Case Discussion #5

De Los Reyes, Maalim, Mandal, Sandoval

Case:
A 28 year old man presented to the emergency room with a 3 day
history of chills, headache, nausea and myalgias.
History
General Data: M.V., 28 year old, male, Filipino, single, currently residing in Sta
Cruz, Manila City, consulted for the first time in MCU-FDTMF Hospital on Jan. 22,
20201 at 2pm.

Chief complaint: Chills

History of Present Illness:

Four days prior to admission, patient had onset of intermittent fever Tmax
39.2C associated with generalized body pains more pronounced in both arms and
legs, dull in character, with a scale of 3-4/10, spontaneously relieved by rest,
aggravated by doing physical activities such as walking. No other associated
manifestations noted. No consult was done.
 Three days prior to consult, he still has intermittent high grade fever
associated with chills, frontal headache which is pressing in character,
non-radiating, with a pain scale of 5/10 accompanied by nausea, temporarily
relieved by Paracetamol intake. No vomiting, nor abdominal pain noted. Redness of
both eyes without eye discharge, non-itchy, painless was also noted. No other
associated manifestations.
One day prior to admission, febrile episodes persisted along with headache and
generalized body pains with no change in character and severity which prompted
consult.
Past Medical History: Unremarkable.

Family History: Unremarkable.

Personal and Social History:

Patient is a pedicab driver, No current sick contacts. No history of eating
uncooked foods, and animal bites. Patient waded in flood 2 weeks ago. Occasional
alcohol beverage drinker, Non smoker. Drinking water source from boiled tap
water.
GENERAL (-) sudden weight loss
HEENT (-) sore throat (-) dysphagia
RESPIRATORY (-) difficulty of breathing (-) cough and colds
CARDIOVASCULAR (-) chest pain (-) chest discomfort
GASTROINTESTINAL (-) abdominal distension/ pain (-) melena/ hematochezia
(-) abnormal movements
GENITOURINARY (-) hematuria (-) dysuria
MUSCULOSKELETAL (-) joint swelling/ pain
NEUROLOGY (-) weakness (-) convulsion
HEMATOLOGY (-) bleeding episodes (-) easy bruising
Physical Examination:
General: At the ER, he was conscious, coherent, ambulatory, in quiet regular breathing

Vital signs:
BP – 120/90 mmHg
CR = 95 bpm
RR = 18
T= 39⁰C

Physical Exam:
● (+) Anicteric Sclera
● (+) conjunctival suffusion, no jaundice or rashes
● Hyperactive bowel sounds, no tenderness.
SKIN: No skin discoloration. Skin is generally warm to touch, dry and with good turgor.
No lesions noted.
HEENT: Size of head proportionate to body size, no palpable mass, no tenderness. He
has anicteric sclerae, pinkish palpebral conjunctivae, non sunken eyeballs, no nasoaural
discharge. No palpable cervical lymphadenopathies, non hyperemic, non swollen tonsils,
dry lips.
Lungs: Symmetric chest expansion, in quiet regular breathing, no palpable mass, good air
entry, vesicular breath sounds.
Heart: Adynamic precordium, no heaves, no thrill, regular cardiac rhythm, no murmur
Abdomen: Flat, no visible lesions, normoactive bowel sounds, tympanitic, liver span is
7cm, soft, non tender, and had palpable liver edge 5cm below right subcostal margin
midclavicular line.
Extremities: No gross deformities, no tenderness, no limitation of movement, full pulses,
CRT <2 seconds
Neurologic:
V - (+) corneal blink reflex
Cerebral: conscious, coherent, obeys commands
VII – no facial asymmetry upon
Cerebellar: intact; no dysdiadochokinesia grimacing
Cranial Nerves VII – able to hear
I - can read letters without difficulty IX, X –(+) gag reflex
II - pupils equally round, reactive to light XI – no lagging of shoulders
III, IV, VI - no notable deviation of eyes, intact XII- no tongue deviation
extraocular movements
(-) nuchal rigidity, (-) Brudzinski sign,
(-) Kernig’s sign
Differentials Rule In-Features Rule Out-Features

Dengue Fever
● 4-day Intermittent high grade-fever ● No facial flushing
with warning
sign ● Generalized dull body pains more ● No macular rash
pronounced in both upper and lower during the 1st 2 days
extremities of fever and last day
● Frontal headache of fever
● Nausea ● No vomiting
● Chills
● Conjunctival injection/hyperemia
 Rule In-Features Rule Out-Features

Enteric Fever
● Age: more common in children and ● Myalgia most
young adults prominent to
● Onset Abrupt extremities
● Fever ● No abdominal pain
● Headache (moderate to severe) ● No vomiting
● Nausea ● No diarrhea
● Risk factor: Eating street foods
 Rule In-Features Rule Out-Features

