SocialMedicine Posted April 16, 2013 Share Posted April 16, 2013 39 year old male present with 2 weeks of symptoms which include HA, fever (not initially but last 10 days), body aches, r arm rash (urticarial like and started today, might be unrelated he says, "sometimes I see this pop up when stressed"), nausea w/o vomitus, no appetite, initially few, diarrhea episodes (w/o blood or mucous), mild cough, mild lower abd pain (2/10). Sx not improving, maybe worse. PMHx: NONE, PSHx: NONE, MEDS: self Rx w/ Tylenol 1 gram QID for fever/pain and Amoxicillin 875 BID last 4 days from an old prescription. NKDA. VITALS: TEMP 102, HR 110, 118/78. I saw this patient in the North East of the united states end of winter. Other questions? Are labs necessary at this point? Link to comment Share on other sites More sharing options...
GingersHuman Posted April 16, 2013 Share Posted April 16, 2013 I'd definitely throw in an HIV test, as pessimistic as it sounds. General malaise, poor appetite, body aches... Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 16, 2013 Moderator Share Posted April 16, 2013 fever illness and amox - - rash - > mono tick born illness in there as well as is flu gotta do more work up, febrile, tachy, 2 weeks into an illness is concerning...... Ddx Brewing Appy Colitis - strange with fever pneumonia " - post flu tick borne illness mono (little old) Link to comment Share on other sites More sharing options...
SocialMedicine Posted April 16, 2013 Author Share Posted April 16, 2013 HIV antibody 1 and 2 test negative via ELISA CBC normal CHEM normal aside from what is listed below. Urine, influenza antigen screen negative. given the symptoms, geography, and duration away from vector season I did not test for LYME, RMSF, or ehrlichiosis, but lets assume they were negative as well (maybe I should have though, not saying you are wrong). heterophile antibody test is +. Is positive. Does the work up stop here? His physical exam is normal ...aside from the vitals. NO lymphadenopathy, no pharyngitis or exudate. What other exam or treatments do we do at this time ? Other questions to ask ? Maybe the student who had HIV concerns wants to ask more about this guys history etc. [TABLE=width: 100%] [TR] [TD=bgcolor: #4c8cbc, align: center]F[/TD] [TD=width: 30%] ALKALINE PHOSPHATASE[/TD] [TD=width: 30%]175[/TD] [TD=width: 5%] H[/TD] [TD]40-115 U/L[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc, align: center]F[/TD] [TD=width: 30%] GGT[/TD] [TD=width: 30%]197[/TD] [TD=width: 5%] H[/TD] [TD]3-95 U/L[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc, align: center]F[/TD] [TD=width: 30%] AST[/TD] [TD=width: 30%]197[/TD] [TD=width: 5%] H[/TD] [TD]10-40 U/L[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc, align: center]F[/TD] [TD=width: 30%] ALT[/TD] [TD=width: 30%]256[/TD] [TD=width: 5%] H[/TD] [TD]9-60 U/L[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc, align: center]F[/TD] [TD=width: 30%] LD[/TD] [TD=width: 30%]406[/TD] [TD=width: 5%] H[/TD] [TD]100-220 U/L[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc, align: center]F[/TD] [TD=width: 30%] IRON,TOTAL[/TD] [TD=width: 30%]30[/TD] [TD=width: 5%] L[/TD] [TD]45-170 mcg/dL[/TD] [TD]TBR [/TD] [/TR] [/TABLE] Link to comment Share on other sites More sharing options...
d2305 Posted April 17, 2013 Share Posted April 17, 2013 I wonder if the elevated LFTs are from the Tylenol? Need results on RPR also. Sounds like EBV, but that would be too simple. Did he have a social history. IVDA, MSM, ETOH, Hepatitis C? What did the abdominal US/CT reveal? Lymphoma can have a + heterophile antibody test. Link to comment Share on other sites More sharing options...
Corpsman2PA Posted April 17, 2013 Share Posted April 17, 2013 Can toxoplasmosis pop (+) on the heterophile? But, without swollen glands or hepatosplenomegaly, this is lower on the ddx. (but the elevated LFTs may accound for this). Maybe he's immunocompromised because he's stressed, and this allowed the toxoplasmoso's to seize an opportunity for infection? But the rash...hmm.. I agree with d2305...mono sounds good, but would be too easy right? Link to comment Share on other sites More sharing options...
SocialMedicine Posted April 17, 2013 Author Share Posted April 17, 2013 Patient advised likely mono due to ebv based on labs. Told to f/u in 1 week d/c Tylenol and any alcohol. No lymphadenopathy quite odd for e b v but stranger things have happened. Pt calls in 5 days saying he had a 102 fever last night and it is constant. Myalgias especially l forearm 7/10 dull ache. Malaise and no appetite. At this point I have him return a bit early. To further clarify the monospot i run serology .. The ebv igg + with igm - Very Unlikely an e b v infection w those labs at week 3 of symptoms. Follow up exam still unremarkable aside from 99.9 temp and 110 heart rate neg ivda Msm momonogamous I did not order us at this time but my guess is it would be unremarkable no ln or megaly included other labs. CBC lymphocytosis at 8000 w WBC 9, all the above ast ggt ld alt alp improve slightly. Normal chem, ua, plt, rpr toxo neg. ha hb immune and hc ab negative Toxo usually does not bring about an elevated liver alt ast. Also keep in mind those enzymes are in other tissues. Not saying it is not in this case tho Link to comment Share on other sites More sharing options...
Timon Posted April 17, 2013 Share Posted April 17, 2013 Would one consider running a Lactate, Blood Cultures x 3, and lumbar puncture? Just shooting from the hip here after we had a meeting this morning at work regarding sepsis and our new "code sepsis" protocol. Link to comment Share on other sites More sharing options...
