Infectious disease call

[harold1981]

This one is definately worth sharing with you guys, and I am especially interested in hearing from the guys that have previous experience in the (sub)tropics:

Last week our ALS-unit responded to the following call:
´´Unresponsive 30yo female with high fever, just returned from Africa.´´

We entered the apartment wearing facial masks, and encountered a sick patient on the couch, gray skin color, sweating profusely with a GCS of 3-5-5, temperature of 40,6 degrees Celsius, sats of 96% on room air, BP of 75/35, sinusrythm of 90bpm (!). Clear lung sounds. BG is 4.9. Patient´s partner states that the patient is a microbiologist and just returned from a two-month field work project in rural Botswana 3 days ago. Yesterday night she started feeling unwell, with anorexia, sore joints and muscles and agitated behaviour, No other symptoms are reported. This morning the partner notices that the patient started developing a fever and he called for EMS when in the evening she suddenly became lethargic and difficult to arouse. He also states that the patient started a profylactic treatment for Malaria, but never finished it and that she was stung or bitten by an unknown insect three weeks ago.

We gave the patient supplemental oxygen per nonrebreathing mask, started aggresive fluid management with two large bore IV´s, 1G of acetaminophen IV and transported code 3 to a level III hospital with a tropical medicine department. During the 25-minute trip the patient now has a GCS of 4-6-5, a pink skin color, BP of 90/50, pulse still 90, sats 97%. She denies any other complaints.

- What diseases would you consider with this information?
- Is a viral infection more likely than a bacterial or parasitic infection or can´t we say?
- Would you take more, the same or less protective precautions, and why?
- Could you explain why this patient wasn´t tachycardic?
- In general, how would you have managed this call?

 

[MonkeyArrow]

Very interesting. I will be the first to admit that I have very little experience with tropical medicine. Honestly, I would have tried to ask the patient herself what she thought was infected with. Then, prior to much invasive treatment or transport, I would call and consult with med control for their opinion and transport considerations/needed isolation precautions.

 

[luke_31]

Could be malaria. But there are several other diseases that would present with those symptoms too. Malaria is just one of the most common tropical diseases. We get a few of those every so often at the hospital we are based out of.

 

[Summit]

- What diseases would you consider with this information?
- Is a viral infection more likely than a bacterial or parasitic infection or can´t we say?
- Would you take more, the same or less protective precautions, and why?
- Could you explain why this patient wasn´t tachycardic?
- In general, how would you have managed this call?

1. DDx
Malaria - surely was on prophylaxis over there?
Q Fever - what was he working with over there?
Yellow Fever... but there is none in Botswana (and probably had a vaccine as a tropically traveling microbiologist) did he hang out somewhere else?
Typhoid... but no GI symptoms and certainly has this vaccine
Legionella - perhaps hanging out around nasty swamp coolers, but no Pna symptoms
Sepsis due to non-tropical disease
Drug Fever
2. Unable to discern viral v bacterial v parasite at this time. Pt was in Botswana long enough for any tropical disease to manifest at the current time depending on when they were exposed.
3. Standard precautions seem fine at this time
4. Fagets sign - sphygmothermic dissociation, helps narrow the ddx, but nothing fits all that well
5. Like any severe sepsis, but I like the tropical disease capable facility you chose

Really only have sepsis presentation with fever+Fagets sign, but without mention of pulmonary or GI symptoms nor skin signs in a patient with a foreign exposure and microbio lab exposure. That is not much to go on.

ED treatment:
Labs: Blood cultures, CBC w manual Diff (inc thick/thin films), CMP, PT+PTT, lactate, sendout micro labs
Tx: vanc+zosyn+metronidazole, continue fluids
Admit to medicine service with ID consult either IMC or floor status depending on ED course

No skin signs? No GI symptoms?

 

[EpiEMS]

We entered the apartment wearing facial masks,

Just curious, did you consider asking your dispatch whether they were able to ascertain where the person returned from prior to entering the house? That is - potentially - an important piece of information for you and could lead you to increase your PPE use (e.g. if the patient was coming back from, say, somewhere where there was a recent outbreak). If I could not obtain that information, I would likely err on more PPE, because it is not possible to ascertain if the patient is afflicted with, say, a viral hemorrhagic fever (which would necessitate you using more PPE) or something where standard precautions are fine (e.g. malaria).

@Summit, would you have made entry to the scene given the dispatch info only without additional PPE?

As far as the presentation goes, I think your course of treatment was fine. We don't have IV acetaminophen, so I would have been out of luck, there.

 

[Summit]

@EpiEMS You point is very fair... now I can cheat and say that Fagets Sign is not consistent with VHF, but I would't know that without seeing the patient. I could say Botswana is not known for VHF although they did have a Rift Valley Fever outbreak in 2010 and CHV and Lassa or known to have been seen so since this is a microbiologist yea caution would be well warranted at least through assessment. I also like your idea of ask the patient... in this case they probably would have a better idea than anyone but a TM or ID doc of what they have.

Also, I thought this was interesting reading last week:

https://www.slideshare.net/Singaram_Paed/pyrexia-of-unknown-origin-14869069

Because we had a pyrexia of unknown to the point of SIRS rxn without infectious etiology... we worked up after multiple outpatient/ED and it was determined to be some kind of drug rxn.

Which of course begs the question of what meds the pt is on and which antimalarial?

Also, I left Psittacosis and Leptospirosis off the list. I am still thinking a drug fever is high on the list, although a good history will clarify that likelihood. Unless the patient states likely exposure to something on the list... also I think this would be a bit atypical for Malaria as I don't associate with Fagets. I guess I should ask what meds the patient is on again because if they are beta blocked and we have a pseudo-Fagets, then I absolutely vote Malaria for the top of the DDx.

