Tropical Fevers Case 1: 27 year old woman comes to a local health unit with history of a gradual onset of fever and headache and loss of appetite over the past 4 days. She is a farmer and is pregnant but thinks she has only missed 3 periods. She does not have a cough or dysuria, or other profound symptoms. At the time of assessment she does have a temperature of 38.7 C, but general physical exam is normal with uterus about 18 weeks size. She does not have a rash. You give her Paracetamol and send her home with diagnosis of viral infection. What should you also be considering in your differential diagnosis?
24 hours later she returns to the clinic. She is now feeling very sick with myalgias, back ache, dysuria, fever, and severe headache. She also has a rash that is maculopapular and confined mostly to her trunk. You do not see an eschar. Her temperature is 39 and her PR is 60 Will you change your diagnosis? What are the possibilties and what will you do now?
There are no tests available at the health unit other than a rapid malaria test which is negative. You cannot test her for urinary tract infection but you do have other medications available In your opinion, what is the most likely cause for her symptoms of Headache, fever, myalgias, and rash without eschar? Should you give her any Rx?
In this case, the patient had a spontaneous abortion 2 days later. After being transferred to the district hospital they were able to do a more tests and found her to have Typhus. She was treated with Doxycycline and recovered. She may well have had a UTI or Dengue etc. If you had seen her in the hospital initially and were able to do lab tests what would you have expected in a CBC? LFT?
Discussion: Tropical fevers can always be confusing and in the absence of tests you must consider and treat for suspected: –Malaria –Typhus –Dengue –Leptospirosis –Typhoid –As well as UTI, Viremia etc Complications of Typhus (spontaneous abortion etc ) The treatment for Typhus in pregnancy can be Azithromycin or Erythromycin or Chloramphenicol Always consider co-morbid infections
Case 2: 19 year old primiparous woman at 30 weeks gestation is admitted to the Provincial Hospital in the rainy season. She has a 5 day history s of headache, retro-orbital pain, intense muscle aches, fever, diarrhea and a dry cough. On examination she is pale, has conjuctival injection, mild hepatomegaly with RUQ tenderness and a temperature of 40 C. She has a faint, blanching rash on her body and her face is flushed. The uterine size is 29 cm and FHR is 155. Uterus is soft and not tender. What is your Differential Diagnosis? What will you order and do?
Malaria test is negative, Rapid Dengue IgG and IgM are negative, but Tourniquet test is positive with 22 petechiae in 2.5 sq cm. CBC shows Hct of 34% and platelets of 90,000. Do you think she has Dengue Fever, Typhus, Typhoid, Leptospirosis or other infection? Does she fulfill criteria for DHF?
The next day her fever breaks and the rash becomes more pronounced and she starts to feel better. However, as she is pregnant you elect to observe her for another day as she lives far from the hospital. The next day her fever returns and she develops severe abdominal pain, vomiting and becomes very restless. She has also developed a generalized purpuric rash. You order an urgent CBC and her Hct is 52% and her platelets are 50,000. Of course the rapid Dengue test is now positive Does she fulfill criteria for DHF or DSS? How do you manage this case?
Discussion: Dengue is a common, acute febrile illness with clinical diagnosis Saddleback fever as in leptospirosis and sometimes typhoid Rash does not often appear until day 4 or 5 Initial rapid Dengue serology often negative Hemorrhagic signs are common especially in 2 nd phase of disease but does not mean DHF unless there is evidence of all 4 criteria: –Evidence of plasma leakage/Hct increase by > 20% –Thrombocytopenia < 100,000 –Fever 2-7 days –Hemorrhagic tendency or spontaneous bleeding DSS symptoms, signs and management Beware of fluid overload/pulmonary edema especially in pregnancy