Portal de Periódicos da CAPES

A Fall in Ghana

2009; Elsevier BV; Volume: 122; Issue: 12 Linguagem: Inglês

10.1016/j.amjmed.2009.09.002

1555-7162

Michael Eberlein, Mayy Chahla, Sammy A. Baierlein, Richard T. Mahon,

Climate Change and Health Impacts

A fall marked the beginning of a perilous medical journey for a 34-year-old man. He had traveled from the United States, where he lives with his family, to Accra, Ghana for business purposes and was well until the ninth day of his trip, when he fell and twisted his lower back. Although he was able to stand immediately afterwards, the back pain worsened as the morning progressed and was then compounded by malaise, leading him to spend the remainder of the day in bed. He had no neurologic deficits or loss of bowel or bladder continence. That evening, the patient developed a fever of 102.1° F (38.9° C) with chills and progressive malaise. His health status began to rapidly deteriorate, and he was evacuated to the United States the following day. En route he developed hypoxia, which was corrected with supplemental oxygen. Tachycardia and hypotension responded to intravenous fluid. Upon arrival, he was evaluated at a community hospital, where he received empiric ceftriaxone. He was determined to be in critical condition and was transferred urgently to the intensive care unit (ICU) of the National Naval Medical Center in Bethesda, Md for further management. Previously healthy, the patient had an unremarkable medical history. A systems review revealed no further complaints, and he had been fully compliant with his malaria prophylaxis. Throughout his stay in Ghana, he had no contact with sick people, animal exposure, or insect bites. He did not leave the luxury hotel complex and only ate approved prepared meals, except for 1 dinner on day 3, which took place at a high-end restaurant with colleagues. His vaccinations were current. Upon admission to the ICU, the patient's temperature was 102.9° F (39.4° C). He was tachypneic, with a respiratory rate of 47 breaths per minute and an oxygen saturation of 96% on 100% oxygen via a non-rebreather mask. His heart rate was 116 beats per minute with a blood pressure of 90/50 mm Hg. He was somnolent but appropriately conversant. Lung examination revealed accessory respiratory muscle use, diffuse rales, and bibasilar lung crackles. Cardiac, abdominal, and neurological exams were unremarkable. Scleral icterus was noted, but the patient had no rash or skin lesions. Initial laboratory results were significant for thrombocytopenia, coagulopathy, renal insufficiency, and hepatitis (Table 1).Table 1Laboratory EvaluationVariablesReference RangeValues on AdmissionValues on Hospital Day 1Values upon DischargeHematology WBCs (× 103 cells/mm3)4.5-117.16.410 Neutrophils (%)94.4 Lymphocytes (%)3.8 Monocytes (%)1.7 Basophils (%)0.1 Eosinophils (%)0.0 Hematocrit (%)41-5331.52726.7 Hemoglobin (g/dL)13.5-17.510.59.18.9 Platelets (× 103/mm3)150-350121,00084,000597,000 PTT (sec)22.1-35.143.3 PT (sec)11.1-13.120.4 INR1.81.0 D-dimer (μg/mL)<0.59.36Chemistry Sodium (mEq/L)136-145140143145 Potassium (mEq/L)3.5-53.74.14.5 Chloride (mEq/L)98-106110117110 Carbon dioxide (mEq/L)21-30232326 Urea nitrogen (mg/dL)10-20233221 Creatinine (mg/dL)0.8-1.21.21.51 Total bilirubin (mg/dL)0.3-135.51 Direct bilirubin (mg/dL)0.1-0.34.5 Total protein (g/dL)5.5-8555.5 Albumin (g/dL)3.5-5.52.72.42.8 AST (U/L)0-354611554 ALT (U/L)0-354310947 ALP (U/L)30-120488472 Amylase (U/L)60-180101191 Lipase (U/L)0-160132113 Calcium (mg/dL)9.0-10.57.48.1 Lactate (mmol/L)0.6-1.71.3 CK (U/L)60-400806646 CK-MB (ng/mL)0-787 Troponin-I (ng/mL)0-0.40.040.04 TSH (μU/mL)0.5-4.71.7 Cortisol (μg/dL)5-2534.7Immunology