Case Report:
A 58-year-old woman presented with a continuous fever that persisted for 16 days. The patient stated that 16 days prior, she was in good health. Then she had a moderate grade fever of 103°F that wasn’t accompanied by chills or rigor. She also reported experiencing 2 weeks of progressively worsening epigastric discomfort accompanied by a feeling of abdominal fullness. There was no history of rashes, chest pain, coughing, loose stools, nausea/vomiting. Additionally, the patient also stated that she had no prior history of thyroid disease, pulmonary TB, diabetes mellitus, or hypertension. She said that she does not smoke, although she does consume 200 ml of alcohol twice daily. The most recent intake was about two weeks ago.
On examination, the patient was presented as conscious, pale, icterus, had a low grade fever of 100.5oC along with bilateral pitting edema, oral ulcer, and abdominal tenderness in epigastric region. Vital checkup of patient presented hypotension (BP = 80/60 mmHg), Tachycardia (PR= 116 beats per minute), Respiratory rate of 20 beats per minute, low level SPO2 i.e. 89% in room atmosphere.
Considering the recent dengue outbreak in Nepal, 2022 and based on the patient’s presenting symptoms, test for dengue (NS1 and IgG/IgM), andSalmonella typhi IgG/IgM was requested along with hematological and biochemical parameters. Furthermore, urine culture and routine examination as well as blood culture was also requested. Blood tests revealed Dengue Anti- IgM positivity along with thrombocytopenia, both of which are consistent with dengue infection. Moreover, bilirubin and liver enzymes were increased with subsequent hypoalbuminemia. The results of the S. typhi IgM test were positive, indicating possible concurrent Salmonella typhi and dengue infection. Hydration therapy with crystalloid fluid was initiated instantaneously. Additionally, 100mg hydrocortisone was also injected immediately. The patient received three doses of a 1000mg paracetamol tablet each day and two daily injections of the ceftriaxone, 1000mg. Domperidone 10 mg & Ondansetron 4 mg were given to the patient to treat the nausea and vomiting that accompanied the indigestion. Tables 1 and 2 documents the serological testing and subsequent hematological as well as biochemical profile respectively following patient hospitalization.
Three to four days following hospitalization, the blood parameters were initially checked. With the exception of normal platelets and a total WBC count, the aberrant blood values were concerning. Urine and blood cultures test requested during admission came out negative despite routine examination reported increase in pus and epithelial cells. No clinical improvements were noticed. Consequently, the follow-up tests for Dengue IgG/IgM and S. typhi IgG/IgM as well as several tests for tropical fever panel (Scrub typhus IgG/IgM, LeptospiraIgG/IgM, tests for Brucella Ab, K-39 total Ab test for Leishmaniosis, and smear for malarial parasite) were required. Acute infection of Scrub typhus with IgM positivity was reported despite having no physical signs of eschar as seen in patients with scrub typhus infection. Additionally, positive IgG Ab for Leptospira , Dengue and S. typhi was also recorded. Leishmanial (K-39) Ab came back negative, but the test for Brucella Ab agglutination came back positive implying exposure of the patient to the bacteria but did not establish acute or previous infection. For the treatment, 100mg Doxycycline was immediately initiated. Follow up I serological testing and subsequent hematological as well as biochemical profile is documented in Table 1 and 2.
Regular follow-up and no adjustments to the prescription were made. Subsequent follow-up showed no improvement in the liver enzyme levels − ALP value of >1600 U/L; bilirubin levels had dropped from the first follow-up but had remained clinically higher. Low hemoglobin level, low hematocrit %, low RBC indices, lymphocytosis, neutropenia, increase in bilirubin, and liver enzymes were seen throughout the follow- up course. Platelets level fluctuated during the course but eventually returned to normal. Patient was discharged when she was hemo-dynamically stable and symptomatically better. All the follow-up laboratory investigations performed until discharge was represented in Table 2.
The patient was informed upon discharge of any potential warning indications. It was advised to stay hydrated and to use insect repellant and/or mosquito nets. The patient was given a full explanation of how to take the prescribed prescriptions on a regular basis.