A 51-year-old man comes to the physician after recently returning from a trip to Bangladesh. He reports 1 week of fever and left lower-quadrant abdominal pain. His medical problems include type 2 diabetes mellitus and hypertension. The patient does not use tobacco, alcohol, or illicit drugs. His current medications include metformin and lisinopril.
His temperature is 103° F (39.4 C), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 14/min. Examination shows an uncomfortable-appearing man in no acute distress. There is an erythematous, macular, patchy rash across his lower abdomen. The abdomen is soft with left lower-quadrant tenderness. There is no rebound tenderness or involuntary guarding. The remainder of the examination is unremarkable.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 51-year-old man comes to the physician after recently returning from a trip to Bangladesh.  He reports 1 week of fever and left lower-quadrant abdominal pain.  His medical problems include type 2 diabetes mellitus and hypertension.  The patient does not use tobacco, alcohol, or illicit drugs.  His current medications include metformin and lisinopril.  
His temperature is 103° F (39.4 C), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 14/min.  Examination shows an uncomfortable-appearing man in no acute distress.  There is an erythematous, macular, patchy rash across his lower abdomen.  The abdomen is soft with left lower-quadrant tenderness.  There is no rebound tenderness or involuntary guarding.  The remainder of the examination is unremarkable.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_984f_162b_853d_69f0795bcfb7_MD0002_00 This patient's presentation is suggestive of typhoid fever, which is caused by Salmonella typhi or Salmonella paratyphi and is commonly seen in the developing world. Patients typically present with fever and bacteremia within 5-20 days after ingestion of contaminated food or water. They can also present later with abdominal pain and a characteristic erythematous, macular rash. Laboratory studies may show a normal platelet count, leukopenia or leukocytosis, and abnormal liver function tests. The most serious stage of typhoid fever is intestinal perforation (due to hyperproliferation of Peyer's patches), which can lead to peritonitis, bacteremia, septic shock, and death. Diagnosis is made by culture, and S typhi and S paratyphi can be isolated from stool, urine, and intestinal contents. However, bone marrow is the most sensitive (> 90%), with a higher yield of organisms than other body fluids. Blood cultures are usually performed out of convenience, but the sensitivity in isolating S typhi or S paratyphi ranges from 40%-80%. Bone marrow cultures can be particularly useful as they remain positive in a high percentage of patients who received antibiotics for several days prior to culture. (Choice A) Classic dengue fever presents with fever lasting 5-7 days, headache, retro-orbital pain, rash, and body aches ("breakbone fever"). Laboratory findings include leukopenia, thrombocytopenia, and elevations in serum aspartate aminotransferase levels. (Choice B) Leptospirosis presents with abrupt onset of fever, myalgias, headache, and abdominal pain. An important clinical feature is conjunctival suffusion (redness of the conjunctiva without inflammatory exudates), which is not present in most other infectious diseases. (Choice C) Patients with malaria present from an endemic region with nonspecific symptoms such as fever that waxes and wanes, chills, headache, abdominal pain, nausea, and vomiting. They usually have splenomegaly, and initial laboratory data show anemia, thrombocytopenia, and hyperbilirubinemia. Rash is not a common clinical feature of malaria. (Choice E) Patients with acute viral hepatitis usually present with fever, abdominal pain, nausea, vomiting, jaundice, and hepatomegaly. Common laboratory abnormalities include marked elevations in serum aminotransferases (> 1000 U/L and alanine aminotransferase > aspartate aminotransferase), total and direct bilirubin, and alkaline phosphatase levels. Educational objective: Typhoid fever usually presents in patients with recent travel to an endemic region with fever, bacteremia, and relative bradycardia. Patients later develop abdominal pain and a macular rash. Bone marrow culture is the most sensitive method for isolating the causative organism. __________ References: Clinical pathogenesis of typhoid fever. (http://www.ncbi.nlm.nih.gov/pubmed/19741286) Comparative study on infection-induced thrombocytopenia among returned travelers. (http://www.ncbi.nlm.nih.gov/pubmed/22350868)

A 51-Year-Old Man Comes to the Physician After Recently Returning