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SAEM Clinical Image Series: Fever and Aches

Posted by Brianna Miner, MD on

A 62 year old female with no past medical history presented to the ED with fevers, generalized weakness, severe muscle aches, and a rash. She had returned home from the Philippines 3 days prior to evaluation. Twenty-four hours prior to arrival, the patient noticed a rash on her shins. She denied any nausea, vomiting, diarrhea, abdominal pain, chest pain, shortness of breath, cough, sore throat, dysuria, urinary frequency, headache, and neck pain. The patient was in the Philippines for a family funeral and was indoors for most of the trip. She was unsure if she was stung by any bugs or mosquitos.

Additional Images

Physical Exam

General: Well-appearing

Skin: Petechial rash on bilateral shins

HEENT: Petechiae on hard and soft palate

Abdominal: Mild splenomegaly

Labs

CBC: WBC 3.1 x 10^9/L; Hgb 13.1 g/dL; Hct 38.5%; MCV 86.7; PLT- 14 x 10^9/L (Neutrophils 49%; Lymphocytes 31%; Monocytes 18%; Eosinophils 0%)

Morphology Smear: Unremarkable

BMP:

  • Na 134 mmol/L
  • K 3.1 mmol/L
  • Cl 97 mmol/L
  • CO2 26 mmol/L
  • BUN 15 mg/dL
  • Cr 0.65 mg/dL
  • Ca 8.3 mmol/L
  • Glucose 109 mg/dL

LFT:

  • AST 117 U/L
  • ALT 82 U/L
  • ALK 100 U/L
  • Bili 0.7 U/L

Case Question: What is the significant finding in both photos?

A petechial rash on bilateral shins and on the hard and soft palate.

Her laboratory values are remarkable for leukopenia and thrombocytopenia as well as transaminitis.

Case Question: What is the diagnosis?

With her travel history, fevers, body aches, thrombocytopenia, and leukopenia, the patient’s presentation is most consistent with dengue fever.

Case Discussion

Take Home Points

  • Dengue fever can be difficult to identify as its presentation overlaps with several other infectious diseases including typhoid fever, West Nile virus, malaria, and leptospirosis.
  • Dengue fever is identified clinically by the presence of fever and 2 or more of the following in a febrile person who traveled to or lives in a dengue-endemic area:
    • Headache
    • Retro-orbital or ocular pain
    • Myalgia and/or bone pain
    • Arthralgia
    • Rash
    • Hemorrhagic manifestations (including petechiae)
    • Leukopenia
  • The diagnosis can be confirmed with serologies or nucleic acid amplification tests.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

Author information

Brianna Miner, MD

Resident
Advocate Christ Medical Center

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The post SAEM Clinical Image Series: Fever and Aches appeared first on ALiEM.

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