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.