A case of suspicious fever


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A case of suspicious fever

  1. 1. A Case of Suspicious FEVER Prof.Dr.P.Vijayaraghavan’s Unit Dr.T.J.Senthil Manikandan
  2. 2. <ul><li>Saurav Das a 23 year old medical student returning from Denmark after a stay of 4 days [21 st to 25 th April] was admitted for fever of 12 days </li></ul><ul><li>HOPI:H/O fever-12 days </li></ul><ul><li>- high grade </li></ul><ul><li>- associated with chills &rigors </li></ul><ul><li>- esp. in the evenings </li></ul><ul><li>No h/o headache </li></ul><ul><li>No h/o altered sensorium </li></ul><ul><li>No h/o visual disturbance/seizures/loc </li></ul>
  3. 3. <ul><li>No h/o vomiting/diarrhea </li></ul><ul><li>h/o cough+ </li></ul><ul><li>h/o sore throat+ </li></ul><ul><li>h/o bodyache+ </li></ul><ul><li>No h/o post nasal drip/running nose </li></ul><ul><li>No h/o jaundice </li></ul><ul><li>No h/o chest pain/palpitation/syncope </li></ul><ul><li>No h/o pedal edema/abd.distension </li></ul><ul><li>No h/o oliguria/hematuria </li></ul><ul><li>No h/o dysuria </li></ul><ul><li>No h/o bleeding tendancy/rash/joint pains </li></ul>
  4. 4. <ul><li>So with h/o travel to a foreign country[confirmed flu cases reported] and fever with mild respiratory symptoms the diagnosis of swine flu was entertained.Throat &Nasal Swabs were taken for viral studies. </li></ul><ul><li>On further elaboration of history patient gave h/o fever starting on the day of his journey to denmark; he had landed with fever there. </li></ul><ul><li>Since there was h/o fever with rigors malaria also was considered as a possibility. </li></ul>
  5. 5. <ul><li>On questioning patient gave a past h/o treatment for malaria 6 months back with chloroquine and became alright </li></ul><ul><li>There was no other significant past history. </li></ul>
  6. 6. <ul><li>Personal History: </li></ul><ul><li>Non smoker,non alcoholic </li></ul><ul><li>Mixed diet </li></ul><ul><li>Family history: </li></ul><ul><li>No other member has a similar illness.His Father is a diabetic </li></ul>
  7. 7. <ul><li>O/E: </li></ul><ul><li>Patient conscious,oriented,afebrile </li></ul><ul><li>Not pale,anicteric </li></ul><ul><li>No cyanosis,no clubbing </li></ul><ul><li>JVP º,PEº,LNº </li></ul><ul><li>no external markers of TB,no rash </li></ul><ul><li>BP-130/90mmHg,PR-90/m,RR-16/m </li></ul><ul><li>HT- 175 cms,WT-80 kgs,WC-36&quot; </li></ul>
  8. 8. <ul><li>CVS- S1,S2 + </li></ul><ul><li>no murmurs </li></ul><ul><li>RS- BAE+,NVBS </li></ul><ul><li>No added sounds </li></ul><ul><li>P/A- soft </li></ul><ul><li>spleen was just palpable </li></ul><ul><li>CNS-NFND </li></ul><ul><li>No neck stiffness </li></ul>
  9. 9. <ul><li>Investigations </li></ul><ul><li>Hb -11.6gms% </li></ul><ul><li>PCV-39% </li></ul><ul><li>TC -6400/cmm </li></ul><ul><li>DC- P66 L30 E2 M2 </li></ul><ul><li>ESR-21/45 </li></ul><ul><li>RBS-116 mgs/dl </li></ul><ul><li>Bld urea-22 mgs/dl </li></ul><ul><li>Sr creatinine-0.7 mgs/dl </li></ul><ul><li>sr electrolytes Na-137,K-4.9meq/l </li></ul><ul><li>Cl-102,HCO3-24 meq/l </li></ul>Platelet count Day 1 Day 2 Day 4 Day 7 51000 65000 87000 160000
  10. 10. <ul><li>Sr bilirubin-3.2mgs/dl </li></ul><ul><li>Direct-1.9 mgs/dl </li></ul><ul><li>SGOT-36 u/l </li></ul><ul><li>SGPT-41u/l </li></ul><ul><li>ALP-161 Iu/l </li></ul><ul><li>Total protein-6.3 gms%,sr albumin-2.6 gms% </li></ul><ul><li>PT-14 s,INR-1,aPTT-26s </li></ul><ul><li>ECG-sinus tachycardia </li></ul><ul><li>CXR-PA-WNL </li></ul><ul><li>Urine R/E-alb,sugar-nil </li></ul><ul><li>1-2 pus cells </li></ul>
  11. 11. <ul><li>QBC-MP-+Ve </li></ul><ul><li>Peripheral smear-p.vivax+ </li></ul><ul><li>MSAT- -ve </li></ul><ul><li>Widal- -ve </li></ul><ul><li>Dengue IGM- -ve </li></ul><ul><li>Nasal and throat swab for HINI virus-negative </li></ul><ul><li>USG abdomen-focal sparing in fatty liver,splenomegaly -suggested follow up with CT or MRI[MGE OPINION] </li></ul>
