related to her peanut allergy
Cholera.
2
There were two giveaways: the white, frothy vomit, and that cholera is frequent in Kenya. That was the only preventable disease that she did not get vaccinated for.
Did I misread the data, or has a fever never been documented? Hard to diagnose a febrile illness without a fever. Do we know her baseline WBC? Perhaps her PCP knows that she has chronic neutropenia, and that her present white count is in fact her baseline. Psychogenic causes should be included in the differential.
It's interesting after the fact to see the various diagnoses. Making the right one can be difficult in itself and made more so by billing and record limitations such as rushing and overabundance of boxes and clicks . Mary Garcia got it right. Perhaps as a patient it might be useful to keep the possibility of diagnosis on one's radar.
porphyria
Severe allergic reaction to Malaria medication - body rejection of medication.
1
Depression
Belharzia. I used to live in E. Africa, and that would be my guess - but it's just a guess.
I would add that Belharzia can take decades to manifest, so it may be that her trip to Kenya simply triggered what was already there from her childhood, and my guess is that her doctor is from East Africa, so he was equipped to recognize that which her other doctors would have had no experience with.
Coxiella burnetti
parasite in the gut.
Kidney infection
Ulcer caused by bacterial infection, not cured by the antibiotics used.
Mono with liver involvement.
Hep C
Early kidney failure due to malaria parasitic cysts in kidney. The better functioning kidney masked the damage of the affected kidney.
Lead poisoning.
I'll say it because I don't think anyone else has... Still's disease? The increased liver enzymes and ferritin, facial rash, nausea/anorexia, myalgias would fit. Usually get leukocytosis though, and there's no mention of a sore throat.
Doesn't sound like schisto to me (ie Katayama fever), almost always get eosinophilia.
Also doesn't sound like dengue. Usually get thrombocytopenia, and the time course is unusual.
No Chagas in Kenya.
Primaquine is usually the classic antimalarial that causes hemolysis with G6PD. Not so much mefloquine or malarone
Doesn't sound like schisto to me (ie Katayama fever), almost always get eosinophilia.
Also doesn't sound like dengue. Usually get thrombocytopenia, and the time course is unusual.
No Chagas in Kenya.
Primaquine is usually the classic antimalarial that causes hemolysis with G6PD. Not so much mefloquine or malarone
1
Hemolysis due to g6pd deficiency precipitated by the antimalaria drugs taken prior to the trip.
1
DVT related to traveling on airplane
2
Relapsing fever
Reaction to the Malarone.
1
Hemochromatosis secondary to sickle cell anemia. Look at those ferritin and TIBC levels! I'm attuned to those tests because I have been severely anemic and was not able to get as many IV iron transfusions as I needed (or as quickly as I needed) due to the possibility of developing hemochromatosis.
That seems right to me. Malaria meds made her stomach bleed?
Leptospirosis
Gastrentritis?
leptospirosis
Thyrotoxicosis
How do we know the answer?
Did she ingest poison somehow, hence damage to the liver and the fever and chills?
It will be posted later this afternoon.
She has gallstones. It's not affected her common bile duct yet because pancreatic enzyme is still normal.
@G Kadar,
Gallstones that are not picked up by RUQ U/S which is diagnostic gold standard?
Just to be different and throw out something that hasn't been mentioned yet--drug induced lupus? Not sure if mefloquine can cause it but just a thought. I feel pretty confident that most infectious causes are ruled out, and that systemic and autoimmune diseases are more likely. The hepatitis with necrosis and marcophages really grabs my attention. Hemochromatosis is a great though, but no stainable iron on liver biopsy. G6PD seems unlikely with more evidence of hemolysis and elevated bili. The pregnancy thoughts are great, but too many other symptoms (leukopenia, hepatitis).
2
If you are right, I am going to feel stupid because I have systemic lupus and also just had a bout of drug-induced lupus.
A severe and antibiotic resistant UTI, and it could have become a kidney infection. Doxy wasnt enough to clear it and the anti-malarials made it worse, not to mention how the doxy probably added to the nausea. I had the same symptoms a few months ago, it took 15 days of cipro to clear the infection.
1
Q fever
Haven't completely finished reading all of it yet, but...
The major Ddx's have been looked at, including Malaria, but there was little men of sleeping sickness & kissing bug disease.
Very curious on the blood results for CMV/EBV, as these infections would fit this.
Kudos to the mention of hemachormatosis. Wasn't thinking of that one.
BUT . . . thers is one possibility still left out . . . REACTION TO HER MALARIA MEDICATION!!!
Just sayin'!
