AN ELDERLY WOMAN WITH A FEVER Case Presentatoin Dr M Haghighi.
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Transcript of AN ELDERLY WOMAN WITH A FEVER Case Presentatoin Dr M Haghighi.
AN ELDERLY WOMAN WITH A FEVER
Case Presentatoin
Dr M Haghighi
A
woman in her seventies presented to the
emergency department because of a
febrile illness of one week's duration. She
reported daily fevers up to 104°F
(40°C), rigors and sweats.
S
he also reported a dry cough, without
shortness of breath, sinus congestion,
headache, abdominal pain, nausea,
vomiting, diarrhea, dysuria or urinary
frequency.
PAST MEDICAL HISTORY
S
he had hypertension and left bundle branch
block, a previous history of invasive melanoma
(status post excision in four years before) and,
many years before, Lyme disease. She had
never had a blood transfusion.
MEDICATIONS
S
he took verapamil daily.
ALLERGIES
S
he had no allergies.
SOCIAL HISTORY
S
he was retired, and had previously
worked in an office.
EPIDEMIOLOGICAL HISTORY
S
he lived in Tehran. She had traveled extensively,
including to Africa, Europe and South America. Her
most recent international trips were eight months
earlier to South Africa where she visited Kruger
National Park and participated in game drives and
walking safaris and one year earlier to Kenya.
S
he did not take anti-malarial
prophylaxis. She did not report any
recent sick contacts or insect bites.
PHYSICAL EXAMINATION
T
he patient appeared diaphoretic, but was not in
any acute distress. The temperature was 104.7°F
(40.4°C ), blood pressure 122/69 mm Hg, pulse
68 beats per minute, respirations 18 breaths per
minute and oxygen saturation by pulse oximetry
94% while breathing room air.
T
here were fine crackles in the bases of
both lungs, and the examination was
otherwise normal.
STUDIES
T
he level of hemoglobin was 12.0g/dl, white
blood count 4,400 cells per cubic millimeter
(61% neutrophils, 32% lymphocytes, and 6%
monocytes) and platelet count 52,000 per cubic
millimeter (reference range 150,000-450,000).
T
he level of aspartate aminotransferase was 193
U/L (reference range 8-37 U/L) and alanine
aminotransferase was 157 U/L (reference
range 8-35 U/L). Results of other routine
laboratory tests and urinalysis were normal.
A
chest radiograph revealed small
bilateral pleural effusions
C
ultures of the blood and urine were
sterile.
T
hick and thin peripheral blood smears are
shown, The intraerythrocytic parasites
were thought to represent Plasmodium
falciparum with 1.11% parasitemia.
PERIPHERAL SMEAR, WRIGHT-GIEMSA STAIN
PERIPHERAL SMEAR, WRIGHT-GIEMSA STAIN
PERIPHERAL SMEAR, WRIGHT-GIEMSA STAIN, X1250 MAGNIFICATION
A
tovaquone and proguanil hydrochloride
(in combination, 4 tabs orally, daily)
were administered.
O
n the evening of the first day, fevers persisted and
the level of parasitemia was 0.83%.
O
n the second day, the maximum temperature was
104.2°F (40.1°C). The platelet count was 62,000 per
cubic millimeter and the level of parasitemia 0.74%.
M
alaria PCR was negative.
WHAT IS THE DIAGNOSIS?
T
hick and thin peripheral blood smears revealed intraerythrocytic ring
forms including multiple vacuolated forms (Figures 2 through 4). No
schizonts or gametocytes were visualized. Because of the persistent
fevers, the peripheral smears were reviewed and additional testing
performed.
M
alaria PCR was negative. Babesia PCR was positive for Babesia microti ;
Babesia microti IgG and IgM were elevated at greater than 1:1024
(reference range less than 1:64) and greater than 1:320 (reference range
less than 1:20), respectively.
FINAL DIAGNOSIS
B
abesiosis caused by Babesia
microti.