Hot Seat #85: 13yo returning traveler with fever and abdominal pain
Posted on: November 27, 2016, by : Caleb Ward MD
Caleb Ward MB BChir, Children’s National Medical Center
with Sabrina Guse MD, Children’s National Medical Center
The Case
A 13 year old, previously healthy male presents to your ER in the summer of 2016 with fever, headaches and myalgia. He has 4 days of fever with a Tmax of 104.9. Fevers are worse in the evenings. He has had associated temporal headaches, joint and muscle pains.
He has recently returned from a 2 year stay with relatives in Nigeria. During his time in Nigeria, he had malaria twice (family are unsure which type), with the most recent episode 6 weeks prior and treated with Coartem (Artemether-lumefantrine) for 3 days. His Mother re-started Coartem 2 days prior to this ER visit, but it does not seem to be helping.
He has no known sick contacts. He has additional recent travel to Miami, Florida.
ROS:
Positive: loose, non bloody stools, non-bloody emesis x 1, mild diffuse abdominal pain
Negative: easy bleeding or bruising, jaundice, change in urine color, sore throat
PE:
Temp 40.3, HR 130, RR 18, BP 110/68mmHg, SpO2 100% on RA
Tired, appears uncomfortable
Supple neck, no lymphadenopathy, no meningismus
PERRL, no jaundice
TMs clear, no pharyngeal erythema
Tachycardia, no murmur, cap refill < 1s
Lungs clear to auscultation without adventitial sounds
Soft, non distended abdomen, mild RUQ tenderness, liver edge at 2cm
Alert, no focal neurological deficits
No rash
You ask the nurse to place an IV, obtain initial labs and administer a 20cc/kg NS bolus.
Question:
His initial labs show the following:
WBC 5.8 (58% PMNs, 13% monocytes, 28% lymphocytes, 1% eosinophils), Hgb 10.4 (MCV 75), Plt 85
Na+ 134, K+ 4.0, CO2 26, Cr 0.9, AST 40, ALT 60, Alb 2.5
Blood, urine and stool cultures are pending. A chest radiograph did not show any infiltrate. His ultrasound abdomen shows: an edematous thickened gallbladder wall with layered biliary sludge and mild hepatomegaly and splenomegaly.
Another Question:
The Binax test is positive for P. falciparum. His malaria thin prep shows a 0.3% parasite burden. You elect to admit him to the hospital.
More Questions:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
Interesting case regarding how to best approach fever in a returning traveler. Any returning traveler with a fever must be approached differently than a routine patient with fever, while acknowledging that the patient may have a more “routine” infection that should not be overlooked either. I would ask further questions on hx. How recently did he return from Nigeria? Did the fever start 4 days ago or has he had intermittent fevers prior to this? Questions must be specific to address timing of possible exposure and timing of presentation. Also, did he take malaria chemoprophylaxis while in Nigeria? Which, if any, vaccinations did he receive prior to going to Nigeria? Is he otherwise up to date on the rest of his immunizations?
Given the patient’s recent travel and presentation, he warrants a thorough work-up, as well as management of fever and tachycardia. My next step after obtaining a thorough hx and assessing the patient, is to use the cdc.gov travel website to quickly check the illnesses present in a specific country. The WHO website is another helpful resource. I would send CBC w/ diff, Binax if available and thick/thin smears, hepatic function panel, BMP, blood cx (typhoid), cxr and UA. Keep in mind that malaria smears can be negative initially if a non-immune individual is symptomatic at very low parasitemia. Smears should be repeated q12-24hrs x3 sets if clinical suspicion remains high.
Regarding treatment of malaria, I would again rely on resources available via the CDC or WHO since treatment does vary by country and resistance patterns. Treatment guidelines are posted on the CDC website. There is also a CDC malaria hotline, with clinicians available to help guide treatment, if needed. And of course, our ID colleagues can help too.