BACKGROUND
A 25-year-old fourth-year Filipino medical student presents to a California walk-in clinic with an intermittent fever, chills, and cough lasting almost 5 days. He has had progressively worsening muscle aches. Over the last 48 hours, he has noticed increasing difficulty in taking a deep breath. Because the patient has had no prior medical illnesses and only occasional colds, he did not seek medical care earlier.
For the first 2 days of this illness, the patient had a mild runny nose, a sore throat, and some diarrhea, all of which were self-limited. Since his illness began, he has had an on-and-off headache, in addition to increasing weakness and anorexia. On systemic review, the findings are otherwise essentially negative, including the absence of a rash, headache, abdominal pain, vomiting, and back pain. The patient smokes less than a pack of cigarettes per day but does not have chronic bronchitis. He denies using alcohol, illicit drugs, and prescription medications.
The patient is finishing an 8-week hospital-based rotation in Southeast Asia in which he was an acting intern. He wanted to study internal medicine and critical care medicine in the region because he aspires to work in international health. During his rotation, he was in Manila for 4 weeks and then Singapore for 2 weeks. A week and a half ago, he returned to the United States to finish his final 2 weeks at the hospital associated with his California medical school.
The patient reports that, during his elective, several nursing staff had been sick with respiratory symptoms "at the same time" and that the morale was poor among those who were relatively well. On further questioning, the patient states that he had direct contact with several patients in the ICU and emergency department. Additionally, he recalled escorting several septic patients to the radiology department for their imaging studies.
The patient is 5 ft 9 in tall and weighs 155 lb (70.3 kg). He appears apprehensive and acutely ill, with a cough but no sputum. His vital signs are as follows: temperature, 101.3°F (38.5°C) on admission to the emergency department; blood pressure, 110 mm Hg systolic, 65 mm Hg diastolic; heart rate, 108 beats per minute; and respiratory rate, 18 breaths per minute with no retractions. The patient's mental status is normal with a nonfocal neurologic examination; he has no meningismus. The patient's mucous membranes are dry, and he has a few petechiae on his upper palate and no pharyngeal exudates. The patient has diffuse bilateral rhonchi with few bibasilar rales. Slight splinting is observed on both sides when the patient is asked to take a deep breath. No murmur or gallop is noted. The patient has no edema or rash in the extremities. Examination findings of the abdominal, genitourinary, and musculoskeletal areas are negative.
CBC findings are as follows: WBC count, 2.5 X 109/L (no left shift); lymphocyte count (LYC), 0.8 X 109/L; hemoglobin (Hgb), 11 mg/dL; hematocrit (Hct), 33%; and platelet count, 89,000 per cubic milliliter. Chemistry findings are as follows: sodium, 131 mg/dL; BUN, 35 mg/dL; creatinine (Cr), 1.6 mg/dL; aspartate aminotransferase (AST), 73 mg/dL; alanine aminotransferase (ALT), 65 mg/dL; lactate dehydrogenase (LDH), 397 mg/dL; and O2 saturation, 89%. ABG measurements are pH, 7.32; pCO2, 31 mm Hg; and pO2, 56 mm Hg.
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Hint
This is an acute, febrile, progressively worsening respiratory illness. Epidemiologic clues include the patient^s recent international travel and exposure to a hospital health care worker.
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Author:
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Asim A. Jani, MD, MPH, FACP
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Faculty, University of South Florida College of Medicine and Public Health; Staff Member, Department of Epidemiology, Virginia Department of Health
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