The Gorgas Courses in Clinical Tropical Medicine

Selected Cases Seen by 2009 Course Participants

History:  31 yo male admitted with a 3-day history of fever, chills, diffuse myalgia, progressive dyspnea and jaundice.  There is no present history of rash, retro-ocular pain, cervical or lumbar pain.  15 days earlier a 1-day febrile episode, which included self-limited watery diarrhea, had occurred.  A non-pruritic macular rash that lasted 1 day had occurred within a few hours of receiving an injection of an unknown medication during this initial episode.

Epidemiology:  Born and lives in Lima, but travels every 3-6 months to Pucallpa in the high jungle to cut wood.  Recent visits were 5 and 2 months earlier, and then for 2 days immediately prior to the episode of diarrhea described above.  No history of routine vaccines or against yellow fever, or hepatitis B.  No history of malaria or TB.  In the jungle there is frequent exposure to rivers and ponds and non-potable water is consumed.  Heavy rains had occurred just prior to his illness.

Physical Examination:  T 37.8°C, pulse 79, respiration 30, BP 120/80.  Marked jaundice as well as scleral icterus [Image A].  Rales were present in both lungs; greater on the right side.  No lymphadenopathy or hepatosplenomegaly.

Laboratory Examination:  Hb 12.5 g/dl; WBC 15,400 with 78% neutrophils, 10% lymphs, 4% bands; 16,000 platelets; INR: 1.26; creatinine 4.4 mg/dl (N=<1.0); urea: 117 mg/dl (N=<20); total proteins 6.7 g/dl (normal), albumin 3.7 g/dl (normal); potassium (2.9 mEq/l).  Total bilirubin: 7.7 mg/dl, 5.8 mg/dl direct.  ALT 71 IU/l (N=< 40); alk phosphatase 123 mg/dl (normal), LDH 694.  O2 saturation 98% with FiO2 0.25.  Chest x-ray: progressive appearance of diffuse alveolar and interstitial infiltrates, more pronounced on the right [Images B, C].  Brucella and Salmonella agglutination tests were negative.  Negative malaria smear.  Hepatitis B core IgM was negative.

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