ANANegativeNegative ANCANegativeNegative Anti-GBM AbNegativeNegativeWBCs=white blood cells; PTT=partial thromboplastin time; PT=prothrombin time; INR=international normalized ratio; AST=aspartate aminotransferase; ALT=alanine aminotransferase; ALP=alkaline phosphatase; CK=creatine kinase; CK-MB=creatine kinase, MB fraction; TSH=thyroid-stimulating hormone; ANA=antinuclear antibody; ANCA=antineutrophil cytoplasmic antibodies; Anti-GBM Ab=anti-glomerular basement membrane antibodies. Open table in a new tab WBCs=white blood cells; PTT=partial thromboplastin time; PT=prothrombin time; INR=international normalized ratio; AST=aspartate aminotransferase; ALT=alanine aminotransferase; ALP=alkaline phosphatase; CK=creatine kinase; CK-MB=creatine kinase, MB fraction; TSH=thyroid-stimulating hormone; ANA=antinuclear antibody; ANCA=antineutrophil cytoplasmic antibodies; Anti-GBM Ab=anti-glomerular basement membrane antibodies. The patient's progressive respiratory failure required intubation and mechanical ventilation. Continuous infusion of norepinephrine was initiated for persistent hypotension despite adequate volume resuscitation. Pulse contour analysis of a good-quality invasive radial arterial pulse tracing showed a cardiac index of 5.1 and a systemic vascular resistance of 631 dyn·sec·cm−5. Computed tomography of the chest disclosed no evidence of pulmonary embolism. Bilateral diffuse infiltrates with dense alveolar consolidations in the dependent areas were consistent with a diagnosis of adult respiratory distress syndrome (Figure 1). Empiric antibiotic coverage with doxycycline, meropenem, levofloxacin, vancomycin, atovaquone/proguanil, oseltamivir, and quinine was administered. Bronchoscopy with bronchoalveolar lavage showed normal airways and turbid lavage fluid with a white blood cell count of 960 × 103 cells/mm3 and a normal differential cell count. Gram-staining of the bronchoalveolar lavage fluid showed no organisms. A peripheral malaria smear was negative, as was a Binax NOW immunochromatographic assay. Further microbiologic studies are summarized in Table 2. Abdominal and pelvic computed tomography indicated nonspecific diffuse bowel-wall thickening and mesenteric lymphadenopathy; a complete abdominal ultrasound examination was unremarkable. Computed tomography of the head was normal. A lumbar puncture yielded normal results.Table 2Microbiology StudiesTestResultLegionella antigen, urineNegativeStreptococcus antigen, urineNegativeBlood Cultures On admission (at community hospital)Gram negative bacteria First day (4 draws out of 4)Negative Second day (2 draws out of 2)Negative Third day (4 draws out of 4)NegativeStool CulturesNo growthNegative for ova and parasitesClostridium difficile toxinNegativeLumbar punctureNo growthBAL Bacterial cultureNo growth Viral cultureNo growth Fungal cultureNo growth AFB smear and cultureNegative Influenza, CMV, RSV antigenNegativeSerologies LeptospiraNegative Hepatitis A, B, CNegative EBVNegative CMVNegative BrucellaNegative HIVNegativeBAL=bronchoalveolar lavage; AFB=acid-fast bacillus; CMV=cytomegalovirus; RSV=respiratory syncytial virus; EBV=Epstein-Barr virus; HIV=human immunodeficiency virus. Open table in a new tab BAL=bronchoalveolar lavage; AFB=acid-fast bacillus; CMV=cytomegalovirus; RSV=respiratory syncytial virus; EBV=Epstein-Barr virus; HIV=human immunodeficiency virus. Acute febrile illness and rapidly progressive cardiopulmonary failure in a previously healthy 34-year-old man generated a broad differential diagnosis focusing on infectious causes (Table 3). Annually, 4 million travelers become ill enough to seek health care abroad or upon returning home.1Freedman