AUTHOR : MD EBADULLAH , DAVAO DOCTORS' HOSPITAL , DAVAO CITY , PHILIPPINES
Davao Doctors’ Hospital
Case Presentation of a 20 year old female with complaints of Headache and Fever
In partial fulfillment for the requirement in the Department of Internal Medicine
Submitted by :
MD EBADULLAH
General data:
Patient S.A. is a 20 years old female having a birthdate of 10/27/1996 is a Student by occupation from Banga, South cotabato is a Filippino came in with a chief complaint of Headache and Fever .
Informant : Self and aunt with a good reliability
History of Present Illness :
24 days Prior to admission (PTA) patient went with her family to place one hour away from their place Surallah, South Cotabato for swimming in freely flowing river.in the interim , no signs or symptoms noted .
21 days PTA ,Patient experienced a sudden onset of Intermittent Fever ( Tmax : 39 degree celsius ).No consultation done ,self medicated with Paracetamol 500mg /tab. Associated signs and symptoms includes vomiting two episodes moderate in amount non bloody no bilious ,non projectile along with Loose bowel movement 4 x day x loose brown stools x 1 cup in amount along with crampy epigastric pain ( pain scale grade 5/10 ),no aggravating or relieving factor noted.in the Interim signs and symptoms persisted and were well tolerated by the patient.
17 days PTA Admitted in a Local Govt. Hospital due to crampy Epigastric pain with a pain scale grade of 5/10 , managed as a case of UTI , AGE and was treated with Ciprofloxacin 500/tab xBIDx7days.Patients signs and symptoms improved and was discharged from the hospital 15 days prior to admission.
14 days PTA , Patient complained of frontal headache persistent in thumping in nature ( pain scale grade 10 /10 ) with no other aggravating or relieving fact. Associated signs and symptoms include Vomiting post prandial x 2 cups /day x projectile along with intermittent fever. In the interim, signs and symptoms worsened in severity and
6 days PTA , consultation done to a private physician at a private hospital . Work up done . Managed as a case of Typhoid Fever . 3 unrecalled meds taken for three days. 3days PTA, Patient started to have Visual auditory hallucination ( not suicidal , irritable and with intermittent fever and vomiting 4 x day ,projectile ,non bilous no bloody .Patient was taken to and admitted at a local Private Hospital.
2 days PTA, patient noted to have one episodes of Epistaxis. Managed as a case of Typhoid Fever with neuro-psychotic SLE.no improvement of signs and symptoms noted.12 hours PTA ,Persistence of Same S/Sx mentioned above Referred to our institution for further consultation . Hence admission.
Past medical History :
2016 : diagnosed with Appendicitis even though surgery was not done and was not a part of the treatment .
Family History :
Paternal Side : (+) hypertension
(+) diabetes mellitus
Personal and Social History :
Education : College level pursuing Education
Good interpersonal relation with family and friends
No hx of taking alcohol, smoking or any substance abuse as claimed by the watcher .
REVIEW OF SYSTEMS
General : (+) Anorexia (-) Weight Loss (+) Fever
HEENT : (+)Photophobia , No dysphagia or odynophagia. (+) neck stiffness.
Gastro-intestinal (-) Diarrhea ,(+) Vomiting
Pulmonary : No Dyspnea, (-) Cough.
Cardiac : No Palpitations, No Chest pain, No Orthopnea.
Vascular : No Phlebitis, No Varicosities.
Genito-Urinary : (-) No Dysuria, (-) No Flank Pain, No Discharges, No Urgency.
Neurologic : No Memory Loss, No Seizures, No loss of consciousness
Musculoskeletal : (+) Joint Pains, No Cramps.
Psychiatric : (+) Behavioral change as claimed by the watcher
Physical Examination :
PHYSICAL EXAMINATION:
General examination :Patient is examined awake, febrile, Irritable not in respiratory distress.
SHEENT :
S :Warm skin [+] jaundice ,good skin texture and turgor .no signs of dehydration
H : Normocephalic Atraumatic skull ,[-] scars ,diffuse black hair distribution
E : Pink palpebral conjunctivae, [-]discharges [+] icterus
E : ear grossly normal, anatomically symmetric
N : [-] discharges, septum midline , normal nasal turbinates
T : [-]erythematous tonsils, [-] exudates
NECK : midline trachea, [-] bilateral CLAD , ( -) neck vein engorgement
CHEST:
I : not in respiratory distress. No retractions, scars, masses.
P : equal chest expansion. Tactile fremitus equal on both lung fields
P : resonant all over
A : clear breath sounds, no adventitious sounds heard.