The major Ddx's have been looked at, including Malaria, but there was little men of sleeping sickness & kissing bug disease.
Very curious on the blood results for CMV/EBV, as these infections would fit this.
Kudos to the mention of hemachormatosis. Wasn't thinking of that one.
BUT . . . thers is one possibility still left out . . . REACTION TO HER MALARIA MEDICATION!!!
Just sayin'!
2
leukopenia, transaminitis - viral. Lyme
What's unusual is how normal, or near-normal, her lab findings were over time compared to the severity of her symptoms. Despite the intriguing tropical travel history, I suspect the diagnosis is not an infection acquired in Kenya. No single diagnosis explains every finding, but my top DDx includes ehrlchiosis (bicytopenia & transminitis, but unlikely locale/season), drug-induced lupus and G6PD deficiency reaction (brought on by long-term mefloquine usage, which has an extraordinarily long half-life that could explain ongoing symptoms many weeks after stopping its use). The fact that her PCP made the diagnosis makes me lean towards one of the latter.
1
Paroxysmal Nocturnal Hemoglobinuria
1
The patient is having an intense reaction to the anti-malaria medication.
4
Adverse Reaction to the Hep. A vaccine she received before travelling. Incubation period is 2 to 7 weeks and the symptoms fit with Hepatitis A.
5
Side effects of Mefloquine including Neuropsychiatric and leukopenia
1
diabetes
Everybody ... please look at these medical notes to see how absolutely impossible it is to find the information that you need in an emergency. The physical exam is generated by a computer after clicking multiple boxes. This is designed to maximize the likelihood that the Dr will be paid by the insurer. But if you wanted to know if anything was found on exam you would never find it in the exam section since it is just a long list of what was normal. Then note how complex it is to read what the doctors are doing or thinking. EVERYTHING on those notes is written in order to satisfy billing rules rather than for the purpose of treating the patient. TIme spend on that idiocy is time not spent looking up what might be causing this person's problems.
55
Can you explain how the results of one physician's exam can show up in the record produced by another physician in the same clinic (on another day, etc.)? Especially when the second physician didn't DO an exam. Is this computer generated? And this is billing?
@ross
uh its actually really easy to read once you've gone to medical school and spent several years reading notes. what youre saying is like complaining of how mathematicians use random symbols like del and prime to denote gradient and derivative in their differential equations...
Ferritin levels are significantly increased. African Iron Overload?
2
Porphyria, congenital, triggered in adulthood by medications.
The primary care doctor diagnosed it upon taking a urine sample, and, serendipitously not having stat lab availability, left the urine specimen exposed to light, whereupon it turned purple.
And we can speculate that the patient grew up in Kenya as a Mormon missionary. Porphyria is relatively common in the Utah Mormon population.
The primary care doctor diagnosed it upon taking a urine sample, and, serendipitously not having stat lab availability, left the urine specimen exposed to light, whereupon it turned purple.
And we can speculate that the patient grew up in Kenya as a Mormon missionary. Porphyria is relatively common in the Utah Mormon population.
1
Typhoid (vaccination is only 60 to 70% effective) and symptoms are suggestive
typhoid fever- (salmonella typhi)-not 100% protective and if the oral vaccine orm a live vaccine) is not taken at least 10 days prior to travel and prior to starting meds that lessen its effectiveness (like malarone, which has proguanil in it)) than even more likelihood of vaccine failure
Pheochromocytoma
1
Porphyria.
Plasmodium Vivax
The flu.
Rift Valley Fever
Chronic hepatitis B infection
1
Sickle cell anemia- late onset perhaps caused by being a carrier instead of having the full blown condition which would have presented in childhood.
Paratyphoid fever. Difficult to culture, causes leukopenia, rash and the constipation. Also wouldn't be covered by a typhoid vaccine as well (they are known to fail anyways). Eosinophilia rules everything else out. G6PD deficiency is attractive, but been said multiple times already in the comment section.
Entamoeba histolytica
G6PD deficiency caused by antimalarial.
My guess is schistosomiasis.
1
Comment on the woman returned from Kenya with fever and vomiting. Maybe African Trypanosomiasis--sleeping sickness.
This could be an extreme adverse reaction to Malarone.
Leptospirosis
I agree with G6PD deficiency as for almost all chronic infections there is a waxing and winning course...and clues were given in write up about treatment worse than disease regular doctor knew ..all in all a very good case but I think people appearing for MCQ exams have better chance..
Lead poisoning
Liver fluke.
Glucose 6 phosphate dehydrogenase deficiency. Interacts with the red blood cell causing haemolytic anemia.
