Question

A 27-year old white female presented her self at her local physician on August 15. On physical exam, the patient had a fever of 38.5C. She appeared fatigued, had tender abdomen and complained of headache, stiff neck and backache with diarrhea. The physician noted an irregular heartbeat. The patient complained of lack of ability to concentrate. The patient gave the following history: She is a graduate student in the wildlife program at the University in her town. She was in the field for three weeks in Wisconsin during the months of May and June. She tracks small mammals in the field and studies their behavior. It had been a warm, wet spring and she complained of a large number of flies in the area. She felt sick the last day there after eating some canned food, as there was no cooler there. You had no time for culturing, as you need to take action fast. 1. What type of disease she could have based on the symptoms and why? You are not required to name a specific disease but a general type of disease. Naming a disease means you have answered the question wrong. 2. What features are not critical to your diagnosis from the case & why? 3. What further steps should be taken to precisely identify the case & why? What microbes you will not consider and why [name 4]. 4. What steps would you take to ensure that the patient is stable till diagnosis is confirmed; explain why would you do this?

Answer 1

1. She could probably have a disease caused by fly in the are that she had been to, may be tick-borne infections. The reason for doubting it to such an infection is based on the symptoms that she described. Except for diarrhoea and abdominal bloating/irritation which could have been due to her eating habit over the past few days, the rest of symptoms more likely sounds similar to those of long- untreated tick-borne disease.

2. Features that may not serve very critical are in personal details her age and with the history, her eating canned food. Generally diseased conditions caused due to canned foods, including food poisoning or because of her lifestyle that includes exposure to irritable bowel syndrome, may all last for 10 days to a month. However, in this case the history dates back to an event occurred 2-3 months prior. Thus, food and related issues can be put slightly on hold. Other important nervous and muscular issues may be given more weightage owing to their coming together being result of fly/tick-infected diseases.

3. Since the patient is fair, paleness and hypopigmentation may not be easily understood. Having heard these discomforts she is facing, the physician should primarily check for peculiar marks/rashes on her body, especially at regions that were exposed on days of her trip. The patient should be enquired of having experienced mood changes, any loss of hearing or ear-ringing. It is likely for the physician to check if the girl is immunocompromised. It will be better to have ER test done and a Western blot conducted, which in this case could be better than ELISA.

Microbes that will not be considered are:

1. Salmonella enterica, infection of which may have similar symptoms but lasts only for maximum of three weeks.

2. Clostridium botulinum, since there is hardly any chance of food poisoning and if at all, would not have lasted this long.

3. Tickborne encephalitis virus, a Flavivirus will not be considered as this is common to Europe and Asia and has not been reported in Wisconsin.

4. Ricketssia helvetica will also not be screened for the same reason that it is more localized to Brazil.

5. Administering doxycycline will be a good option to have the patient stable till diagnosis is completed. Because for all the symptoms that she is facing and with the doubtful causative agent/(s), doxycycline works as a broad range antibiotic. Mild breathing exercises can be suggested for respiratory check and reduction of palpitation/randomness in heartbeat.