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Emerging Infectious Diseases

A 33-year-old woman presents to the emergency department (ED) with 8 days of subjective fever, headache, sore throat, and malaise. She states that acetaminophen and ibuprofen have failed to help her symptoms. She recently returned from a 2-year volunteer trip with the Peace Corps in West Africa. She endorses taking her mefloquine weekly. Vitals signs are blood pressure (BP) 115/75 mm Hg, heart rate (HR) 110 beats/minute, respiratory rate (RR) 18 breaths/minute, temperature 101.2°F, and pulse oximetry 98% on room air. She has bilateral conjunctival injection as well as a truncal maculopapular rash.

Which of the following tests is most likely to be abnormal in this patient?

a. Chest x-ray (CXR)

b. Computed tomography (CT) scan of the chest for pulmonary embolism (PE)

c. Complete blood count (CBC), liver function tests (LFTs), and prothrombin time (PT)

d. Peripheral blood smears

e. Purified protein derivative (PPD) skin test

The answer is c. This patient is presenting with signs and symptoms concerning for infection with EVD. EVD symptoms are initially nonspecific and include fever, arthralgia, conjunctivitis, vomiting, and diarrhea. She should be evaluated for abnormal CBC, LFTs, and coagulation profile. Early in the disease course, laboratory testing will show leukopenia, lymphocytopenia, mild thrombocytopenia (50,000-100,000 platelets), and transaminitis [aspartate transaminase (AST) > alanine transaminase (ALT) and in the 1000 IU/L range]. Later in the disease course, there will be leukocytosis with a left shift on the differential (increased neutrophil count) and signs of disseminated intravascular coagulation (DIC) [prolonged PT/PTT (partial thromboplastin time) and elevated fibrin degradation products].

CXR (a) would be nonspecific and indicated in patients in which tuberculosis (TB) would be suspected. Travel history alone increases the risk for PE (b); however, other signs and symptoms of Epstein-Barr virus (EBV) infection make this less likely. While patients returning from Malaria endemic areas are susceptible, the lack of cyclical fever, presence of rash, and adherence to prophylaxis makes this less likely. In the absence of prophylaxis, peripheral blood smears (d) would be useful. Thick smears allow for detection of the intracellular parasites while thin smears allow for speciation. The patient’s presentation is not consistent with TB infection and therefore a PPD skin test (e) is not indicated.

A 33-year-old woman presents to the emergency department (ED) with 8 days of subjective fever, headache, sore throat, and malaise. She states that acetaminophen and ibuprofen have failed to help her symptoms. She recently returned from a 2-year volunteer trip with the Peace Corps in West Africa. She endorses taking her mefloquine weekly. Vitals signs are blood pressure (BP) 115/75 mm Hg, heart rate (HR) 110 ...

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