On July 25, 2015, a 69 yr-old man in reasonably good health for his age called as he arrived at Houston Intercontinental Airport. He had just gotten into his car and was headed in our direction. “Can you see me today? I’ve just returned from a dove-hunting trip in outback Argentina, and I’ve been sick for the past 2 days with fever, headache, and chest congestion. I can barely sit up.” We told him to come straightway.
Upon entering the exam room, this patient, who I had seen when healthy, appeared 10yrs-older, hunched over in his chair, pale, and dehydrated. He answered questions in a weak, muted voice. On just cursory observation, it looked like he might need a hospital. He related that he had started an antibiotic, Z-pack (azithromycin) two days before, with no apparent benefit. He was not aware of any insect bites (such as ticks) and he was in an area in northern Argentina where malaria can be an issue. He had no specific symptoms, such as sore throat, urinary symptoms, diarrhea, or specific pain. Fever, chest congestion, headache, and nausea were about it.
His physical exam was unremarkable other than for his dehydration and general weakness.
The patient had come to the International Medicine Center because of our reputation and expertise in diagnosing and treating uncommon and “exotic” diseases from foreign lands. Lab tests and a chest x-ray would be needed, but this patient was significantly ill and immediate action was required based on the available facts to avert destabilization.
What were the material facts?
- Antibiotic (bacterial) unresponsive illness
- No specific, prominent organ system involvement (such as diarrhea)
- Onset Northern Argentina, July 23rd (winter there!)
What might be considered? Malaria, leptospirosis, typhus, tularemia, babesiosis, ricketsial infection, bacterial pneumonia, viral syndrome.
With these facts, I decided influenza was the most likely problem. Because of the patient’s age and infirmity, I rapidly hydrated him with two liters of IV fluid and prescribed oseltamivir (Tamiflu) for possible influenza A. This medicine must be given as early in the illness as possible to have any beneficial effect. And, flu, in this age-group, can have substantial complications and risk of death. So, immediate action must be taken on clinical grounds, prior to available lab results. Again, time is of the essence. The patient improved substantially in the next few hours and then the next few days on Tamiflu, without hospitalization. Two days later, the samples from the respiratory tract were positive for influenza A.
The decisive clue in this non-descript case was what appeared to be a respiratory illness with fever acquired in the winter months where the patient had been (while we were in the midst of sweltering Houston summer here). This is the nature of complex diagnostic thinking. You need to think “outside-the-box” with international travel cases, but you also must know and consider “the box”. The circumstances may be highly unusual, but the serious disease may be “usual”. And, it was critical to pay close attention to all the contextual nuances of the story, not just the obvious complaints. The patient didn’t even volunteer to comment on the weather conditions, until it occurred to me to ask, and he then said it had been cold. On further questioning, he also disclosed a co-traveler on the hunt had had fever, headache, chills, and cough. This raised the issue of a contagious respiratory illness.
In medical school I was taught that meticulous history-taking will provide the ultimate answer to the case over 90% of the time without the benefit of any diagnostic studies, provided your fund of knowledge is adequate. In this case, the patient’s course and outcome pivoted not on data, but on the realization that illness onset was in “winter” (in July here). 40 years of doing this and over 45,000 cases later and I can affirm that this is as true today as it was then. It is what I love about being a diagnostician and cognitive medicine.
E. Rensimer, MD