Mild
● Age: more common in children and
Leptospirosis
young adults
● Onset abrupt
● Intermittent high-grade fever
● Myalgia most prominent to
extremities
● Headache (moderate to severe)
● Jaundice
● anicteric sclera
● Nausea
● Conjunctivitis
● Chills
Etiology:
● Leptospirosis is caused by spiral bacteria
that belong to the genus Leptospira.
● These spirochetes are finely coiled, thin,
motile, obligate,slow-growing aerobes
● Nevertheless, any leptospira serovar can
lead to the signs and symptoms seen with
this disease.
Epidemiology:
●In 2019, around one thousand reported
leptospirosis cases were located in the National
Capital Region (NCR) of the Philippines.
Leptospirosis cases were lowest in the
Bangsamoro Autonomous Region of Mindanao
(BARMM), which only had eight cases.
Transmission:
The bacteria that cause leptospirosis are spread through the urine of infected animals, which
can get into water or soil and can survive there for weeks to months. Many different kinds of
wild and domestic animals carry the bacterium. These can include,but are not limited to:
Humans can be infected through:
● Contact with urine (or other body fluids, except saliva) from infected animals.
● Contact with water, soil, or food contaminated with the urine of infected animals.
● The bacteria can enter the body through skin or mucous membranes (eyes, nose,
or mouth), especially if the skin is broken from a cut or scratch.
● Drinking contaminated water can also cause infection. Outbreaks of leptospirosis
are usually caused by exposure to contaminated water, such as floodwaters.
● Person to person transmission is rare.
 Clinical Manifestation:
● The time between a person’s exposure to a contaminated source and becoming sick is 2

days to 4 weeks. Illness usually begins abruptly with fever and other symptoms.
Leptospirosis may occur in two phases:
● After the first phase (with fever, chills, headache, muscle aches, vomiting, or
diarrhea) the patient may recover for a time but become ill again.
● If a second phase occurs, it is more severe; the person may have kidney or liver

failure or meningitis. The illness lasts from a few days to 3 weeks or longer. Without
treatment, recovery may take several months.
Anicteric Leptospirosis:
● A smaller proportion of infections, but the overwhelming majority of the recognized

cases, present with a febrile illness of sudden onset. Other symptoms include chills,
headache, myalgia, abdominal pain, conjunctival suffusion, and less often a skin rash If
present, the rash is often transient, lasting less than 24 h.
● This anicteric syndrome usually lasts for about a week, and its resolution coincides with

the appearance of antibodies.

● The fever may be biphasic and may recur after a remission of 3 to 4 days. The headache

is often severe, resembling that occurring in dengue, with retro-orbital pain and
photophobia. Myalgia affecting the lower back, thighs, and calves is often intense
Icteric Leptospirosis:
● Icteric leptospirosis is a much more severe disease in which the clinical course is

often very rapidly progressive.

● Between 5 and 10% of all patients with leptospirosis have the icteric form of the

disease.
● The jaundice occurring in leptospirosis is not associated with hepatocellular necrosis,

and liver function returns to normal after recovery .

● Serum bilirubin levels may be high, and weeks may be required for normalization .
● There are moderate rises in transaminase levels, and minor elevation of the

alkaline
phosphatase level usually occurs.
● The complications of severe leptospirosis emphasize the multisystemic nature of

the disease. Leptospirosis is a common cause of acute renal failure (ARF), which
occurs in 16 to 40% of cases
Diagnosis:
MAT

● The microscopic agglutination test (MAT) is the reference test for the diagnosis of
leptospirosis. MAT is a test where serial dilutions of patient sera are mixed with
different serovars of Leptospira.

● The mixture is then examined under a dark field microscope to look for
agglutination. The highest dilution where 50% agglutination occurs is the result.
MAT titres of 1:100 to 1:800 are diagnostic of leptospirosis.
PCR
● Leptospira DNA can be amplified by using polymerase chain reaction(PCR) from
serum, urine, aqueous humour, CSF, and autopsy specimens.

● PCR can detect Leptospira DNA in blood even before the antibody response
develops. As PCR detects the presence of Leptospira DNA, it is useful even after
antibiotic treatment has started
CBC, Electrolytes, Urinalysis:
● CBC For those who are infected, a complete blood count may show a high white
cell count and a low platelet count.

● Blood urea and creatinine levels will be elevated. Leptospirosis increases

potassium excretion in urine, which leads to a low potassium level and a low sodium
level in the blood.

● Urinalysis may reveal the presence of protein, white blood cells, and microscopic
haematuria. Because the bacteria settle in the kidneys, urine cultures will be positive
for leptospirosis starting after the second week of illness until 30 days of infection.
Treatment and Management:
● Antibiotics – First Line Treatment
Doxycycline contraindications
● Pregnancy
● Breastfeeding
● Children <8 y/o
● Allergy to Doxycycline or tetracyclines
Doxycycline Precautions
- Kidney and Liver disease
- Taking OCPs
- Skin exposure to sunlight or UV rays
- Iron, calcium, multivitamins supplementation
- Drug interactions
● Antacids
● Cholesterol lowering medications
● Penicillin antibiotics
● Adverse reactions
- Severe allergic reactions
- Diarrhea
- Others: Severe headaches, dizziness, blurred vision, fever, chills, body
aches, severe rashes, jaundice, tachycardia, etc.

● How to prevent side effects and adverse effects?

- Take doxycycline with a meal or after a meal
- Don’t lie down for an hour after taking Doxycycline
- Avoid taking doxycycline with medications that have known GI side effects
THANK YOU!