1/Break out your schemas! Let’s talk about a case tweetorial-style courtesy of @dminter89 . Thanks @tonybreu, @MedEdPGH , @BCM_InternalMed and @medrants and many others for the inspiration. :)
2/ A 30 yo man presented with 1 week of fevers, chills, & headache after travel to South America. Take a mental pause and think through your DDx.
Here is one approach to fever in a returning traveler
clinicalproblemsolving.com/%20dx-schema-f…
Here is one approach to fever in a returning traveler
clinicalproblemsolving.com/%20dx-schema-f…
3/ He spent one week in Peru, Ecuador, and Colombia. He spent time both in the mountains as well as the Amazon jungle. His fever started 2 weeks after returning home. Now = 3 weeks after return
4/ Based on the incubation period, which of the following infections is less likely?
5/ VS: T 38.6, P110, BP 110/78, 100% RA. Exam: Scleral icterus, palmar crease pallor, and hepatomegaly. Otherwise unremarkable. Wbc 5, Hgb 5.8, plt 150, T bili 4.5, d bili 0.3, LDH elevated, retic count elevated
6/ The patient is suspected of having a hemolytic anemia.
Pause and think about how you'd think through that.
Here is one approach -
clinicalproblemsolving.com/dx-schema-hemo…
Pause and think about how you'd think through that.
Here is one approach -
clinicalproblemsolving.com/dx-schema-hemo…
7/ What is the next test to help you identify the cause?
8/ Blood smear photo - Giemsa stain with intracellular organisms (from review article linked below) 
9/ What is your most likely diagnosis?
10/ The answer is Bartonellosis! Bartonella bacilliformis is an intracellular gram negative bacteria endemic to the Andes mountain range of Peru, Ecuador, and Colombia. It is transmitted by bites from the Lutzomyia verrucarum fly.
11/ It causes two main forms of disease: (1) an acute febrile illness with hemolytic anemia called “Oroya fever” and (2) a later appearing phase with hemangioma-like cutaneous eruptions called “verruga peruana” (aka peruvian warts).
12/ In Oroya fever, hemolytic anemia results when bacteria invade RBCs. Diagnosis is typically made by visualization of intraerythrocytic bacteria on a thin blood smear or by blood culture.
14/ Bartonellosis, also called “Carrion’s Disease” after the Peruvian medical student Daniel Carrion.
15/ He attempted to establish a link between the two manifestations of the disease, Oroya fever and verruga peruana, by inoculating himself with blood from a verruga lesion, after which he, unfortunately, died from overwhelming infection in 1885. @AdamRodmanMD