D.O. Weld L.H. Kozarsky P.E. et al.GeoSentinel Surveillance NetworkSpectrum of disease and relation to place of exposure among ill returned travelers.N Engl J Med. 2006; 354: 119-130Crossref PubMed Scopus (890) Google Scholar The GeoSentinel database, a network of 30 specialized clinics on 6 continents, provides information regarding the association between travel destination and the probability of clinical diagnoses.1Freedman D.O. Weld L.H. Kozarsky P.E. et al.GeoSentinel Surveillance NetworkSpectrum of disease and relation to place of exposure among ill returned travelers.N Engl J Med. 2006; 354: 119-130Crossref PubMed Scopus (890) Google Scholar Malaria is the most frequent cause of systemic febrile illness among sick travelers; several reports note adult respiratory distress syndrome as a complication. Furthermore, rickettsial infections can be complicated by adult respiratory distress syndrome. Typhoid fever is a primary contributor to systemic febrile illness among travelers returning from South Central Asia, and less commonly, from Africa.Table 3Differential Diagnosis of Fever and Rapidly Progressive Cardiopulmonary FailureBacterial Infection Severe community-acquired pneumonia Meningitis, endocarditis Rickettsial disease (babesiois, ehrlichiosis, Rocky Mountain spotted fever, scrub typhus, Mediterranean spotted fever) Q-Fever (Coxiella burnetii) Brucellosis Plague (Yersinia pestis) Tularemia (Francisella tularensis) Typhoid fever/salmonellosis Leptospirosis (Leptospira interrogans) Anthrax Mycobacterial infectionsViral Infections Viral pneumonia (influenza, CMV, EBV, VZV, SARS) Hantavirus Dengue fever and yellow fever Hemorrhagic fever (Lassa, Marburg, or Ebola viruses)Fungal infections Coccidiomycosis Cryptococcus Histoplasmosis BlastomycosisParasitic infections Malaria Leishmaniasis Schistosomiasis StrongyloidesNoninfectious causes: Inflammatory Rapid-onset interstitial pneumonia (acute interstitial pneumonia, acute hypersensitivity pneumonitis) Acute eosinophilic pneumonia ARDS due other causes (inhalation injury, drug overdose, trauma) Rheumatologic disorders Wegener granulomatosis, Churg-Strauss disease, Goodpasture's syndrome Systemic lupus erythematosus, antiphospholipid syndrome Other Malignancy, lymphoma, lymphoproliferative disease, leukemia Pulmonary embolism, aortic dissection, acute myocardial infarction Adrenal insufficiency, thyroid stormCMV=cytomegalovirus; EBV=Epstein-Barr virus; VZV=varicella zoster virus; SARS=severe acute respiratory syndrome; ARDS=acute respiratory distress syndrome. Open table in a new tab CMV=cytomegalovirus; EBV=Epstein-Barr virus; VZV=varicella zoster virus; SARS=severe acute respiratory syndrome; ARDS=acute respiratory distress syndrome. In the case presented here, blood cultures obtained at the community hospital became positive for Gram-negative rods and grew Salmonella paratyphi, serogroup C. A diagnosis of typhoid fever associated with adult respiratory distress syndrome and multiple organ dysfunction syndrome was made. Typhoid fever is an acute systemic disease caused by ingestion of food or water contaminated with Salmonella enterica, serotype Typhi or Paratyphi. Typically, after an asymptomatic period of 7-14 days (range, 3-60 days), the onset of bacteremia is marked by fever and malaise.2Connor B.A. Schwartz E. Typhoid and paratyphoid fever in travelers.Lancet Infect Dis. 2005; 5: 623-628Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar Patients typically present with influenza-like symptoms and few physical signs.3Hoffman S.L. Punjabi N.H. Kumala S. et al.Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone.N Engl J Med. 1984; 310: 82-88Crossref PubMed Scopus (228) Google Scholar It is estimated that 21 million cases of typhoid fever arise annually worldwide; 90% occur in Asia.2Connor B.A. Schwartz E. Typhoid and paratyphoid fever in travelers.Lancet Infect Dis. 2005; 5: 623-628Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar In the US, about 500 cases per year are reported, and 75% are associated with foreign travel.4Sharma A.M. Sharma O.P. Pulmonary manifestations of typhoid fever Two case reports and a review of the literature.Chest. 1992; 101: 1144-1146Crossref PubMed Scopus (19) Google Scholar There is a wide spectrum of clinical manifestations. Severe typhoid fever is defined as fever plus delirium, stupor, coma (in Greek, typhus means "fog"), or shock and is associated with fatality rates of 44-56%.5Rogerson S.J. Spooner V.J. Smith T.A. Richens J. Hydrocortisone in chloramphenicol-treated severe typhoid fever in Papua New Guinea.Trans R Soc Trop Med Hyg. 1991; 85: 113-116Abstract Full Text PDF PubMed Scopus (34) Google Scholar Many complications of typhoid fever have been described (Table 4). Although cough is a common symptom, occurring in 11-86% of cases, pulmonary complications of typhoid fever are rare, documented in only 1-6% of cases.6Huang D.B. DuPont H.L. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection.Lancet Infect Dis. 2005; 5: 341-348Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar Reported pulmonary manifestations include bronchitis, pneumonia, lung abscess, pleural effusion, and empyema, yet sputum cultures are usually negative.4Sharma A.M. Sharma O.P. Pulmonary manifestations of typhoid fever Two case reports and a review of the literature.Chest. 1992; 101: 1144-1146Crossref PubMed Scopus (19) Google Scholar, 6Huang D.B. DuPont H.L. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection.Lancet Infect Dis. 2005; 5: 341-348Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar Adult respiratory distress syndrome is a very rare complication of typhoid fever, which is surprising, given the bacteremia and endotoxinemia associated with the disease. To our knowledge, only 5 cases are reported in the literature.7Buczko G.B. McLean J. Typhoid fever associated with adult respiratory distress syndrome.Chest. 1994; 105: 1873-1874Crossref PubMed Scopus (14) Google Scholar However, in a report on 5 fatal cases of typhoid fever, features of adult respiratory distress syndrome were discovered on autopsy in 3 cases, suggesting that the disorder might be underreported.8Azad A.K. Islam R. Salam M.A. et al.Comparison of clinical features and pathologic findings in fatal cases of typhoid fever during the initial and later stages of the disease.Am J Trop Med Hyg. 1997; 56: 490-493PubMed Google ScholarTable 4Manifestations and Complications of Typhoid FeverOrgan SystemPrevalenceRisk FactorsAbdominal10-25% Gastrointestinal hemorrhage10%HIV, IVDU, pyogenic infection, hemoglobinopathy Gastrointestinal perforation1-3% Hepatitis, cholecystitis20% Pancreatitis20% Hepatic or splenic abscesses1-5%Cardiovascular1-5% Myocarditis, Endocarditis1-5%Existing valvular abnormalities Pericarditis, arteritis1%Neuropsychiatric3-35% Cerebral edema, seizuresPulmonary infections, meningitis, ventriculitis, trauma, surgery, osteomyelitis of the skull Encephalopathy Meningitis Cerebral abscess, ventriculitis Guillain-Barré-syndromeRespiratory1-6% Bronchitis, Pneumonia, EmpyemaPast pulmonary infection, sickle cell disease, HIV, alcohol abuse ARDSHematologicCommon Anemia, DIC, thrombocytopeniaCommon Hemophagocytic syndrome<1%Renal5-10% GlomerulonephritisHepatitis Acute renal failureOthers Focal abscess<1% Pharyngitis<1% Osteomyelitis<1%Sickle cell disease