SocialMedicine Posted April 17, 2013 Author Share Posted April 17, 2013 Keep in mind he is out patient without an elevated WBC. Hemodynamically stable. No meningeal signs. Fever of 3 weeks is serious but I did not see a reason to have him admitted or do lumbar puncture. Blood culture not unreasonable. We can start that process. No growth at 24 hours comes back tomorrow and he has similar sx stress can induce cortisol Serum levels which has some disease and infection association but I have never heard it causing fever of 3 weeks or an opportunistic infection (if this is one) Link to comment Share on other sites More sharing options...
Metallicat Posted April 17, 2013 Share Posted April 17, 2013 Did you get a CK? Rhabdo can be caused by viral illness and Hx of myalgias, tachycardia, abdominal pain etc could all be symptoms of Rhabdo. Blood in the UA/Dark colored urine would have further supported this, but still...could explain the elevated LFTs as well. Link to comment Share on other sites More sharing options...
Will352ns Posted April 17, 2013 Share Posted April 17, 2013 Any jaundice? Viral hepatitis...via EBV? Can cause a viral rash as well...though a viral rash doesn't really look like urticaria. Link to comment Share on other sites More sharing options...
d2305 Posted April 17, 2013 Share Posted April 17, 2013 I would get a CMV titer. Link to comment Share on other sites More sharing options...
SocialMedicine Posted April 17, 2013 Author Share Posted April 17, 2013 CK was normal range ...... Initially I ordered two tests not mentioned here. He was travelling in Puerto Rico and I have in the last 2 years treated two cases of Dengue Fever in NYC from travel to that region. Dengue IGM was negative (given that Sx started 2 weeks prior to that first visit I was pretty comfortable with this as a rule out in an immunocompetent patient). I also ordered HIV PCR testing. If you are concerned the symptoms are a primary HIV infection the antibody test will often we nonreactive or minimally. This patient has CMV it seems, with some interesting persistent upper ext pains. Not sure how common CMV neuritis is. For a young healthy man to have a symptomatic mononucleosis infection caused by CMV for almost a month is pretty uncommon. I like this case because it shows the importance of a physical exam. If the exam does not suggest EBV do not just accept a monospot and LFT elevation. CMV more often than not will have no diffuse adenopathy. Link to comment Share on other sites More sharing options...
d2305 Posted April 17, 2013 Share Posted April 17, 2013 I saw a hiv neg patient with CMV and another with mycobacterium avium which was fatal. Link to comment Share on other sites More sharing options...
rcdavis Posted April 17, 2013 Share Posted April 17, 2013 Sounds like good dx for CMV. I would ask: did you consider an LP? Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 17, 2013 Moderator Share Posted April 17, 2013 Mono + LFT's elevation is normal with mono duration might be a little long, but is he improving? spleen? CMV is the final Dx? or EBV? Link to comment Share on other sites More sharing options...
CAdamsPAC Posted April 17, 2013 Share Posted April 17, 2013 Patient advised likely mono due to ebv based on labs. Told to f/u in 1 week d/c Tylenol and any alcohol. No lymphadenopathy quite odd for e b v but stranger things have happened. Pt calls in 5 days saying he had a 102 fever last night and it is constant. Myalgias especially l forearm 7/10 dull ache. Malaise and no appetite. At this point I have him return a bit early. To further clarify the monospot i run serology .. The ebv igg + with igm - Very Unlikely an e b v infection w those labs at week 3 of symptoms. Follow up exam still unremarkable aside from 99.9 temp and 110 heart rate neg ivda Msm momonogamous I did not order us at this time but my guess is it would be unremarkable no ln or megaly included other labs. CBC lymphocytosis at 8000 w WBC 9, all the above ast ggt ld alt alp improve slightly. Normal chem, ua, plt, rpr toxo neg. ha hb immune and hc ab negative Toxo usually does not bring about an elevated liver alt ast. Also keep in mind those enzymes are in other tissues. Not saying it is not in this case tho What did his differential show? Monocytes in particular and eos? Link to comment Share on other sites More sharing options...
CAdamsPAC Posted April 17, 2013 Share Posted April 17, 2013 Patient advised likely mono due to ebv based on labs. Told to f/u in 1 week d/c Tylenol and any alcohol. No lymphadenopathy quite odd for e b v but stranger things have happened. Pt calls in 5 days saying he had a 102 fever last night and it is constant. Myalgias especially l forearm 7/10 dull ache. Malaise and no appetite. At this point I have him return a bit early. To further clarify the monospot i run serology .. The ebv igg + with igm - Very Unlikely an e b v infection w those labs at week 3 of symptoms. Follow up exam still unremarkable aside from 99.9 temp and 110 heart rate neg ivda Msm momonogamous I did not order us at this time but my guess is it would be unremarkable no ln or megaly included other labs. CBC lymphocytosis at 8000 w WBC 9, all the above ast ggt ld alt alp improve slightly. Normal chem, ua, plt, rpr toxo neg. ha hb immune and hc ab negative Toxo usually does not bring about an elevated liver alt ast. Also keep in mind those enzymes are in other tissues. Not saying it is not in this case tho What did his differential show? Monocytes in particular and eos? Link to comment Share on other sites More sharing options...
rcdavis Posted April 17, 2013 Share Posted April 17, 2013 Also, if fevers and sx persist, beside the lp, you might consider febrile agglutins.. Think brucellosis, etc. Link to comment Share on other sites More sharing options...
rcdavis Posted April 17, 2013 Share Posted April 17, 2013 Also, if fevers and sx persist, beside the lp, you might consider febrile agglutins.. Think brucellosis, etc. Link to comment Share on other sites More sharing options...
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