Fever, headache, belly pain

1
Fever, headache, belly pain
2
HPI

• 37 yo Somali male was in his usual state of
  health until 9 days ago he developed fever, HA
  and body aches
• Fever not measured, some relief with Tylenol but
  returns intermittently throughout the day/night
• Headache bilateral and constant, worse in
  temporal regions, no visual changes, having vivid
  dreams, has a sore neck but not stiff, good ROM.
• Abdominal pain- gassy bloating, poorly localized,
  6/10. Worse with meals, unclear alleviating
  factors. Stooling with normal color, frequency,
  and consistency. No nausea or vomiting, eating
  normally up to today(now anorexic).

3
HPI

• Two days later at work, he became weak and fell.
  No trauma from fall - told to go home. Since then
  he has been resting at home.
• Sought medical attention at local ER 2 days ago -
  says no tests were done and he was sent home with
  Tylenol.
• Symptoms acutely worsened last night and
  developed a bloody nose, dark urine (like coffee,
  yellow eyes per his sister.
• Similar to what he had about 1.5 yrs ago while in
  Uganda- was diagnosed with malaria and given
  shots. Remained in Uganda 4-5 months after
  treatment, but says when he arrived in USA Jan
  2006 he was tested negative for malaria.
• Other Questions?

4
Past Medical History

• Malaria several times in Somalia, always
  goes away with medicine
• Immigrant screening
• RPR neg 9/06/05
• HIV ELISA neg 9/06/05
• ppD to 19 mm, negative CXR, prescribed INH. He
  only took 3 months of INH
• No medications or allergies

5
Social Family history

• Arrived in Virginia in January 2006 from Somalia
  via Uganda never left MN since
• Moved to MN March 2006 never left since
• Works in a Turkey packing plant with raw meats,
  in Fairbault.
• He lives in apartment with friends. His mother
  and sister live in Mpls, other siblings in the
  US, no children, not married.
• Smokes tobacco cigarettes - half ppd. Denies
  alcohol or other drug use ever.
• FHX noncontrib, except malaria while in africa

6
Physical exam

• General Appearance NAD, thin.
• BP 109/64 Pulse 101 Temp 102.6 Resp 20 Ht
  5' 6" (1.68m) Wt 137 lbs 2.0 oz (62.2kg) SaO2
  100
• Body Mass Index is 22.14 kg/(m2).
• HEENT Normal- Head shows no signs of trauma or
  recent fall
• -Eyes Normal- EOMI, scleral icterus. Pupils
  equal and reactive to light.
• -Nose Normal- free of discharge.
• -Mouth Normal- No lesions present, throat is
  free of erythema, no tonsillar enlargement. Fair
  dentition. Mucous membranes dry.
• -Ears Normal- Hearing grossly intact.
• -Neck Normal- No thyromegaly, no stiffness.
  Normal neck girth.
• CARDIOVASCULAR Normal- Regular rate and rhythm,
  normal S1/S2, no murmurs, rubs or extra heart
  sounds. Pedal pulses intact, no JVD, no edema, no
  carotid bruit
• LUNG Normal- Lungs show no wheezes, crackles or
  course lung sounds. Chest excursion normal
• ABDOMEN Normal- BS present. No organomegaly.
  Tender in RUQ and epigastric area, no rebound or
  guarding. No abdominal scars.
• MUSCULOSKELETAL Normal- No joint erythema,
  edema, or tenderness. Muscles are nontender to
  palpation. Normal ROM.
• LYMPHATIC/VASCULAR Normal- No cervical,
  supraclavicular or axillary LAD.
• SKIN Normal- No rashes or lesions present, no
  bruising.
• NEURO Normal- Cranial nerves intact. Patellar
  and biceps reflexes intact. Finger grip, triceps
  and biceps strength 5/5 bilaterally.

7
Physical exam

• General Appearance NAD, thin.
• BP 109/64 Pulse 101 Temp 102.6 Resp 20 Ht
  5' 6" (1.68m) Wt 137 lbs 2.0 oz (62.2kg) SaO2
  100 on RA
• Body Mass Index is 22.14 kg/(m2).
• HEENT Normal- Head shows no signs of trauma or
  recent fall
• -Eyes Normal- EOMI, scleral icterus. Pupils
  equal and reactive to light.
• -Nose Normal- free of discharge.
• -Mouth Normal- No lesions present, throat is
  free of erythema, no tonsillar enlargement. Fair
  dentition. Mucous membranes dry.
• -Ears Normal- Hearing grossly intact.
• -Neck Normal- No thyromegaly, no stiffness.
  Normal neck girth.
• CARDIOVASCULAR Normal- Regular rate and rhythm,
  normal S1/S2, no murmurs, rubs or extra heart
  sounds. Pedal pulses intact, no JVD, no edema, no
  carotid bruit
• LUNG Normal- Lungs show no wheezes, crackles or
  course lung sounds. Chest excursion normal
• ABDOMEN Normal- BS present. No organomegaly.
  Tender in RUQ and epigastric area, no rebound or
  guarding. No abdominal scars.
• MUSCULOSKELETAL Normal- No joint erythema,
  edema, or tenderness. Muscles are nontender to
  palpation. Normal ROM.
• LYMPHATIC/VASCULAR Normal- No cervical,
  supraclavicular or axillary LAD.
• SKIN Normal- No rashes or lesions present, no
  bruising.
• NEURO Normal- Cranial nerves intact. Patellar
  and biceps reflexes intact. Finger grip, triceps
  and biceps strength 5/5 bilaterally.

8
Laboratory Data
AST 65 (10-42) ALT 62 (10-40) Alk Phos 149
(34-104) Total bili 5.9 (lt1.6) Dir Bili 2.6
(lt0.3) Lipase 35
INR 1.2 Alb 2.8
UA SG 1.029, pH 6.0, 2 prot, large blood,
urobilinogen increased, neg LE, neg nit, WBC 2-5,
RBC 0-2
Differential 56 N 0 Eos 15 L 22 Bands 6
M 1 Myelocytes
Nasal swab neg Influenza AB
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Imaging

• CXR normal
• RUQ US normal liver, gall bladder, and biliary
  ducts.

10
Call from the lab
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Diagnosis?
Plasmodium vivax
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P. Vivax - Thin Smear Appearance

• Gametocytes large oval scattered brown
  pigment /- Schuffners dots
• Ring stage large chromatin dot(s) ameoboid
  shape /- Schuffners dots
• Schizonts large, 12-24 merozoites /-
  Schuffners dots /- ruptured

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Diagnosis

• Classical microscopy during daylight hours
• PCR send out to Mayo
• Binax rapid diagnostic test
• Falciparum or NOT

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Plasmodium vivax
www.dpd.cdc.gov/dpdx