Thread by @RosenelliEM

The @CPSolvers #VirtualMorningReport is great to watch and the chat is loaded with #ClinicalPearls. And I know we have already forgotten some of them already. Who is ready for a recap! from 4/7 on A Fever, diarrhea, & Rash in a returning traveler @jackpenner @rabihmgeha @DxRxEdu

Some of these pearls are random & evolved during the case discussion.

Problem representation: 20ish yo male with no pmh who is presenting with a 4 day hx of watery diarrhea and high fevers. On exam, he has an erythematous rash and no tachycardia. Enjoy

clinicalproblemsolving.com/morning-report…

- Chronicity of fever is helpful (i.e., acute suggests infection and subacute/chronic includes anything)

-Conjunctival suffusion: leptospirosis

-Cancer in yo males: ALL, testicular CA, lymphoma

-Vitals are important! If you have a fever and bradycardia, think Faget sign: This is seen in all intracellular organisms. Legionella, Coxiella, malaria, babesia, leptospirosis, typhoid etc. litfl.com/faget-sign/

Pulse Temp Dissociation:

https://twitter.com/txid_edu/status/1229131794676514817?s=21

-The fever pattern with malaria: Remember that with RBCs lysis every day that you will get an asynchronous release of parasites and near-daily fevers
-Diarrhea is an uncommon presentation of malaria
-Osmotic diarrhea usually resolves with fasting

-Diarrhea and cytopenias think salmonella as it likes to go to the bone marrow

-A great resource to know about diseases more assoc with a specific country wwwnc.cdc.gov/travel/yellowb…

-Epidemiology affects pretest probability

-Legionella may present w/ pneumonia plus other sxms

So far doesn't seem to fit a typical dengue picture as there are no myalgias, arthralgias, no headache, or fatigue. Diarrhea isn't a common symptom; usually, severe dengue w/ GI symptoms are abdominal pain and repeated vomiting

-Zika is very rarely associated with a high fever

-Chikungunya is unlikely as there are no MSK symptoms, which typically are the most important.

-AST>ALT think hemolysis vs muscle
-In acute hepatitis the LFTs would be in the 1000s

-Trichinella, Influeza, Legionella can cause CK elevation “baby rhabdo”

-When a bicytopenia is present, think about CMV & Rickettsia

-Gram negative sepsis -> can get leukopenia

@rabihmgeha just said

1. “Japanese encephalitis” , ncbi.nlm.nih.gov/books/NBK47042…

2. "Kikuchi-Fujimoto disease"
ncbi.nlm.nih.gov/pubmed/22856412

3. Orientia tsutsugamushi, ncbi.nlm.nih.gov/pmc/articles/P…

-Salmonella can be associated with rhabdo but rare, tick-borne infection can also be associated with rhabdo.

-Organisms that go to the bone marrow: brucellosis ,salmonella, histo, blasto, TB, CMV, EBV, and Parvo

-Hepatitis A as a cause of pancytopnia

Trust your pretest probabilities. Dengue is high for fever in returning traveler.

-Top 3 for returning traveler: malaria, salmonella, mosquito (chik, dengue, zika)

Tourniquet test - using bp cuff can cause purpura, can be indicative of dengue.

Framework for returning traveler- ABCDEE

-Adventure (where)
-Body (syndrome)
-Chronology (time)
-Defense (prophy/vaccines)
-Exposure (milk, hunting)
-Eosinophilia

We always think about dengue hemorrhagic fever, which is less common, and more likely in people who have had dengue before. Don't forget about the milder presentations.

See the case overview and teaching points. clinicalproblemsolving.com/wp-content/upl…