1
Let's take a look at this, shall we?
- G6PD causes lysis of red blood cells. Massive amounts of RBC lysis tends to result in jaundice and increased bilirubin. She is not jaundiced and her bilirubin is within normal limits.
- She is also covered in an itchy rash, has a waxing-waning fever, is neutropenic, has symptoms of kidney disease, anemia, and mild increased alk-phos. In the setting of a normal pancreas, this suggests bone source.
Given the history, I think dengue or chikungunya; hell, there's a chance of zika if she's been sick before.
Not all people with dengue have horrible bone pain.
- G6PD causes lysis of red blood cells. Massive amounts of RBC lysis tends to result in jaundice and increased bilirubin. She is not jaundiced and her bilirubin is within normal limits.
- She is also covered in an itchy rash, has a waxing-waning fever, is neutropenic, has symptoms of kidney disease, anemia, and mild increased alk-phos. In the setting of a normal pancreas, this suggests bone source.
Given the history, I think dengue or chikungunya; hell, there's a chance of zika if she's been sick before.
Not all people with dengue have horrible bone pain.
4
Mefloquine side effect w/ resulting subacute liver damage and thyroid disease.
5
Cryptosporidiosis.
2
Whipple disease (I sent this as email to Dr. Sanders as well this am, when the website wouldn't let me comment!!)
Antoinette Rose MD
Antoinette Rose MD
2
Relapsing fever caused by infection with Borrelia recurrentis which is carried by lice and is found in eastern Africa.
2
Ths cases are never easy... Fever in a returned traveler have to consider 3 diagnoses: 1) malaria which has been ruled out by multiple smears and she was taking prophylaxis, 2)typhoid fever which remains possible and often has a gastrointestinal presentation (.constipation more than diarrhea in adults); sometimes Salmonella can cause cholecystitis which could add to the GI picture. Would have expected more overt fevers with this. 3) Dengue can cause a febrile illness though usually more self limited. Low white cell count and hepatitis common. Rash present in half the cases and myalgias often painful which didn't seem present in this case. Other things to consider not necessarily related to travel o Kenya-- CMV which can cause a mono like illness either low white clip cell count and liver function abnormalities but again would expect more fevers. Acute HIV needs to be considered if she had unprotected sex in Kenya and the incubation period is 2-4 wks. Low WBCs common with lymphocytosis. Rash and lymph node swelling seen in more than half the cases. Would expect her to have responded to doxy if this were Rickettsial disease.
1
Hemophagocytic Lymphohistiocytosis
1
She has hemochromatosis
Hemochromatosis
She has some type of worm that multiples in warm moist dark area.
Thyrotoxicosis
2
Intestinal parasite infection.... or worms ...maybe giardia lamblia?
1
Rift Valley Fever
1
G-6-P deficiency.
Worse with fava beans in Kenya and then the anti-malaria drugs.
Worse with fava beans in Kenya and then the anti-malaria drugs.
She is pregnant. As simple as that
2
I think she has diabetes.
So when do we know the answer?
1
The answer will be posted Friday afternoon.
Honestly, isn't this just a 'textbook' case of how broken the medical system is??
15
No
7
I cannot imagine an examination which includes any suspicion of infection failing to examine the neck and other lymph nodes for swelling. If that had happened it seems the case would have been normal open and close since hyperthyroidism is not that uncommon or mysterious. Additionally, bulging eyes were not noticed. Granted the eye symptom might better be picked up by a doctor familiar with the patient's appearance. Take away is to see your own doctor if you have one.
second phase Leptospirosis
1
Schistosomiasis from Schistosoma mansoni
Sexual history...syphilis?
Anxiety and Depression
Recurrence of dormant malaria which would not be detected without repeat malaria testing.
Possibly new malaria case that was missed in initial testing. Test needs to be repeated and testing needs to look for different strains of malaria and drug resistant malaria.
Possibly new malaria case that was missed in initial testing. Test needs to be repeated and testing needs to look for different strains of malaria and drug resistant malaria.
1
I think they did multiple smears for malaria.
1
African Sleeping Sickness from the bite of a tse-tse fly
Macrophage activation syndrome secondary to malaria
Some strain of typhoid. Confirm with bone marrow aspiration.
she started taking the meds too late
1
Scrub typhus
G6PD deficiency
Leptospirosis
I'm thinking she is pregnant. Her doc would know whether she was menopausal or not. Everyone was so focused on her being in Kenya they missed the obvious first question. Was she sexually active? Could she be pregnant?
