)aren't going to be having to hock their houses or their mudders the day the shit hits the fan, and they (or I) need something expensive done. No "uninsured" here...

    8. No f'ing pre-authorisations or paperwork from imbecilic clerks at insurance companies : if my patient needs it, I do it :-)

    3, 4, 7 and 8 mitigate not driving a Porsche.

    P.S. Don't misunderstand me, I don't particularly like my mudder, and would probably hock her if I could ;-)

  24. Anonymous: I treat a shitload of infection, have done so for years, in a real big ugly hospital with the busiest emergency department in the Southern Hemisphere. I get paid a pittance by our ungrateful government to do this. No ivory tower for me, although I have published our local experience on treating malaria in developed countries. Nice assumptions though!

    Artemesinin-based therapy is the standard Rx for malaria in every part of the world now - apart from North America. Check out the SEQUAMAT study - artesunate saves more lives than quinine. Ironically, people in developed countries are being held back from getting IV artesunate for their severe malaria by overcautious regulatory authorities because the stuff isn't made in a GMP-compliant factory..... and its cheaper than quinine too.

    We think our patients should get the best drug available for severe malaria, so we go to the trouble of importing it, testing it for potency, and using it when indicated. Works great, no cinchonism, no need for cardiac monitoring, BGL checks etc.

    Re: "context" - where does it say in the history she was "deployed"? It says she "served"....served where? In the canteen at military training school? Most meningococcal disease comes in not dead; many have neutrophilia and low platelets. Where I live, fever + OS travel/military deployment + low platelets is just as likely to be dengue than malaria....

    Think I'll shut up now.

    Just sayin... :-)

  25. Heh, heh, pulling your leg, R.J., don't take it to heart : I have NO doubt whatsoever you know a SHITload more about infectious diseases than I do ;-)

    Of course they were assumptions, but the point was to illustrate the realities of access.

    And yeah, I'm more than familiar with the SEQUAMAT study. There are hordes of others confirming Artesunate's superiority. But kinda means diddly squat if you can't get hold of the stuff quickly for a sicky who is tanking.

    Kinda ironic that WHO has Artesunate listed as first line therapy in developing third world nations, but it's fairly inaccessible in North America, eh ? Economies of scale, I suppose, and heck, let's also blame it on overlawyered North America, shall we ?

    My buddies in South Africa have easier access to it than I do in Canada, which is kinda frustrating when I have the odd sailor coming in sick with malaria.

    The "context" was the hint in the scenario, 911 mentioned "Army" for a reason - in the context of the case, it illustrated the need for a travel history, as opposed to the local base canteen : typical exam case type strategy.

    Dengue ? Never seen a case :-) But loads of brucella in the Middle East.

  26. Oops, afterthought.

    Invasive meningococcaemia (as opposed to colonisation), with symptoms and signs such as fever, myalgia, nausea, diarroeah and producing thrombocytopenia, missed as a daignosis at initial early presentation, don't generally come back living three days later in my neck of the woods - they come back in a wooden casket or an urn...

    Just sayin' ;-)

  27. I know a Canadian Doc, makes loads of money(the real kind, with guys like George Washington and Andrew Jackson on the front).
    That's cause he practices in Dothan Alabama.
    Gotta call Bullshit on the 300-400K per year, even in Canadian Loons that sounds pretty high, not sayin your a liar, just you probably misplaced a decimal point or two.
    Oh, and thanks for letting Mohammed Atta through Customs.

    Frank "Only good thing out of Canada was Celine Dion" Drackman

  28. Celine Dion?? Drackman I always thought you had penis..Regards, OF

  29. Awwwww, Frank, you're not gonna make me post my T4, are you ?

    The brain drain south turned around in recent years when the US economy started tanking...

    Don't make the mistake of looking at published government online averages to estimate Canadian ER incomes - they don't tell the full story ;-)

    I'm in a relatively "poor" Canadian province - average semirural fulltime ER MD can expect around 280 k per annum in ER billings, if you're prepared to work a bit. Then add in for moi 60 k last year in OR assists, worker's comp billings, critical ambulance escorts, flight calls, out of province billings,out of country billings, peer reviews - we're up to 340 k gross, but no overhead. And I'm a lazy sod... many of my colleagues do more.

    I'm currently negotiating a contract for next year in the oilsands in Alberta - granted, it's in the schticks, but the current incumbent's audited income last year was $ 55k per month - location, location, location.

    And that beats going back to thobes/ghutras and/or watching camels humping in the desert as a pre-retirement top up ;-)

    Anonymous "If I were Celine's momma I would have aborted her" MD

  30. Oldfart,
    dont make me break out those pics of you playin hide the salami with Adam Walsh, Old Farts like you dont do so well in prison, or so I'm told.
    it takes a Real Man to admit he likes ABBA, and Neil Diamond, and yeah, Celine Dion.
    Call me skeptical, but 340K sounds like alot for a country that only has one Major League Baseball Team, and NO NFL teams.
    We are talkin American Dollars??
    And when did Canada stop usin the Pound Sterling for Money?? I know y'all drink tea, drive on the left, and talk funny...

    Frank "I Hope Obama gets Lung Cancer" Drackman

  31. Aw, hell yes! Fartie, 911, Frankie, and our new Canuck friend, all makin' fun with very cool meddy talk. I'm home again. Happy sigh.

  32. So, Army girl was overseas for a time, probably taking anti-malarials, we don't know if it was consistent or not. Then she returns to the US, and 7 months later she gets malaria?? Can someone explain how this works?

    Did she get it from overseas and it just popped up 7 months later? Or did she get it in the US?

  33. Bulrush...
    I know its complicated but to catch Malaria all you need is..
    A: Mosquitos
    B: Someone with Malaria

    both of which we have in the US, heck I'm not sure the President(Peace be upon Him) doesn't have Malaria, would explain alot.


  34. Bulrush, it "popped up later" - there are no endemic malaria areas in North America, so she didn't "get it" in the US.

    She likely had the vivax / ovale variety,lying dormant in her liver, as opposed to the (nastier) falciparum variety.

    Here's an easy read :

    Anonymous "Don't f**ck with falciparum, it'll bite ya arse : take your pills, pray it's not resistant, cover up after dark, and use your goddam repellants / bednets" MD

  35. Psssssstttt, but seal your borders to the south ;-)

    And don't forget Dominican Republic, where all those crazy Canucks go to holiday (Punta Canada) ;-)

    As far as I know, the vast majority of documented malaria cases in the US are in returning travellers / new immigrants, and acquired out of country.

    R.J. ? You still lurking like a wet dream ? Correct me ?

  36. Oi, Frank, interesting theory ;-)


    Anonymous "I bet a mozzie at a US Abba concert bit an Army chick with HIV, then snacked on Neil Diamond, who then had unprotected sex with Celine : proabably explains a lot, kinda thang" MD

  37. I haven't met an MD from South Africa, working in Canada that I didn't absolutely love working with.... :) ...and anon just proved the point. Like the way you defended the "system"..... :) Needs work, but then nothin's perfect. And I agree, Celine is crap.