A 29-year-old man comes to the physician because of high fevers, headache, and muscle pains mainly in the lower back and thighs. His symptoms began abruptly 2 days ago. He returned from a two-week vacation in Costa Rica 6 days ago, and did not receive any vaccinations prior to travel. During his trip, he ate local foods, drank alcohol, visited the beach, and participated in a 4-day river rafting excursion. He denies any sick contacts and reports no direct contact with animals. He has no past medical history.
His temperature is 39.4 C (103 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 14/min. Examination reveals an uncomfortable appearing man in no acute distress. His skin is warm and flushed, but there is no rash. Eye examination reveals bilateral redness of the conjunctiva. There is no lymphadenopathy. The abdomen is soft with mild right upper quadrant tenderness. The liver edge is palpable 2 cm below the costal margin. There is no rebound tenderness or involuntary guarding. There is tenderness over the lumbar paraspinal muscles bilaterally. The remainder of the examination is unremarkable.
Laboratory results are as follows:
Urinalysis shows 10-20 WBC/hpf and 2+ proteinuria.
Which of the following is the most likely cause of this patient's illness?

Question

A 29-year-old man comes to the physician because of high fevers, headache, and muscle pains mainly in the lower back and thighs.  His symptoms began abruptly 2 days ago.  He returned from a two-week vacation in Costa Rica 6 days ago, and did not receive any vaccinations prior to travel.  During his trip, he ate local foods, drank alcohol, visited the beach, and participated in a 4-day river rafting excursion.  He denies any sick contacts and reports no direct contact with animals.  He has no past medical history.
His temperature is 39.4 C (103 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 14/min.  Examination reveals an uncomfortable appearing man in no acute distress.  His skin is warm and flushed, but there is no rash.  Eye examination reveals bilateral redness of the conjunctiva.  There is no lymphadenopathy.  The abdomen is soft with mild right upper quadrant tenderness.  The liver edge is palpable 2 cm below the costal margin.  There is no rebound tenderness or involuntary guarding.  There is tenderness over the lumbar paraspinal muscles bilaterally.  The remainder of the examination is unremarkable.
Laboratory results are as follows:
 Urinalysis shows 10-20 WBC/hpf and 2+ proteinuria.
Which of the following is the most likely cause of this patient's illness?

Quizplus · Accepted Answer

11ec193a_9853_0dd3_853d_0d455346a5d6_MD0002_00 This patient's recent travel to a tropical area, abrupt onset of systemic symptoms (e.g., fever, myalgias, abdominal and muscle pain), and conjunctival suffusion are consistent with Leptospirosis (hemorrhagic jaundice). Leptospirosis is a zoonotic infection caused by the spirochete Leptospira interrogans, and is most frequently seen in tropical (Hawaii) and temperate climates. The organism commonly infects both wild and domestic mammals (rodents) and these animals shed the organism in their urine. Humans become infected following contact with infected urine. The severity of illness can range from subclinical to severe. Symptomatic patients present with abrupt-onset systemic and GI symptoms. Physical examination may show muscle tenderness and hepatosplenomegaly. Conjunctival suffusion (redness of the conjunctiva without inflammatory exudates) is characteristic of leptospirosis and is not seen in most other infectious diseases. Diagnosis is made by serologic testing or culture of the organism from blood/urine or CSF. Most cases of leptospirosis are mild and self-limiting. Symptomatic patients are treated with doxycycline or penicillin. (Choice A & D) Alcoholic hepatitis and hepatitis A infection are not associated with conjunctival erythema. (Choice B) Dengue fever can present as a febrile illness associated with headache, retroorbital pain, and marked myalgias and arthralgias. Conjunctival findings are not typical. (Choice C) Ehrlichiosis may present with findings similar to this patient, but it is not usually associated with conjunctival erythema. Educational objective: Leptospirosis should be considered in patients with epidemiologic exposure to Leptospira (e.g., rodent urine) who present with an acute febrile illness. Conjunctival suffusion is a common and specific finding. Appropriate treatment is with doxycycline or penicillin. __________ References: Leptospirosis: An emerging disease in travelers (http://www.ncbi.nlm.nih.gov/pubmed/20188303) Leptospirosis (http://www.ncbi.nlm.nih.gov/pubmed/11292640)

A 29-Year-Old Man Comes to the Physician Because of High