Arthritis<1% Genitourinary system, orchitis<1%Urinary tract pathologyHIV=human immunodeficiency virus; IVDU=intravenous drug use; ARDS=acute respiratory distress syndrome; DIC=disseminated intravascular coagulation.Adapted from: Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis. 2005;5:341-348. Open table in a new tab HIV=human immunodeficiency virus; IVDU=intravenous drug use; ARDS=acute respiratory distress syndrome; DIC=disseminated intravascular coagulation. Adapted from: Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis. 2005;5:341-348. The standard diagnostic method is blood culture, positive in 60-80% of patients. Bone marrow cultures are more sensitive, with ≥85% of infected patients testing positive. Stool culture sensitivity is about 30%. Serologic testing, the Widal's test, is controversial due to varying sensitivity, specificity, and predictive values in different geographic areas.9Parry C.M. Hien T.T. Dougan G. et al.Typhoid fever.N Engl J Med. 2002; 347: 1770-1782Crossref PubMed Scopus (1038) Google Scholar Randomized controlled trials indicate that fluoroquinolones are the most effective typhoid fever treatment.9Parry C.M. Hien T.T. Dougan G. et al.Typhoid fever.N Engl J Med. 2002; 347: 1770-1782Crossref PubMed Scopus (1038) Google Scholar In severe typhoid fever, fluoroquinolones should initially be given intravenously, and treatment should last for at least 10 days. Furthermore, patients with delirium, stupor or coma, and shock might benefit from the prompt administration of dexamethasone. In a randomized double-blind trial involving 38 patients in Indonesia with severe typhoid fever, mortality was decreased from 50% to 10% (P=.003) when high-dose dexamethasone was administered (3 mg/kg over 30 minutes, followed by 1 mg/kg every 6 hours for 8 doses).3Hoffman S.L. Punjabi N.H. Kumala S. et al.Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone.N Engl J Med. 1984; 310: 82-88Crossref PubMed Scopus (228) Google Scholar Lower dosages of steroids were not found to be effective.5Rogerson S.J. Spooner V.J. Smith T.A. Richens J. Hydrocortisone in chloramphenicol-treated severe typhoid fever in Papua New Guinea.Trans R Soc Trop Med Hyg. 1991; 85: 113-116Abstract Full Text PDF PubMed Scopus (34) Google Scholar Chronic biliary carriage might occur in 2-5% of cases even after treatment and can last as long as a year. In that situation, antibiotic therapy might be necessary; cholecystectomy also might be necessary if gallstones are present. The cumulative efficacy at 3 years for Ty21a, an attenuated live vaccine, and the Vi typhoid vaccine, which is based on the purified capsular polysaccharide, are similar at 51% and 55% respectively, but, as was the case with our patient, who received the polysaccharide vaccine, the agents do not guarantee protection.10Fraser A. Paul M. Goldberg E. et al.Typhoid fever vaccines: systematic review and meta-analysis of randomized controlled trials.Vaccine. 2007; 25: 7848-7857Crossref PubMed Scopus (127) Google Scholar Our patient was treated with a 14-day course of levofloxacin. He did not have neuropsychiatric symptoms, and his shock resolved within 24 hours, so he was not treated with dexamethasone. He remained in the ICU for 11 days, was extubated on day 6, and was discharged to rehabilitation on hospital day 16. By discharge, all of his laboratory abnormalities had resolved, and a repeated stool culture showed no evidence of Salmonella paratyphi. In summary, typhoid fever should be considered as a possible diagnosis in patients with an acute febrile illness and rapidly progressive cardiopulmonary failure, especially for patients who have traveled from endemic regions.