  12. 12. <ul><li>ELISA for HIV- -ve </li></ul><ul><li>HBsAg- -ve </li></ul><ul><li>Anti-HCV- -ve </li></ul><ul><li>Blood C&S- -ve </li></ul><ul><li>Urine C&S- -ve </li></ul><ul><li>Lipid profile </li></ul><ul><li>tot cholesterol-220,LDL-135 </li></ul><ul><li>HDL-38,TGL-284 mgs% </li></ul><ul><li>FBS-71 mgs% </li></ul><ul><li>PPBS-203 mgs% </li></ul>
  13. 13. <ul><li>FINAL DIAGNOSIS </li></ul><ul><li>MALARIA[P.VIVAX] </li></ul><ul><li>METABOLIC SYNDROME ->DM </li></ul>
  14. 14. <ul><li>TREATMENT </li></ul><ul><li>Because of initial consideration of swine flu 1 dose of TAMIFLU was given </li></ul><ul><li>On getting the peripheral smear report </li></ul><ul><li>T chloroquine was started and full course </li></ul><ul><li>was given-since fever persisted </li></ul><ul><li>Inj Artesunate was given in the usual dose.Fever subsided </li></ul><ul><li>Radical treatment with T primaquine was given </li></ul>
  15. 15. <ul><li>He was asked to come for followup to work the case up regarding diabetic status, metabolic syndrome,fatty liver and abnormal LFT </li></ul>
  16. 16. <ul><li>This case is being presented since on admission there was a clinical suspicion of swine flu. </li></ul><ul><li>But lab investigations were not in favour of this diagnosis and suggested a relapse of malarial fever because radical treatment was not given during the first episode 6 months back. </li></ul>
  17. 17. <ul><li>SWINE FLU –THE NEW H1N1 </li></ul>
  18. 19. <ul><li>HINI VIRUS </li></ul>
  19. 20. <ul><li>The Influenza Pandemic of 1918 </li></ul><ul><li>Known as &quot;Spanish Flu&quot; or &quot;La Grippe&quot; </li></ul><ul><li>It killed more people than the World War I > 20 to 40 million people. </li></ul><ul><li>It has been cited as the most devastating epidemic in recorded world history. More people died of influenza in a single year than in four-years of the Black Death Bubonic Plague from 1347 to 1351. </li></ul><ul><li>It was caused by H1N1 </li></ul>
  20. 21. <ul><li>H1N1-Swine flu </li></ul><ul><li>The 2009 outbreak of Influenza A virus subtype H1N1 is an epidemic of a new strain of influenza virus commonly referred to as swine flu. </li></ul><ul><li>It is thought to be a mutation (reassortment) of four known strains of influenza A virus subtype H1N1: one endemic in humans, one endemic in birds, and two endemic in pigs (swine). </li></ul><ul><li>The WHO&CDC have raised its alert level to Phase 5 out of the six maximum, indicating that a pandemic was &quot;imminent&quot;. </li></ul>
  21. 22. <ul><li>outbreak ->PANDEMIC? </li></ul>
  22. 25. <ul><li>Travel advisories </li></ul><ul><li>The new strain has spread widely beyond Mexico and the U.S., with confirmed cases in >50 countries </li></ul><ul><li>To avoid travelling to infected areas, especially Mexico & USA </li></ul><ul><li>Virulence </li></ul><ul><li>Most fatalities have been in Mexico (87%, as of May 24, 2009) primarily young, healthy adults </li></ul>
  23. 26. <ul><li>Symptoms and expected severity </li></ul><ul><li>They are similar to usual influenza, and include a fever, coughing, headaches, pain in the muscles or joints, sore throat, chills, fatigue and runny nose </li></ul><ul><li>Diarrhea and vomiting have also been reported in some cases. </li></ul><ul><li>People at higher risk of serious complications include </li></ul><ul><li>1.people age 65 years and older </li></ul><ul><li>2.children younger than 5 years old </li></ul><ul><li>3.pregnant women </li></ul><ul><li>4.people of any age with underlying medical </li></ul><ul><li>conditions such as asthma, diabetes, obesity, </li></ul><ul><li>heart disease, or immunocompromised pp </li></ul>
  24. 27. <ul><li>Emergency medical attention </li></ul><ul><li>In children, look for blue lips and skin, dehydration, rapid breathing, excessive sleeping and significant irritability that includes a lack of desire to be held. </li></ul><ul><li>In adults, shortness of breath, pain in the chest or abdomen, sudden dizziness or confusion may indicate the need for emergency care. </li></ul>
