Here is a really great case supplied to me from a distant hospital in Japan. It is anonymised as usual to safeguard patient confidentiality.
A 63 year old female was admitted with a four-day history of
- Generalised arthralgia and mylagia
Fever: The fever was initially high up to 40 degrees C and fluctuated over several days. At the onset of the fever there was one episode of a chilly feeling but no overt rigors.
Headache: This was occipital in origin but not severe. In was dull in nature and the patient did not complain of neck stiffness or photophobia. There was no nausea, vomiting or overt rash.
Arthralgia: This affected the larger joints such as the elbows, knees and shoulders. There was no complaint of joint swelling or redness. The arthralgia symptoms worsened during the rising fever. The myalgia was described as generalised and mild.
On further questioning, the patient denied eating raw or under cooked food, she drank bottled water. There was also weight loss of 4 kilos during the period of travelling abroad.
Importantly, the patient admitted to receiving a mosquito bite on her right ankle at dusk within the hotel which she stayed. The bite predated the onset of her symptoms.
There was no confusion, vomiting, diarrhoea, abdominal pain, cough, chest pain, dyspnoea, rash, and no UTI symptoms.
The patient also admitted to retro-orbital pain at the onset of the illness (pain behind the eyes).
No malaria prohphylaxis was taken.
Previous Medical History included
- Sick Sinus Syndrome (permanent pacemaker inserted)
- Colonic carcinoma 5 years ago (cured)
- Lansoprazole 30mg O.D.
- Ferrous sulphate 200mg T.D.S
- Digoxin 125mcg O.D.
- Allopurinol 100mg O.D.
Father- gastric cancer
Mother - stroke disease
Never smoked, Alcohol 1 beer per week.
Otherwise fit and independent.
No Sexual History was Taken.
On admission the patient looked slightly unwell. GCS 15/15; fully alert and conversant.
General: mild petechial type rash on the left anterior abdominal wall. No JACCOL.
HEENT: - nothing particular of note. No conjuctival pallor or jaundice.
CVS: Pulse 70 regular, BP 110/61mHg, JVP not raised, no heaves or thrills. Heart sounds 1 & 2 present. No added sounds or murmurs.
RESP: RR 12 / min, SpO2 94% breathing ambient room air. Percussion resonant, Auscaultation normal vesicular breath sounds.
ABDO: Soft, flat, non-tender, no hepatomegaly, mild splenomegaly. Normal bowel sounds. No bruits.
MUSC-SKEL- Normal range of movement of the joints. Non-tender, no swelling or erythema. Slight muscle pain.
Abbreviated Neuro Exam- No neck stiffness, Brudzinski and Kernig Signs negative. Normal movement of the upper and lower limbs. Gross power intact. Babinski sign negative.
Pupils equal and reactive to light. Normal extra-ocular movements. Otherwise intact cranial nerve. Fundoscopy revealed no bleeding and no papilloedema.
Total White Cell Count 1.4 x 10-9/L (decreased); neutrophils 25%.
Hb 13.4 g/dl
MCV 89.1 fl
Platelets 129 x 10-9/L (decreased)
Creatinine Kinase (CK) 816 IU/L (elevated)
AST 82 IU/L (elevated)
ALT 41 IU/L
LDH 331 IU/L (elevated)
ALP 151 IU/L
gamma GT 13 IU/L
Bilirubin (total) 1.0 mg/dl
Amylase 94 IU/L
1) Bearing in mind the history, physical examination, and basic laboratory data, please make a problem list.
2) Taking into account the geographic location please list the possible differential diagnoses that could result in the above features.
3) What tests need to be done?
4) What is the likeliest diagnosis in this patient?
5) What is the treatment?
I would like all the readers to have a go at answering this question. Please post your answers on this blog and I will publish those answers that are submitted with the actual answer in the near future. GOOD LUCK !!!!
Have a great weekend..... :-)