29M with Fever and Rash

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

PATIENT JOURNEY

• 4 days ago (Day 1): Fever started + Fever dreams (of water leaking from roof, etc.) + White coated tongue
• Day 3: Rash seen - Confluent blanchable papules with maculopapular rash on right arm + Explosive diarrhea with lots of flatulence
• Day 4: Dizziness at night + hissing sounds 
• Return of appetite and taste. Showed improvement with ORS
• Sep 1st morning: Drug history of Cefexime 200mg, Doxycycline 100mg, Oral PAN and Sucralfate syrup
• Sep 1st later: vomited twice (small volume yellow vomit after continuous retching)
• Treated with at home IV fluids, PAN, Zofer IV, Buscopan
• Improvement in patient discomfort seen. Fever still present
• Sep 2nd: Temperature reached baseline.

Fever Charts:

LABS:

CONVERSATIONAL DECISION SUPPORT (DISCUSSIONS):

With the first presenting symptoms (fever, rash, diarrhea) and an observation that the pulse rate never crossed 100 even with a temperature of 104 on Day 1, a DDx of Salmonella, Rickettsia, Viral pyrexia was made. It was determined that a CBP showing leucopenia could help start with empirical treatment for typhoid. Meanwhile, the patient was treated with antipyretics and 1 dose of Doxycycline. Rickettsia was temporarily ruled out as there were no swollen lymph nodes or recent cases around the patient's location. Patient gave history of eating outside food, which supported the Typhoid diagnosis. Patient also gave history of smoking in dilapidated area with animals. This made Rickketsia a possibility (though unlikely). It was decided to continue Doxycycline, with specific instructions to drink 500ml of water along with the medication and sit for 30 minutes after to prevent esophagitis. 

[NOTE: About Doxycycline + Lactobacillus combination

"A common side effect of antibiotics is diarrhea, which may be caused by the elimination of beneficial bacteria normally found in the colon. Controlled studies have shown that taking probiotic microorganisms—such as Lactobacillus casei, Lactobacillus acidophilus, Bifidobacterium longum, or Saccharomyces boulardii—helps prevent antibiotic-induced diarrhea." Doxycycline – Health Information Library | PeaceHealth

"Lactobacillus acidophilus produces acids that kill invading bacteria. These and other probiotics inhibit the growth of potentially infectious organisms and have been shown to be effective against some infections....by producing acids, hydrogen peroxide, and natural antibiotics called bacteriocins and microcins, by utilizing nutrients needed by pathogens, by occupying attachment sites on the gut wall that would otherwise be available to pathogens, and by stimulating immune attacks on pathogens."Probiotics – Health Information Library | PeaceHealth]

A recent spike in fever was noticed, but the amplitude was still lower than previous records, suggesting a downtrend. However, just as the fever was improving, the patient had complained that he almost lost consciousness (while urinating, at night) with hissing sounds and blackening of vision. These symptoms were relieved when he sat down. It was hypothesized that this could have been pre-syncope. 

Patient then reported a return of appetite and taste. He was also given ORS for diarrhea with good effect.

Later, patient vomited twice the next morning (small volume yellow vomit after continuous retching). He had taken Cefexime 200mg, Doxycycline 100mg, Oral PAN and Sucralfate syrup (for gastroprotection) before this episode. These symptoms were thought to be drug-induced. 

Patient treated with at home IV fluids, PAN, Zofer IV and Buscopan (for stomach cramps). Improvement was seen in patient discomfort level. This was thought to be either placebo, or the fact that the patient's inflamed stomach lining was not taking  in oral medication.

Labs results were examined: Major finding was LEUCOPENIA

In DDx: Rickettsia still considered a differential, though unlikely. Along with it were typhoid and viral pyrexia.

There were 3 ways to proceed: get a Widal test done immediately, get a Weil Felix done 10 days later or wait for blood culture results. 

"Widal test recorded 81.5% sensitivity, 18.3% specificity, 10.1% positive predictive value and 89.7% negative predictive value. Stool culture showed 31.3% sensitivity, 91.5% specificity, 29% positive predictive value and 91.5% negative predictive value"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6551910/#:~:text=Widal%20test%20recorded%2081.5%25%20sensitivity,and%2091.5%25%20negative%20predictive%20value.

Due to the high negative predictive value of Widal test (89.7%), it was determined that even a positive Widal test would not rule out Rickettsia as a differential.

Blood culture results would be definitive but not sensitive for typhoid. It was decided to wait for the blood culture results. 

Meanwhile, Doxycycline was stopped as patient was unable to tolerate it. 

First serial culture of blood report came back negative.

SUMMARY: Please view this flowchart https://drive.google.com/file/d/1l48HxCQTzJD3k6ODwXgsBCR0ivbNCDGW/view?usp=sharing