  25. 28. <ul><li>Prevention </li></ul><ul><li>Personal hygiene and surgical masks </li></ul><ul><li>Treatment </li></ul><ul><li>The drugs that are used for treating H1N1 flu are called oseltamivir (Tamiflu) and zanamivir (Relenza). </li></ul><ul><li>The drugs work best if given within 2 days of becoming ill, but may be given later if illness is severe or for those at a high risk for complications. </li></ul>
  26. 29. <ul><li>The CDC case definitions </li></ul><ul><li>Confirmed case: A person with an acute febrile respiratory illness with lab confirmed infection at the CDC by one or more of the following tests: </li></ul><ul><ul><li>Real-time reverse-transcription polymerase chain reaction (RT-PCR) </li></ul></ul><ul><ul><li>Viral culture </li></ul></ul><ul><li>Probable case: A person with ILI (ie, an illness with a fever and a cough or sore throat) who is positive for influenza A, but negative for H1 and H3 by RT-PCR. </li></ul>
  27. 30. <ul><li>Suspected case: A person who does not meet the confirmed or probable case definition, is not novel H1N1 test–negative, and is/has one of the following features: </li></ul><ul><ul><li>Previously healthy, less than 65 years of age, and hospitalized for ILI </li></ul></ul><ul><ul><li>ILI and resides in a state without confirmed cases but has traveled to a state or country where there is/are one or more confirmed or probable cases </li></ul></ul><ul><ul><li>ILI and has an epidemiologic link in the past 7 days to a confirmed case or probable case </li></ul></ul><ul><li>Antiviral treatment should be considered for confirmed, probable and suspected cases of novel H1N1 infection, with priority given to hospitalized patients and patients at higher risk for influenza complications </li></ul>
  28. 31. <ul><li>Treatment & Chemoprophylaxis </li></ul><ul><li>Oseltamivir </li></ul><ul><li>Adults & children ≥ 13 yrs </li></ul><ul><li>75 mg capsule twice per day for 5 days,75 mg capsule once per day for 10 days after last known exposure </li></ul><ul><li>Children (12 months to 12 yrs) </li></ul><ul><li>≤ 15 kg-30 mg twice daily for 5 days,30 mg once daily for 10 days after last known exposure </li></ul><ul><li>15-23 kg-45 mg twice daily for 5 days,45 mg once daily for 10 days after last exposure </li></ul><ul><li>24-40 kg-60 mg twice daily for 5 days,60 mg once daily for 10 days after last exposure </li></ul><ul><li>> 40 kg-75 mg twice daily for 5 days,75 mg once daily for 10 days after last exposure </li></ul>
  29. 32. <ul><li>ZanamivirAdults </li></ul><ul><li>Two 5 mg inhalations (10mg total) twice per day for 5 days </li></ul><ul><li>prophylaxis </li></ul><ul><li>Two 5 mg inhalations (10mg total) once per day for 10 days after last known exposure </li></ul><ul><li>ChildrenTwo 5 mg inhalations (10mg total) twice per day (age 5 yrs or older) for 5 days </li></ul><ul><li>prophylaxis </li></ul><ul><li>Two 5 mg inhalations (10mg total) once per day (age 5 yrs or older) for 10 days after last exposure </li></ul>
  30. 33. <ul><li>Vaccines </li></ul><ul><li>The seasonal flu vaccine is not believed to protect against the new strain, therefore any existing stock would not be useful. </li></ul><ul><li>Quarantine-incubation period[1-7 days] </li></ul><ul><li>It is for at least 7 days after last exposure or until we are sure that the person has not been exposed to the virus. </li></ul><ul><li>If he/she develop signs or symptoms of swine flu then quarantine for up to 7 days from the start of symptoms. </li></ul><ul><ul><li>Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. </li></ul></ul><ul><ul><li>Children (especially younger children) and immunosuppressed or immunocompromised persons might be contagious for longer periods </li></ul></ul>
