Tuesday, 23 January 2007

Fever, Diarrhoea and Muscle Pain

This Case Has Been Anonymised to Safe Guard Patient Confidentiality

A 50 year old male patient who is a taxi driver who is normally fit and well who presented with a short 6 day history of:

1) Fever
2) Diarrhoea
3) Muscle pain
4) Dry cough

The fever was the initial symptom and was continuous rather than intermittent. The was no associated rigors (shivering) or sweats. The diarrhoea was non-painful, a dark colour but no visible blood or malaena (tarry stool).

The patient had been having diarrhoea once per day.

On the day prior to admission, he also had vomiting once although this became mixed with the diarrhoea so he was unable to describe the look of the vomitus.

The muscle pain was described more of a dyscomfort and was generalised. There was no associated joint pain or swelling and no skin rash. The cough was intermittent and dry. No sputum and no haemoptysis. No dyspnoea.

On further questioning, the patient had eaten sushi / sashimi one week ago ( one day before becoming unwell) but he could not remember what type of raw seafood as he had also been drinking alcohol on that day. He denied eating raw chicken or oysters. Being a taxi driver he usually bought an o-bento lunch box from the local convenience store and this was usually sushi.

He had no history of inflammatory bowel disease and no eye symptoms. He had never had any joint disease.

Previous medical history included 1) hypertension 2) renal glomerulosclerosis since a child and he took Olmesartan, Amlodipine and Allopurinol.

He otherwise drank alcohol occasionally and was an ex-smoker having at one time smoked 30 cigarettes per day.

On examination, he looked relatively well. Temp was 39 degrees C. No Cervical lymph nodes and no evidence of clubbing or splinter haemorrhages. Eyes showed conjunctival injection and mouth appeared appeared slightly red and the soft palate had white vesicular lesions that could not be scraped off. The tongue was coated and appeared to be candida albicans infection.

Blood pressure was 106/5o, pulse 72 bpm regular, JVP was not raised. There were no heaves or thrills and heart sounds 1 & 2 were present and there were no mumurs evident. Leg examination was normal with no oedema or DVT identified.

Respiratory rate was regular at 18/minute, normal percussion sounds and vesicular breath sounds. There was no wheeze or crepitations.

Abdominal examination revealed a soft, non-tender abdomen, with no evidence of hepatosplenomegally. There was no renal angle tenderness and bowel sounds were slightly increased. Rectal examination by the junior doctor revealed occult blood but there was no evidence of a mass and the examination was non-tender.

Skin was grossly normal.

Clinical Impression / differential diagnosis

Infective Diarrhoea

Bacterial diarrhoea e.g. Salmonella, E. coli, Shigella, Campylobacter, Yersinia enterocolitica, vibrio vulnificans, Clostridium difficile

Viral diarrhoea e.g. adenovirus (sore throat, red eyes, fever, diarrhoea-usually non-bloody)


Inflammatory Bowel Disease e.g. Ulcerative colitis or Crohn's disease (bloody diarrhoea / fever / eye signs)

Systemic Lupus Erythematosis (more a cause of abdominal pain than diarrhoea)
Polyarteritis nodosum

The Laboratory data revealed Hb 15.4 g/dl, low white cell count of 2.9, low platelets of 4.0, high fibrinogen level and normal INR/APTT. BUN was 26 and Creat 2.3 (normally 1.2), normal Na/K. Liver function was normal. CK normal. CRP was 9.

Blood smear showed no fragmented red cells. Stool examination revealed numerous white cells in the stool.

One concern was of a Haemolytic Uraemic Syndrome (HUS), but the history had been going on too long for this problem and the patient was well. Moreover, this clinical syndrome is predominantly seem in children. Another concern was DIC, but the blood smear was normal and the fibrinogen level was HIGH not low and one might see a MicroAngiopathic Haemoltic Anaemia (MAHA), raised INR and a low Haemoglobin is severe circumstances.

Another consideration was of Thrombotic Thrombocytopaenic Purpura (TTP) which is an adult problem associated with E. coli 0157:H7 infection just as is HUS, but there was no report of clumped platelets and the patient had no neuropsychiatric symtoms and no evidence of bleeding or haemolytic anaemia. TTP can also be found as a consequence of drug reactions particularly with Ticlopidine (which is used in Japan) where patients develop antibodies against the ADAMTS 13 protease that usually cleaves vonWillebrand Factor deactivating this enzyme. Familial cases of TTP show no activity of the above protease enzyme.

If this patient had an underlying immunodeficiency, for example AIDS, then other more innocuous infections could be a cause of bloody diarrhoea, fever, exudative sore throat and general systemic upset including: varicella zoster virus / Herpes Simplex Virus / Cytomegallovirus all of which can cause ulceration to the GI tract. Other immune deficient associated infections include the protozoal infections such as cryptosporidium, isospora belii although these do not cause a bloody diarrhoea.

In fact, the low white cells and platelets were likely related to a consumption from sepsis with the target of the sepsis being the bowel, which would explain the numerous white cells seen in the stool.

The patient was treated with intravenous antibiotics to cover the gram negative organisms and was rehydrated. By the next morning, the patient felt alot better and the diarrhoea and vomiting had stopped.

The patient had a colonoscopy to try and rule out inflammatory bowel disease.

The above example, however, shows you that fever, diarrhoea, cough, and myalgia do have a wide spectrum of possible diagnoses.

In view of his food history, which element is often left out of the medical history, it seems more than likely that he picked up a bacterial infection from contaminated food one week ago. In view of the relative bradycardia compared to his high temperature (which should have caused a higher pulse rate) and the dry cough and the invasive nature of this probable infection, this makes me consider invasive salmonella such as salmonella typhi or paratyphi as the cause of an Enteric Fever.

What is your opinion?? Please let me know.....

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