11
G6PD, so she can't handle the anti-malarial drugs
1
I meant to say, G6PD deficiency. Its common in Africa and Mediterranean countries (my husband has it), and people who have it can't take antimalarial drugs, which can cause hemolysis. I imagine that ongoing hemolysis may have damaged her liver, and just made her generally extremely weak.
2
I also agree because clues were hidden like her regular doctor knew and treatment worse than disease
1
Could be brucellosis, especially in a VFR.
2
Weil's disease
1
sickle cell anemia
Leishmaniasis
Leptospirosis
2
systemic lupus erythematosus
1
Amoebiasis
Hepatitis E
She was tested for it. Negative.
1
Hyperthyroid
1
Kala azar
Yellow fever, maybe vaccine wasn't effective
Fascioliasis
1
Amebiasis?
Intestinal parasite
Typhoid fever. She has leukopenia with abdominal pain.
Old treatment was Chloramphenicol. It is not used much in USA. Newer drugs with less chance of blood dyscrasia are used.
Old treatment was Chloramphenicol. It is not used much in USA. Newer drugs with less chance of blood dyscrasia are used.
2
Acute Q fever infection.
Bad reaction to malaria drugs
1
pregnant and CMV?
I think you got it right. Pregnant with some semi common complication.
1
dengue
Q Fever (coxiella)
2
Q fever caused by Coxiella Burnetii
or African trypanosomiasis
Metastatic (Breast) Cancer
Chagas disease
4
serotonin syndrome
2
schistosomiasis
1
Fascioliasis (Liver Fluke). Diagnose with serology or stool for ova and parasites.
Plasmodium falciparum
2
A recurrence of malaria. Her tests had produced false negatives because she had a bit of immunity from prior bouts, but not complete immunity. Perhaps she had a negative reaction to the particular anti-malarial drug she received.
1
Good suggestion -- I was wondering about this possibility. Her doctor might know if she'd had false negatives before, or if she was sensitive to some anti-malarial drugs. (Though one would hope she would know as well.)
1
Homesick
1
Everyone was thinking zebras. What about a good old-fashioned horse - mononucleosis?
3
Hemochromatosis or Hep B infection
2
Lupus
3
R/O adverse reaction to malarial prophylaxis, would also have liked to see a LP and CXR done, and would even go as far as a head scan since other labs did not yield much. Blood work indicates a possible disease of viral nature. Need to R/O viral meningitis
1
Hypersensitivity reaction to anti-malarial drugs.
1
Hopefully this was checked before all of the testing, but pregnancy and hyperemesis?
1
At 50?
1
Hemosiderosis
Bantu Siderosis
Hyperthyroidism - Grave's disease
4
The patient seems to be experiencing the adverse side effects of taking the malaria prophylaxis drugs. This would explain the fever, nausea, cardiac symptoms, and liver damage. Mefloquine is associated with the symptoms the patient is experiencing.
9
I agree. The drug is worse than the disease.
2
Dengue Fever
Not unless she had severe pain in her bones and joints. In Spanish it's called fiebre rompehuesos, bone-crushing fever, for a good reason. I caught a mild case in the Caribbean and was in agony. It felt like somebody was taking a sledgehammer to my legs.
1
Diagnosis aside, it's a terrible commentary that for want of an appointment with her regular doctor, this poor woman was subjected to weeks of misery and extra cost. And then once she could get an appointment, she was diagnosed fairly quickly. That's just tragic.
71
typhus
1
Sickle cell anemia.
Sickle Cell Anemia is a genetic disease, you're born with it, and they would have discovered it with the blood tests. People who have it, are immune to Malaria, so she wouldn't have had it as a child
9
Acute appendicitis
Acute appendicitis is by definition acute. She had this for two months. By then the appendix would have ruptured and she would have died of sepsis.
Schistosomiasis
2
Hemophagocytic lymphhistiocytosis/macrophage activation syndrome
1
Visceral leishmaniasis
Hepatitis E
I assume they ruled this out early on, but could she be pregnant and have hyperemesis gravidarum?
2
Um, she is 50 years old...
Um, still remotely possible.
3
It does not say anywhere that she is post-menopausal, but her doctor would know whether she was.
Pregnancy is possible at 50 if one has not completed menopause.
Pregnancy is possible at 50 if one has not completed menopause.
4
lassa fever
3
typhoid fever
1
Lassa Fever
2
Sounds like hemochromatosis. Her ferritin levels are CRAZY high—like twice the ceiling. Liver damaged. Fatigue. Fever. No distress in lower GI. Labs don't prove infection. So my money is on iron overload.
12
it would have been seen on the liver biopsy