Case (15)

[Kassim]

A 28-year-old male developed fever 5 days after returning from a holiday in Seychelles. Additional complaints were myalgia, nausea, vomiting, and diarrhoea. After an additional 5 days he was not improving,   temperature was 39.3°C, a blood pressure of 120/68mmHg and a pulse rate of 124/min, without dyspnoea. Oxygen saturation was 96%. Abnormal laboratory values were: WBC16.2×109 /L  Platelets 115×10 9 /L ; creatinine 174µmol/L ; AST 243U/L ; ALT 153U/L; CK 5,421U/L. Urinalysis showed some erythrocytes, leukocytes, a few granular casts, and a strong reaction for protein and hemoglobin.

During the next few days, his condition deteriorated rapidly. Jaundice developed, followed by signs of septic shock,
Further investigation, platelet count decreased to a nadir of 48.10 /L,  creatinine increased to 315µmol/L This was complicated by severe haemoptysis, requiring blood transfusion, and progressive dyspnoea developed.
within the next 8 hours his condition become worse and he was transferred to the ICU.

What is the diagnosis?

How would you manage this patient?

What is Prognosis?

[Diagnostic]

it's an interesting case, thanks Kassim
Although this case is a bit complicated and inoveved most of the systems & organs in the body like liver, lungs, kidneys, muscles & blood, I will try to analyse it in order to make the discussion easier and I hope more members will participate.

"A 28-year-old male" = A young tourist man (which disease he can acquire?)
"Developed fever 5 days" = It seems for me an incubation period for a disease.
"From a holiday in Seychelles" = Is there any significance in this part (which disease is endemic in Seychelles?
"Additional complaints were myalgia, nausea, vomiting, and diarrhoea" = Involved muscles and GIT
"After an additional 5 days he was not improving" = the disease is not self limiting, this indicates it needs urgent interfere or may worsen the condition, so a lot of investigations was done.
"Temperature was 39.3°C, a blood pressure of 120/68mmHg and a pulse rate of 124/min, without dyspnoea. Oxygen saturation was 96%." = temperature confirmed the fever, there is tachycardia, does the term "no dyspnoea" means that it will occur? or there is fast breathig but he is not dyspnic yet.
"Abnormal laboratory values were: WBC16.2×109 /L  Platelets 115×10 9 /L ; creatinine 174µmol/L ; AST 243U/L ; ALT 153U/L; CK 5,421U/L." = leukocytosis + fever = infection, thrombocytopenia , kidneys is inovled due to high creatinine, hepatocytes destructed increasing liver enzymes & also muscles were distructed due to high CK (rhabdomyolysis).
"Urinalysis showed some erythrocytes, leukocytes, a few granular casts, and a strong reaction for protein and hemoglobin." = There could be hemorrhage occured in the kidneys and the creatinine was a warning sign.
"During the next few days, his condition deteriorated rapidly" = the disease is creeping to new systems which make his condition life threatening.
"Jaundice developed, followed by signs of septic shock," = I was afraid this things will happen, altred liver enzymes then jaundice, fever + tachycardia + severy ill patient = septick shock
"Further investigation, platelet count decreased to a nadir of 48.10 /L,  creatinine increased to 315µmol/L This was complicated by severe haemoptysis, requiring blood transfusion, and progressive dyspnoea developed." = worst things happened, platelet decreased severly, kidney involved rapidly and hemoptysis occured and progressive dyspnoea developed then for sure pulmonary hemorrhage happened.
"within the next 8 hours his condition become worse and he was transferred to the ICU. " = He needs resuscitation, severe bleeding with progressive dyspnea.

So in conclusion we have here: a young tourist man who acquired an infectious disease (travel history, fever, incubation period, increase WBCs then lately sepsis) from island, this infection involved most of the systems, causing jandice , changes in liver enzymens (liver involved), increase creatinine, hematuria, granular casts, prtinuria & hemoglobinuria (Glomerulonephritis happened), Myalgia & High CK (rhabdomyolysis) and the patient gone into sepsis.
Hemolysis started to occur causing severe thrombocytopenia then bleeding occur especially in lungs and the condition is complicated by pulmonary hemorrhage.
Do you have different analysis than mine?
Do you think by this analysis we can give professional diagnosis?
Post your analysis and differential diagnosis?
If there was a question saying: which more investigation you would like to order, what will you say?
Diagnostic

[Muna1]

thank you Diagnostic for analyzing the case .
think this case about hemorrhagic fever so we have differential diagnosis which is (Ebola hemorrhagic fever (EHF),dengue fever , leptospirosis , yellow fever)
all of them will cause acute deteriorate in liver and kidney function .
Ebola is often characterized by the sudden onset of fever, weakness, muscle pain, headache and sore throat. This is often followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding.
dengue has sudden onset of fever, with severe headache, muscle and joint pains (myalgias and arthralgias—severe pain gives it the name break-bone fever or bonecrusher disease) and rashes. The dengue rash is characteristically bright red petechia and usually appears first on the lower limbs and the chest; in some patients, it spreads to cover most of the body. the disease associated abdominal pain, nausea, vomiting or diarrhea.in dengue hemorrhagic range from microscopic hematuria or increased menstrual flow to hemetemesis, are part of the syndrome. Neutropenia, elevated liver enzymes, and disseminated intravascular coagulation are also common.
yellow fever (symptom) Headache Muscle aches (myalgia)
Vomiting Red eyes, face, tongue Jaundice
in advance yellow fever may show signs of liver failure, renal failure, and shock.Bleeding (may progress to hemorrhage) Delirium, Seizures and Coma.
leptospirosis:(symptom) fever, myalgia, headaches, jaundice with tender liver, conjunctival suffusion, hematuria, transient acute renal failure, thrombocytopenia, elevated white blood cell count (WBC), elevated erythrocyte sedimentation rate (ESR), total serum creatine phosphokinase (CK) elevated to at least twice the normal upper value and a slight increase only in transaminases (GOT, GPT).

i think leptospirosis is the correct answer because it is the only one will cause elevated WBC and it is  common disease in Seychelles.
thanks kassim for this good case .i hope this is the correct answer

[Muna1]

Treatment is with high dose of antibiotic like penicillin iv or doxycycline and iv fluid or blood transfution in this case with antipyretic .
THE PROGNOSIS DEBEND ON THE DURATION AND THE SEVERITY OF DISEAS .IN THIS CASE PATIENT HAS bad prognosis.

[Kassim]

Well, u r right it is a complicated case, and difficult to Dx.  The first time I come across with case was in Mombasa, and the patient died.
Is there any significance in this part (Seychelles): yes, In Seychelles this patient would have been recognized very easily. In 4 moths I come across with more 40 cases.
Yes it’s Leptospirosis in Humans. Weil's syndrome: Severe form of Leptospirosis.
In addition to Penicillin, steroid is given to increase the platelet.
 
Well done Dr  Muna,
thanks for analyzing the case (Diagnostic)                         

[Admin]

Congratulations.
I this case there will be equal points split b/w Diagnostic & Muna1.
Regards
Dr.Mahdi