another scenario/presentation
 

background:
Your team is deployed to Algeria. You are running a field hospital for the local population. The following case presents itself.

• 14 yr old BM
• vitals wnl except temp of 100.5 F
• pt appears much smaller physically than the typical villager for his age
• reported malaise
• history of prior episodes similar to current
• cc of deep pain in his legs which has been prevalent since early childhood
• pt has several small ulcerations on his shins from insect bites

Visual exam reveals the following:

What are you thinking? Any questions you want to ask? Any treatments?

Hepatitis

Dengue/"Bonebreak" fever maybe

Leishmanisis

Re: another scenario/presentation
 

What does "prior episodes" mean in this case? guessing the malaise and the fever. Ulcerations not neccesarily related to this episode. The eyes look really yellow. Malaria?

Any Calabar Swellings???

Eagle

Could the yellow eyes be from liver damage due to Leishmanisis?

Then it would be cutaneous AND visceral form of the disease.

Very good guesses that are possible with the limited info given so far...

Yes, it appears he is jaundice. It can be difficult to see in the skin tone on darkly colored patients. His eyes are indeed "yellow" in appearance and are often the easiest way to pick up on it in dark colored patients.


There are no parasitic calabar swellings present. His leg ulcers appear to be from regular insect bites, but they display poor wound healing signs with secondary infection.

I may need to reemphasize that this pt's painful episodes have been "periodically" present since very early childhood up until this time.

I will throw a bone as it is difficult to Dx with these generic conditions. I wondered if anyone wanted to ask any "history" questions.
I will start...

"Has anyone in his family or living close to him had similar symptoms?"

Answer: "Yes, he had an older brother that had yellow eyes too, was very sick from early childhood. He also had severe episodes of pain in his arms and legs just like this brother. He used to have pain episodes every time he would strenuously exert himself physically. Finally, He got sick and passed away as a young teenager. "

More questions now?

Can anyone rule out the "likelihood" for any of the already given diagnosis guesses?

Is there any more information from a head to toe assessment particularly abdominal?

Or becuase this info wasnt included in the original presentation am I to assume that was also WNL?

Thanks

ccrn












Edit for clarity

I like to give minimal info, then make the Doc ask questions or request certain exams
 

Yes... there is more info available from this patient if you ask or tell me you want a specific test performed. Of course, illnesses don't read the book so not all results are "diagnostic" for the true etiology.

Since you asked, part of your head-to-toe exam did reveal Splenomegaly upon palpation.

Terminal Stages of Sickle Cell Anemia !!

? malaria

wound is an old healed bite
splenomegaly can occur
jaundice is common
malaise, muscle aches possible

high death rate if untreated.

just a guess. certainly not my specialty.

we do have a patient with ascaris on the service now....talk about disgusting...my PA pulled a worm out of the intubated patients MOUTH!

not to hijack my own thread... BUT PICS!!! PICS!!! We want pics Ma'am. LOL

back to thread....

Interesting info, thanks!

Hope you don't mind this little side post.

note:
Wound of insect bite/secondaryinfection is a recent complication. The patient has had severe pain episodes in the legs, hips, and even occasionally abdomen for his entire life since infancy without ever having insect wound infections before.

Pt has had "yellow eyes" since he was about 6 months old according to his mom.

I'm leaning towards malaria also.

Is it possible to do slides(stains) in this environment to r/o?

ccrn

Good Job
 

Well, my thread has taken an interesting and important twist that I had not intended.

The correct answer was sickle cell anemia(congrats A.M.) with an acute sickle cell crisis(pain) beginning to occur.

• Genetic condition commonly affecting African race
• anemia/jaundice/spleen and liver damage
• Small stature/failure to thrive due to constant low RBC
• poor wound healing
• #1 cause of early death in untreated SC juveniles is secondary bacterial infection
• present since birth, not an acute illness

Malaria can have most of these signs too. Coincidently, having the sickle cell trait actually gives partial immunity to malaria which is the reason Darwin's laws haven't removed sickle cell from the population over the centuries.

If we encounter this dilemna in the field, how can one attempt to differentiate the two illnesses from one another?

Then we can cover what pallative treatments should be given to someone experienccing a sickle cell crisis.

Re: Good Job
 

Interesting dilemma.

First a brief lab diversion: you could examine the blood under a microscope to look for the malaria parasites (though they may not be present in large concentrations, so you could not rule out malaria that way). Microscope is also used in some countries to do Peripheral Blood Film to screen for sickling. With a better lab, you could perform electrophoresis or HPLC on the hemoglobin to confirm sickling. DNA testing might also be done, though much less likely in a field lab.

Are there any adverse effects of treating the sickle-cell anemia patient with anti-malarial drugs?

I should have seen that.....


I would imagine that differentiation would be within the means of 18D if trained and equiped in the field, and certainly a basic clinic staffed by an MD, by slide (sickle cell erythrocyte vs stains for parasites in bloodcells).

Palliative measures could include but not be limited to:

*Bedrest w/minimul exercise to promote circulation(avoid DVT).
*Hydration either PO or Parental.
*Analgesia to include local adjuncts if possible.
*Strict I/O.
*Monitor lytes especialy Na.
*Keep pt warm, cold is contra-indicated to avoid vaso-occlusion.
*Also monitor for shock(acute sequestration crisis=probably how sibling died), infection, CVA.
*prophylactic ABX tx if possible (broad spectrum?).
*Support parents/family if time available
*Education of village/family

(Edited for clarity)

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