The Gorgas Courses in Clinical Tropical Medicine

Selected Cases Seen by 2009 Course Participants

History:  22 yo male admitted with a 24-day history of  fever up to 40°C, particularly at night, headache and insomnia.  Urinalysis and WBC on day 4 of illness were normal and antipyretics were prescribed by a physician.  Illness persisted and on day 12 blood cultures were taken and he was started on ciprofloxacin.  After 3 more days of no improvement the patient switched himself to a low dose of chloramphenicol on the advice of his father, a non-physician.  The fever persisted and the patient was brought to the ER after the onset of 3 episodes of significant hematochezia.

Epidemiology:  Lifelong resident of Lima; engineering student at nearby university.  Frequent ingestion of food from street vendors, including ceviche, salads, and drinks with ice.  No history of travel.  No past medical history.  No sick contacts.

Physical Examination:  T 38.5°C, heart rate 106, respirations 19, BP 116/60.  Non-icteric.  Chest clear.  No murmurs or rubs.  Abdomen non-tender with a palpable spleen tip.  No rash, no lymphadenopathy.

Laboratory Examination:  Hematocrit 44%, dropping to 31% over 24 hours; WBC 8350 (57% neutrophils, 35% lymphs, no bands); ESR 72 mm/h; 184K platelets (normal); INR: 1.17.  ALT 224 IU/L (N <40); AST 127 IU/L (N <40); normal glucose, creatinine and electrolytes.  Chest x-ray normal.  Abdominal ultrasound showed only splenomegaly.  A colonoscopy disclosed multiple ulcers lesions [Images A & B] in the terminal ileum and right-ascending and transverse colon.  Blood was present but no bleeding point could be identified.  A biopsy was taken.

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