CARDIAC :
I : Adynamic Precordium
P : [-] heaves [-] thrills
A : s1 s2 heard distinctly, no murmurs appreciated, normal cardiac rate and rhythm
ABDOMEN :
I : no scars no bulging noted
A : normoactive bowel sounds
P : non tender on light and deep palpation [-]kidney punch sign bilaterally, [-] murphys sign, [-] fluid thrill. [+] palpable Hepatosplenomegaly , [-] mass
P : tympanic to percussion in all quadrants
MUSCULOSKELETAL
Grossly normal limbs
(+) tenderness on all joints
Good range of motion in all extrimites: 5/5
sensory fuction : 100% in all four limbs
(+) calf muscle tenderness
[-] edema of hands and feet
Full pulses
CRT = 2sec
NEURO EXAM
Orientation :
Patient is oriented to time and person ,not with place
CRANIAL NERVES
I – Smell intact
II – Visual Acquity intact
III, IV, IV – Patient shows adequate extraocular movements equally and bilaterally
V - Equal Sensation to the face, masseter and buccinator muscle tone are adequate.
VII - Patient does not exhibit facial asymmetry, all facial expressions intact
VIII - Patient is able to hear equally on both sides , ataxia : not assessed
IX, X - Patient is able to swallow, shows adequate gag reflex, uvula is midline.
XI : can shrug her shoulder against resistance
XII : tongue movement intact
(+)Brudzenski sign
(-) Kernig’s sign
Admitting Impresssion :
Leptospiral meningitis vs Cerebral Malaria
Salient Features :
20 years old /female
hx of swimming in a freely flowing river
VA hallucination ( not suicidal ),
irritability ,
intermittent fiver
vomiting 4 x day projectile
Anorexia
Fever
Photophobia
Neck stiffness
Calf Muscle tenderness
Joint Pain
Behavioral Changes
Jaundice
joint pain
palpable hepatosplenomegaly
Course in the Ward :
Discussion on Leptospirosis and complications :
1 million cases occur per year worldwide with a mean case – fatality rate of nearly10%. (source : Harrison’s principles of internal medicine,19 th Edition )
Prevalence : a total of 337 cases of the disease across the Philippines from January 1 to March 25, 2017, including 30 fatalities.
(source : Data from the Public Health Division of Epidemiology Surveillance Bureau of the Department of Health (DOH) )
India : detected 232 cases of leptospirosis in the five years of study period (9 in 2004, 17 in 2005, 25 in 2006, 74 in 2007, and 107 in 2008)
(source : Increasing Trends of Leptospirosis in Northern India: A Clinico-Epidemiological Study Sunil Sethi,1,* Navneet Sharma,2 Nandita Kakkar,3 Juhi Taneja,1 Shiv Sekhar Chatterjee,1 Surinder Singh Banga,1 andMeera Sharma )
Source : [Possibilities for laboratory diagnosis of leptospiroses].
[Article in Czech] Perželová J, Jareková J, Kotrbancová M, Špaleková M
Leptospiroses are worldwide spread zoonoses caused by hydrophilic bacteria of the genus Leptospira.
Humans can be infected by contact with an infected animal or indirectly via staying in a contaminated environment (water, wet soil), in natural foci, while working outdoors, or while doing outdoor sport and leisure activities.
Leptospirosis may manifest as a mild flu-like illness or in a severe febrile form (meningitis, pulmonary haemorrhage, hepato-renal syndrome, or myocarditis).
Survival Rate:
Median series mortality was 2.2% (Range 0.0-39.7%),
mortality is high in jaundiced patients (19.1%) (Range 0.0-39.7%),
those with renal failure 12.1% (Range 0-25.0%)
and in patients aged over 60 (60%) (Range 33.3-60%),
but low in anicteric patients (0%) (Range 0-1.7%).
( Source : A Systematic Review of the Mortality from Untreated Leptospirosis. Taylor AJ1, Paris DH2, Newton PN1)
Host & the Etiologic Agent :
a corkscrew-shaped bacterium called Leptospira interrogans, is often referred to as “rat fever” due to the principal role rats play in spreading the disease (scientists refer this type of animal as a reservoir host).
(Source : Leptospirosis cases up 68 percent in the Philippines in 2017 by ROBERT HERRIMAN )
L. biflexa , L. santarosai ,L. borgpeterseni , L. licerisiae are other species of leptosires (source : Harrison’s principles of internal medicine,19 th Edition )
Pathogenesis:
Source : WHO South-East Asia Regional Office Leptospirosis Fact Sheet
Diagnosis:
Hx & P.E.
Elevated CRP and ESR
Thrombocytopenia ( </ 100 x 10^9 /L) associated with bleeding and renal failure
Aseptic meningitis : C.S.F. pleocytosis with polymorphonuclear cells (>1000 cells/micro liter)
Definitive diagnosis :PCR or MAT
( source : Harrison’s principles of internal medicine,19 th Edition )
THE END