Content area
Full Text
Presentation of Case
Dr. Nkemdilim Mgbojikwe (Medicine): A 21-year-old woman was admitted to this hospital during the winter because of fever, headache, and myalgias.
The patient had been well until 4 days before this admission, when fever, chills, fatigue, malaise, retro-orbital headache, and photophobia developed. On presentation to a clinic affiliated with the university where she was a student, she reported that, 6 days earlier, she had returned from a trip to Indonesia. A blood-smear examination for malaria was negative, and the patient was advised to take acetaminophen and ibuprofen. Over the next 2 days, her symptoms worsened, and abdominal pain in the left lower quadrant and arthralgias affecting the knees developed. On the third day of illness, she presented to the emergency department of another hospital for evaluation.
On examination at the other hospital, the temperature was 41.0°C. The blood lactic acid level and results of liver-function tests were normal; other laboratory test results are shown in Table 1. Tests for heterophile antibodies, influenza, and Clostridium difficile were negative. Blood and urine specimens were obtained for culture, and a lumbar puncture was performed; on cerebrospinal fluid analysis, the white-cell and red-cell counts and protein and glucose levels were normal.
Dr. Rydhwana Hossain: Chest radiography revealed no evidence of focal consolidation, pulmonary edema, or hilar adenopathy. Abdominal radiography revealed multiple air-filled loops of small bowel but no evidence of abnormal bowel dilatation, obstruction, or free air. Four hours later, computed tomography (CT) of the abdomen and pelvis, performed after the administration of intravenous contrast material, revealed the presence of a few subcentimeter mesenteric lymph nodes in the right lower quadrant. There was no bowel-wall thickening, obstruction, ascites, or hepatosplenomegaly. The kidneys were heterogeneous in appearance.
Dr. Mgbojikwe: Acetaminophen was administered, and the patient was admitted to the hospital. High temperatures persisted; cooling blankets were applied, and more than 7 liters of fluid were administered intravenously. On the second hospital day, intravenous doxycycline and ceftriaxone were administered. Three blood-smear examinations for malaria, a stool culture for enteric pathogens, and a stool examination for ova and parasites were negative; other laboratory test results are shown in Table 1. By the third hospital day, cough and mild chest pain had developed, and hypoxemia was reportedly present; supplemental...