A 23-year-old woman comes to the emergency department after an episode of syncope. She began feeling unwell 6 days ago with fever, throbbing pain behind the eyes, diffuse myalgias, and abdominal pain. Her fever improved 2 days ago, but she noticed an erythematous skin rash developing on her trunk and upper and lower extremities. A few hours prior to admission, the patient had an episode of epistaxis and a syncopal episode when cleaning the bathroom. She has no other medical problems. She returned from a trip to southern Mexico 10 days ago and states that one of her travel companions also has had fevers and myalgias. The patient received the typhoid vaccine before her trip.
Her temperature is 37.2 C (99 F), blood pressure is 86/60 mm Hg, pulse is 108/min, and respirations are 14/min. Examination shows mild abdominal tenderness with no hepatosplenomegaly. Examination of the hands is shown below.

Laboratory studies are as follows:

Urinalysis is normal. Which of the following is the most likely diagnosis?

Question

A 23-year-old woman comes to the emergency department after an episode of syncope.  She began feeling unwell 6 days ago with fever, throbbing pain behind the eyes, diffuse myalgias, and abdominal pain.  Her fever improved 2 days ago, but she noticed an erythematous skin rash developing on her trunk and upper and lower extremities.  A few hours prior to admission, the patient had an episode of epistaxis and a syncopal episode when cleaning the bathroom.  She has no other medical problems.  She returned from a trip to southern Mexico 10 days ago and states that one of her travel companions also has had fevers and myalgias.  The patient received the typhoid vaccine before her trip.
Her temperature is 37.2 C (99 F), blood pressure is 86/60 mm Hg, pulse is 108/min, and respirations are 14/min.  Examination shows mild abdominal tenderness with no hepatosplenomegaly.  Examination of the hands is shown below.

Laboratory studies are as follows:

Urinalysis is normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_964e_15d6_853d_734d0914df2b_MD0002_00 Dengue fever (DF) is a common cause of fever in travelers returning from the Caribbean, parts of Asia, and South America. In addition to fever, the first period of illness (usually 3-5 days) is marked by myalgias, retro-orbital pain/headache, and bleeding complications (eg, epistaxis). As these symptoms improve, a characteristic macular or maculopapular rash ("islands of white in a sea of red") may appear. At around the same time, patients enter the critical phase of the illness; some may develop capillary leakage with edema, effusions, hypotension/shock, and severe hemorrhage. A positive tourniquet test may be seen (petechiae following sphygmomanometer inflation for 5 minutes over the arm). Laboratory abnormalities include leukopenia, thrombocytopenia, and an elevated hematocrit due to hemoconcentration (even in the absence of hemorrhage). Diagnosis is made via serology or direct testing for viral components, and care is largely supportive. (Choice B) Epstein-Barr virus can cause infectious mononucleosis, which typically presents with pharyngitis, lymphadenopathy, splenomegaly, and lymphocytosis. (Choice C) Leptospirosis may present similarly to DF. However, patients usually have conjunctival suffusion, pulmonary involvement (eg, cough, dyspnea), and/or renal involvement (eg, proteinuria, electrolyte abnormalities). Leptospirosis (Choice D) Secondary syphilis can present with systemic symptoms and a diffuse maculopapular rash involving the palms and soles. However, it is not usually associated with bleeding diathesis, hypotension, or thrombocytopenia. (Choice E) Typhoid fever typically presents with weeks of sequential fever followed by rose spots (faint salmon-colored macules on trunk and abdomen) and abdominal pain; some cases may progress to hepatosplenomegaly, bleeding, and shock. This patient's clinical presentation is more consistent with DF. In addition, she received the typhoid vaccine before the trip. Educational objective: Dengue fever is a common cause of fever in travelers returning from an endemic area (eg, Caribbean, parts of Asia, and South America). Patients typically develop fever, retro-orbital pain/headache, a characteristic macular rash, and bleeding complications. Leukopenia and thrombocytopenia are common laboratory abnormalities. __________ References: Fever in returning travelers: a case-based approach. (http://www.ncbi.nlm.nih.gov/pubmed/24364573) Dengue viral infections. (http://www.ncbi.nlm.nih.gov/pubmed/15466994)

A 23-Year-Old Woman Comes to the Emergency Department After an Episode