I eagerly await @harold1981 sharing more details and the actual diagnosis.

 

[EpiEMS]

@Summit, that's a really good point - never thought about drug reactions!
I was worried that I might be overcautious, but in the absence of good info about etiology, I figure it's safer to suit up than not.

 

[Summit]

High fever and low pulse/ blood pressure. Typical of malaria (falciparum) or yellow fever.

I stand corrected on the Malaria

 

[harold1981]

Could be malaria. But there are several other diseases that would present with those symptoms too. Malaria is just one of the most common tropical diseases. We get a few of those every so often at the hospital we are based out of.

We put malaria high on our DD, at the same time realizing that there must be many other diseases out there that will present with the same symptoms.

 

[harold1981]

1. DDx
Malaria - surely was on prophylaxis over there?
Q Fever - what was he working with over there?
Yellow Fever... but there is none in Botswana (and probably had a vaccine as a tropically traveling microbiologist) did he hang out somewhere else?
Typhoid... but no GI symptoms and certainly has this vaccine
Legionella - perhaps hanging out around nasty swamp coolers, but no Pna symptoms
Sepsis due to non-tropical disease
Drug Fever
2. Unable to discern viral v bacterial v parasite at this time. Pt was in Botswana long enough for any tropical disease to manifest at the current time depending on when they were exposed.
3. Standard precautions seem fine at this time
4. Fagets sign - sphygmothermic dissociation, helps narrow the ddx, but nothing fits all that well
5. Like any severe sepsis, but I like the tropical disease capable facility you chose

Really only have sepsis presentation with fever+Fagets sign, but without mention of pulmonary or GI symptoms nor skin signs in a patient with a foreign exposure and microbio lab exposure. That is not much to go on.

ED treatment:
Labs: Blood cultures, CBC w manual Diff (inc thick/thin films), CMP, PT+PTT, lactate, sendout micro labs
Tx: vanc+zosyn+metronidazole, continue fluids
Admit to medicine service with ID consult either IMC or floor status depending on ED course

No skin signs? No GI symptoms?

I considered yellow fever as well. And with yellow fever also Ckikungunya, which seems to be widespread as well in the tropics and have a similar symptom presentation. There where no major clues indeed: no coughing or sore thraot, no breathing problems, no GI-problems, no blood, no bruises or rashes, No neuro symptoms, other than the lethargy, which I believed to be due to the sepsis and poor perfusion. I have treated one yellow fever patient before, a young and fit person, who soon after arriving into the ED went into acute renal failure and multi-organ failure and subsequently coded.

 

[harold1981]

Just curious, did you consider asking your dispatch whether they were able to ascertain where the person returned from prior to entering the house? That is - potentially - an important piece of information for you and could lead you to increase your PPE use (e.g. if the patient was coming back from, say, somewhere where there was a recent outbreak). If I could not obtain that information, I would likely err on more PPE, because it is not possible to ascertain if the patient is afflicted with, say, a viral hemorrhagic fever (which would necessitate you using more PPE) or something where standard precautions are fine (e.g. malaria).

@Summit, would you have made entry to the scene given the dispatch info only without additional PPE?

As far as the presentation goes, I think your course of treatment was fine. We don't have IV acetaminophen, so I would have been out of luck, there.

You know what, dispatch only mentioned Africa and we considered whether we should enter with only gloves based on the available info, or also put on a facial mask. If this happened two years ago during the Ebola outbreak, we would probably have stayed away and asked for a specialty team to respond. At this time, we thought that an isolation gown would be disproportional. Maybe we are wrong in thinking that. What would you have done in case dispatch didn´t have any additional info?

When we arrived in the ED, the nurses there did not use any PPE, which makes me wonder if and how you can differentiate between airborne pathogens or transmission via droplets or direct contact, based on the little information that we had at that moment.

 

[harold1981]

@EpiEMS You point is very fair... now I can cheat and say that Fagets Sign is not consistent with VHF, but I would't know that without seeing the patient. I could say Botswana is not known for VHF although they did have a Rift Valley Fever outbreak in 2010 and CHV and Lassa or known to have been seen so since this is a microbiologist yea caution would be well warranted at least through assessment. I also like your idea of ask the patient... in this case they probably would have a better idea than anyone but a TM or ID doc of what they have.

Also, I thought this was interesting reading last week:

https://www.slideshare.net/Singaram_Paed/pyrexia-of-unknown-origin-14869069

Because we had a pyrexia of unknown to the point of SIRS rxn without infectious etiology... we worked up after multiple outpatient/ED and it was determined to be some kind of drug rxn.

Which of course begs the question of what meds the pt is on and which antimalarial?

Also, I left Psittacosis and Leptospirosis off the list. I am still thinking a drug fever is high on the list, although a good history will clarify that likelihood. Unless the patient states likely exposure to something on the list... also I think this would be a bit atypical for Malaria as I don't associate with Fagets. I guess I should ask what meds the patient is on again because if they are beta blocked and we have a pseudo-Fagets, then I absolutely vote Malaria for the top of the DDx.

I eagerly await @harold1981 sharing more details and the actual diagnosis.

This patient was not on any medication. She started antimalaria profylaxis, but didn´t finish the prescription. We know one thing for sure: there was plenty of malaria in that region. But we don´t know what else. Onfortunately I don´t have a follow-up as the receiving hospital is not one that we use on a daily basis.

 

[ERDoc]

Unfortunately, pt 0 will almost always fall through the cracks.