A 32-year-old woman comes to the emergency department with sudden-onset unremitting fevers, chills, and joint pains for the past 2 days. She describes severe, "unbearable" pain in her right shoulder, left elbow, and left knee. She has not had any nausea, vomiting, or diarrhea. Three days ago, the patient returned from a 2-week honeymoon in the Dominican Republic. She spent time camping and swimming in the ocean. Her husband has no symptoms.
The patient's temperature is 39 C (102.2 F), blood pressure is 114/64 mm Hg, pulse is 96/min, and respirations are 18/min. She has no skin rash. Her lungs are clear bilaterally and there are no heart murmurs. Her abdomen is soft and nontender. Joint examination shows swelling in the left elbow and left knee without localized effusions or tenderness. Laboratory results are as follows:
Which of the following is the most likely diagnosis?

Question

A 32-year-old woman comes to the emergency department with sudden-onset unremitting fevers, chills, and joint pains for the past 2 days.  She describes severe, "unbearable" pain in her right shoulder, left elbow, and left knee.  She has not had any nausea, vomiting, or diarrhea.  Three days ago, the patient returned from a 2-week honeymoon in the Dominican Republic.  She spent time camping and swimming in the ocean.  Her husband has no symptoms.
The patient's temperature is 39 C (102.2 F), blood pressure is 114/64 mm Hg, pulse is 96/min, and respirations are 18/min.  She has no skin rash.  Her lungs are clear bilaterally and there are no heart murmurs.  Her abdomen is soft and nontender.  Joint examination shows swelling in the left elbow and left knee without localized effusions or tenderness.  Laboratory results are as follows:
 Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_964c_19ff_853d_7d7bb534fa78_MD0002_00 This patient, who recently returned from a trip to the Dominican Republic, has a classic presentation for Chikungunya fever (acquired by a bite from an infected Aedes mosquito). This includes the abrupt onset of persistent high fevers and characteristic severe polyarthralgias (seen in virtually all cases and often involving multiple joint groups). Some patients develop a rash. Lymphopenia and thrombocytopenia are common; elevated transaminases may also be seen. Serologic studies (or polymerase chain reaction testing in the first 5 days) can confirm the diagnosis. The infection is most often self-limited, although a few patients develop serious complications; rheumatologic symptoms may persist after the acute phase. (Choice B) The absence of gastrointestinal symptoms and presence of arthralgias make enteric fever (eg, typhoid fever) less likely. Many enteric fevers are transmitted through consumption of contaminated water. (Choice C) Hantavirus is transmitted by rodents and can cause hantavirus cardiopulmonary syndrome or hemorrhagic fever with renal syndrome, typically 2-3 weeks following exposure. This patient has normal kidney function, no hemorrhage, no respiratory symptoms, and no rodent exposure history. (Choice D) Malaria would classically be accompanied by gastrointestinal symptoms (vomiting, diarrhea), anemia, and thrombocytopenia. Fevers are typically cyclical (unlike the unremitting fevers seen in this patient), and polyarthralgias would not be as prominent. (Choice E) Meningococcemia (with or without meningitis) would more commonly manifest as progressive rash, pronounced myalgias, and rapid hemodynamic deterioration. Educational objective: Chikungunya virus disease should be considered in patients who develop fevers and severe polyarthralgias shortly after travel to an endemic area. __________ References: Chikungunya: a reemerging virus (http://www.ncbi.nlm.nih.gov/pubmed/22100854) Chikungunya (http://www.ncbi.nlm.nih.gov/pubmed/25244354)

A 32-Year-Old Woman Comes to the Emergency Department with Sudden-Onset