TWiP 253: Sub-Saharan somnolence

TWiP solves the case of the man with somnolence and something extra-erythrocytic, and presents a new puzzle for you to solve.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

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New Case

26-year-old female with no past medical history.  Patient is from Georgia in the US and is volunteering in Hérico, Guinea (town in the Lélouma Prefecture in the Labé Region of northern-central Guinea). She arrived in Guinea in December  2023.  She was taking doxycycline for malaria prophylaxis and says that she has not missed any doses

On October  2024 she presented with fever and dry cough.  Lab work was done and follow up planned for the following day.  The patient slept poorly, was febrile to 104 and had ongoing cough.  The next day she went to the hospital and was evaluated in the ER for acute febrile illness of unclear etiology.  

In the hospital, VS were 97.9F, BP 105/70, P 94 Oxy sat 98%, normal physical exam.

She was started on Augmentin and Coartem.

Pause here to think about the differential at this point and maybe some more history and what testing you might want

WBC 14, Hb 13, HCT 40, PLT 285, Neut abs 8, Eos Abso0.80; BUN/creat  normal, AST normal; ALT 44, GGT 125

Stool parasite screen + for some sort of eggs, malaria smear negative, CXR with b/l infiltrates

She was given a medication (vomited 30 min after dose received).  She then received a second dose of medication 5 hours after the first) and was discharged. The following day the patient returned to the ER, stating that she felt worse.  Her temperature had climbed to 104 overnight, and she developed watery diarrhea and nausea.  There were no additional episodes of vomiting.  She was given an additional dose of a medication, ibuprofen, and started on ceftriaxone 1 gm IV Q12 hrs.  During the day she continued to have low grade fevers and developed abdominal pain.  That night she was again febrile to 104 F.   

She remained admitted for 5 days with ongoing symptoms of diarrhea, nighttime fevers and diffuse abdominal discomfort.  Three more malaria tests were negative (rapid test and slide review)

Blood cultures collected – no growth

She continued to have mild elevation of WBC and slight elevation of AST and ALT.

The patient was transferred to a different hospital. They give her a different medication, and within 24 hours symptoms resolve. 

What is the diagnosis and what happened here with management?

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Music by Ronald Jenkees