DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Fever.
2. Drenching sweats.
3. Possible typhoid.
4. Travel-related illness.
5. Abnormal antistreptolysin-O titers.
6. Dry bronchitic cough.
7. Right axillary induration.
DISCHARGE MEDICATIONS:
1. Rocephin 2 grams IV push q. 24 h. x7 more days or total of 10.
2. Vibramycin 100 mg p.o. b.i.d. x7 days or total of 10.
PROCEDURES: None.
CONSULTANTS: None.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old normally healthy Hispanic male who had gone to Central America. He had flown in from Central America, and at that time, his mother noted that he was probably more tired and had less appetite. They came home on Saturday. He thought he was developing allergy symptoms and vague headache. By Sunday, he began developing drenching sweats, chills, and a temperature of 103 as well as lower back pain. His father started him on antibiotics at this time. On Monday, he was unable to go to work, was constipated, followed by some stools. He continued to have drenching night sweats, and by Tuesday, his father brought him to the emergency room where his white count was 6000, hemoglobin 15.4, and platelets normal. There was mild abnormality of the ALT. Monospot was negative. Malaria smear was negative. Chest x-ray was negative. He was admitted. Blood cultures were obtained. He ate nowhere except at the resort, except for one night. He did no snorkeling. He went into the rainforest. He ate no shellfish, just salmon and marlin.
PAST MEDICAL HISTORY: Right ACL repair and closed reduction, left arm, both 10 years ago.
ALLERGIES: NONE KNOWN.
HABITS: Tobacco: Denied. Alcohol: Occasionally on weekends. Street Drugs: Denied. Transfusions: Denied.
SOCIAL HISTORY: The patient is single and employed. His parents are in good health. He has an older brother.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Otherwise negative, except for some past diarrhea but is basically healthy.
PHYSICAL EXAMINATION: GENERAL: It is confirmed that he has significant sweats and drenches his clothes. VITAL SIGNS: He is 5 feet 7 inches, was not weighed. Temperature is 97.8, pulse 88, respirations 20, and blood pressure 146/88. HEENT: There is no scleral injection. Pupils are equal. Oropharynx is benign. There are areas of a few shotty nodes, particularly on the right. NECK: Perfectly supple. LUNGS: He was observed to be having a dry, hacking, nonproductive cough that improved as he was hospitalized. CARDIAC: Regular rhythm. No murmurs. ABDOMEN: Soft. No organomegaly. LYMPHATICS: He has some shotty nodes. EXTREMITIES: No calf pain. No rash. NEUROLOGIC: Grossly intact. MUSCULOSKELETAL: He has right axillary area induration without actual appreciable masses or nodes.
HOSPITAL COURSE: The patient was asked to give a stool sample, which took several days to accomplish. He was started on Rocephin to cover the possibility of typhoid fever as the symptoms of dry cough, constipation, high fever, normal white count, and a travel history were considered compatible. An ASO titer proved positive at 488, though certainly this does not fit with the cough symptom or the other symptoms.
An ultrasound was done to evaluate liver and spleen size, which were normal. An ultrasound was done to look in the axilla for nodes and no nodes were found. The patient denied any exposure to pets or animals. Because there was a question of adenopathy, lymphadenopathy workup was done. The toxoplasma titers are nondiagnostic and HIV was negative. A mono screen was negative. Herpes simplex PCR in the blood was negative. Lyme serology was negative. CMV IgG was negative. His CMV IgM was negative. Epstein-Barr virus shows an IgG of 7540, compatible with previous mono, with negative IgM. Malaria smears were negative. In addition to this, the patient also had Ehrlichia PCR and Bartonella PCR performed as well as pasteurella serology and tularemia serology.
The patient, by 48 hours, was 80% to 85% better. The sweating seemed to have resolved. His appetite was starting to return. It was elected to send him home and empirically treat him as if he has typhoid. He did note that when he gave stool, it was mucusy and it was our impression that the patient did respond to empiric Rocephin and Vibramycin. It was elected to continue this for another four weeks awaiting labs and cultures. He was told to return in two weeks to follow up. He did have also a normal chest x-ray.
