Some day back, a person was talking about a friend of his who entered into Nigeria from Niger republic. I was interested in this case but was not chanced because I had a lot to do and I asked what the problem was. He mentioned that the person was infected on his way into the country and was rushed to the hospital where doctors had to start doing different lab works and test to verify what the problem of the person was because the person could not talk anymore. This is an example of a case that I will be bringing today and I hope we both learn from this case study.
A 33 year-old man arrived at the hospital and was only able to speak Spanish but through his interpreter, it reported that he had no headaches, chest pain, back pain, changes in vision, rash, dysuria, weight loss, and he had been vomiting, feeling nausea, fever, abdominal pain and coughing of blood for about 2 days before coming to the hospital. At the hospital, his cough had changed to the color of coffee and when he was asked about his smoking attitude, he mentioned that he smoked 1 pack of cigarette everyday for the past 15 years although he had recently quit but he still consumed alcohol a lot. That is a whole lot or what do you think?
Upon physical examination, he had an elevated heart rate of 116 beats/min and his temperature was 38.7 degrees Celsius. He had mild respiratory distress with his lungs clear to auscultation. Tenderness to palpation were moderate at the upper abdomen and there were no enlargement of organs like the spleen and the liver. To check if the blood was as a result of an hemorrhage, examination was done and it was seen that there was no hemorrhage of the oropharynx or the nose.
After physical examination was carried out, a chest radiograph was done and it revealed multi-focal patchy opacities in his lungs. As you would expect, he would not be kept in the hospital without prior administration of medications to help mitigate or fight whatever is a possible cause and so Broad Spectrum Antibiotics including Piperacillin-tazobactam and vancomycin intravenously were administered. The antibiotics were appropriate as it was a possible infectious condition such as Pneumonia, or Aspiration Pneumonitis.
Lab work was done, and result returned with low sodium and low potassium level, White blood cells were normal but neutrophils were increased, low platelet count, and he was mildly anemic. The thromboplastin time was elevated a little, with red blood cell detected but no white cells. Liver test were abnormal with elevated aspertate aminotransferase, elevated bilirubin levels, and elevated alanine aminotransferase.
Along with the antibiotics, the patient was given intravenous fluid along with proton pump inhibitor. The test results showed possible pneumonia or aspiration pneumonitis which can occur as a result of inhaling liquid, food, saliva, or other liquid or gastric content into the lungs. The result also showed possible vasculitis which is the damaging of the vessels leading to inflamation of the blood vessel. The thromboplastin time time test showed possible coagulation problem, while the liver test can show a possible liver damage from alcohol consumption or the liver responding to infection.
To identify the bleeding origin, a bronchoscopy is required. Results showed bloody secretion on the posterior segment of the right upper lobe, and the right and left lower lobes of the lungs. The fluids were collected for testing and this is a possible alveoli hemorrhage and doxycycline was added to the drug being administered. So the alveoli was the source of the bleeding as a result of diffused alveoli hemorrhage which can occur as a result of infectious disease, autoimmune disease and acute respiratory disorder.
After 12 hours of being admitted to the hospital, his blood pressure decreased and he experienced increased shortness of breath, and short, interrupted sounds were heard in his lungs (crackles in his lungs), he became jaundiced, he became hypoxemic and required oxygen through intubation, and went into renal failure thereby requiring a dialysis. Further test were carried out to check for autoimmune disease and they came back negative. So with the current update, there seemed to be a problem but there was no diagnosis.
With no diagnosis, further questioning was done and his family member gave answers. The questions surrounded his origin, travel history and so on. The patient lived in central Mexico but traveled into the United States by swimming across the Rio Grande river, and hiking through the wilderness and he just arrived at Massachusetts about 4 days before he was brought into the emergency room. This information showed that the patient could have been exposed to infections such as Hantavirus and Leptosporosis which could cause possible pulmonary hemorrhage and kidney failure also he could have been suffering from a vectorborne disease and these were not checked for while performing test.
Serologic test to confirm Leptosporosis was positive with IgM antibodies to leptospira species. The disease is common in tropical regions and can be transferred from animals such as livestock although rodents are major reservoirs and they can transfer the disease to humans through contact with their urine or feces in water or soil. So there is a possibility that he might have encountered leptospira when swimming across in the fresh water if it was contaminated.
The patient was then treated with penicillin and doxycycline for 2 weeks as doxycycline is used in cases of mild disease where penicillin is used in cases of severe disease. Other treatment were given to the patient to help with recovery from symptoms that could have arose from the disease and the patient was released after 6 weeks in the hospital.
Post Reference
https://www.lung.org/lung-health-diseases/lung-disease-lookup
https://www.nejm.org/doi/full/10.1056/NEJM200103013440908
https://www.mountsinai.org/health-library/tests/aspartate-aminotransferase
https://www.nejm.org/doi/full/10.1056/NEJMcps2020668
https://www.nhs.uk/conditions/pneumonia/
https://www.niehs.nih.gov/health/topics/conditions/autoimmune
https://www.ncbi.nlm.nih.gov/books/NBK554560/
https://www.msdmanuals.com/home/infections/antibiotics/penicillins
https://www.ncbi.nlm.nih.gov/books/NBK441858/
https://www.nhs.uk/conditions/leptospirosis/
https://pmc.ncbi.nlm.nih.gov/articles/PMC4442676/
Image Reference
Image 1 || Rawpixel || Emergency responders from the 374th Medical Group
Image 2 || Pexels || A Patient in intensive care
Image 3 || Wikipedia Commons || Conjunctival suffusion of the eyes due to leptospirosis
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