A 43-year-old man comes to the hospital with 2 days of persistent fever, headache, malaise, and intense muscle and joint pain. He has been taking ibuprofen, which provides only mild relief. The patient frequently travels internationally for business and returned from India a week ago. He received appropriate vaccinations prior to travel, took all advised prophylactic medications, and consumed bottled water during the trip. His temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 98/min. After an inflated sphygmomanometer cuff is on his arm for a few minutes, he develops severe petechiae; however, he has no other skin rash. He has mild cervical lymphadenopathy. There are no heart murmurs. Lungs are clear to auscultation. The abdomen is nontender, and the liver is palpated 3 cm below the costal margin. Laboratory results are as follows: For which of the following is this patient at greatest risk?

Question

A 43-year-old man comes to the hospital with 2 days of persistent fever, headache, malaise, and intense muscle and joint pain.  He has been taking ibuprofen, which provides only mild relief.  The patient frequently travels internationally for business and returned from India a week ago.  He received appropriate vaccinations prior to travel, took all advised prophylactic medications, and consumed bottled water during the trip.  His temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 98/min.  After an inflated sphygmomanometer cuff is on his arm for a few minutes, he develops severe petechiae; however, he has no other skin rash.  He has mild cervical lymphadenopathy.  There are no heart murmurs.  Lungs are clear to auscultation.  The abdomen is nontender, and the liver is palpated 3 cm below the costal margin.  Laboratory results are as follows:  For which of the following is this patient at greatest risk?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c16e_3b36_8f63_93262f455b91_MD0005_00 This patient's febrile illness after recent travel to an endemic country suggests dengue fever (DF), which is due to viral infection spread by the Aedes mosquito. DF is prevalent in tropical and subtropical regions (South and Southeast Asia, Pacific Islands, Caribbean, Americas). It can present as an acute febrile illness with headache, retro-orbital pain, joint/muscle pain, macular rash, cervical lymphadenopathy, and pharyngeal erythema. Other findings can include hemorrhagic tendencies (eg, petechiae with tourniquet application) or spontaneous hemorrhage (eg, purpura, ecchymoses), thrombocytopenia, leukopenia, and elevated liver aminotransferases. Dengue hemorrhagic fever (DHF) is the most serious dengue viral infection and is due to increased capillary permeability leading to hemoconcentration, pleural effusion, and ascites. Circulatory failure can develop with significant plasma leakage and is sometimes referred to as dengue shock syndrome. Patients typically have marked thrombocytopenia (<100,000/mm³) and prolonged fever. (Choice A) Cerebral edema can occur in Plasmodium falciparum malaria, which usually presents with fever, anemia, and splenomegaly. This patient's absence of anemia makes this less likely. In addition, this patient took all advised prophylactic medications, which included malaria prophylaxis for travel to India. (Choice C) Intestinal perforation can be a complication of typhoid fever, which typically presents more gradually with rising fever, chills, relative bradycardia, abdominal pain, and rose spots (faint salmon-colored macules on the trunk and abdomen). (Choice D) Leptospirosis can sometimes progress to Weil's disease with renal failure and jaundice. The lack of the characteristic conjunctival suffusion makes leptospirosis less likely. Leptospirosis (Choice E) Infectious mononucleosis (IM) usually presents with atypical lymphocytosis, fatigue, fever, pharyngitis, and splenomegaly. IM can rarely progress to splenic rupture. However, this patient's absence of pharyngitis or splenomegaly makes this unlikely. Educational objective: Dengue hemorrhagic fever is the most serious dengue viral infection and is due to increased capillary permeability leading to hemoconcentration, marked thrombocytopenia, prolonged fever, and respiratory/circulatory failure. References: Dengue viruses - an overview. (http://www.ncbi.nlm.nih.gov/pubmed/24003364) Clinical and laboratory predictive markers for acute dengue infection. (http://www.ncbi.nlm.nih.gov/pubmed/24138072)

A 43-Year-Old Man Comes to the Hospital with 2 Days