  31. 34. DANGERS-WHAT&WHY <ul><li>The secondary attack rate of H1N1 range from 22% to 33%. The secondary attack rate of seasonal influenza ranges from 5% to 15%. </li></ul><ul><li>A younger age-group has been affected than seen during seasonal epidemics of influenza. Although cases have been confirmed in all age-groups, the youth of patients with severe or lethal infections is a striking feature of early outbreaks. </li></ul><ul><li>The tendency of the H1N1 virus to cause more severe and lethal infections in people with underlying conditions is of particular concern. </li></ul>
  32. 35. <ul><li>The full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is more widespread. </li></ul><ul><li>The intrinsic mutability of influenza viruses could alter the severity of current disease patterns, if the virus continues to spread. </li></ul><ul><li>Possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses . </li></ul><ul><li>H5N1 avian influenza virus is firmly established in poultry in some parts of the world is another cause for concern. No one can predict how the H5N1 virus will behave under the pressure of a pandemic. </li></ul>
  33. 36. <ul><ul><li>Pigs have been considered a &quot;mixing vessel“, they can be infected with influenza A viruses from avian, human, or swine origin </li></ul></ul><ul><ul><li>The 1918 pandemic began with a relatively mild &quot;herald&quot; wave in the spring of 1918,but the damage the subsequent peaks caused is well known. </li></ul></ul>
  34. 37. <ul><li>The FAO& WHO have reaffirmed that the H1N1 virus is not known to be transmissible from eating cooked pork or pork products. </li></ul><ul><li>CDC was reporting >10000 U.S. cases in 50 states resulting in fourteen deaths, but noted that for the most part, the infections continue to be mild—similar to seasonal flu—and recovery is fairly quick </li></ul><ul><li>Several of the proteins of the virus are most similar to strains that cause mild symptoms in humans. </li></ul><ul><li>Drugs until now have been reasonably effective </li></ul>
  35. 38. <ul><li>THANK YOU </li></ul>
  36. 39. <ul><li>H1N1 caused &quot; Spanish Flu &quot; and the 2009 swine flu outbreak </li></ul><ul><li>H2N2 caused &quot;Asian Flu&quot; </li></ul><ul><li>H3N2 caused &quot;Hong Kong Flu&quot; </li></ul><ul><li>H5N1 is &quot;bird flu&quot;, endemic in avians </li></ul><ul><li>H7N7 has unusual zoonotic potential </li></ul><ul><li>H1N2 is currently endemic in humans and pigs </li></ul>
  37. 40. <ul><li>Name of pandemicDateDeathsSubtype involved </li></ul><ul><li>Asiatic (Russian) Flu 1889–90 </li></ul><ul><li>1 million H2N2 </li></ul><ul><li>Spanish Flu 1918–20 </li></ul><ul><li>40 million H1N1 </li></ul><ul><li>Asian Flu 1957–58 </li></ul><ul><li>1 to 1.5 million H2N2 </li></ul><ul><li>Hong Kong Flu 1968–69 </li></ul><ul><li>0.75 to 1 million H3N2 </li></ul>
  38. 41. <ul><li>Influenza A virus subtype H5N1, also known as A(H5N1) or simply H5N1, is a subtype of the Influenza A virus which can cause illness in humans and many other animal species. [43] A bird-adapted strain of H5N1, called HPAI A(H5N1) for &quot;highly pathogenic avian influenza virus of type A of subtype H5N1&quot;, is the causative agent of H5N1 flu , commonly known as &quot; avian influenza &quot; or &quot;bird flu&quot;. It is endemic in many bird populations, especially in Southeast Asia . </li></ul><ul><li>One strain of HPAI A(H5N1) is spreading globally after first appearing in Asia. It is epizootic (an epidemic in nonhumans) and panzootic (affecting animals of many species, especially over a wide area), killing tens of millions of birds and spurring the culling of hundreds of millions of others to stem its spread. Most mentions of &quot;bird flu&quot; and H5N1 in the media refer to this strain. </li></ul><ul><li>HPAI A(H5N1) is an avian disease. There is no evidence of efficient human-to-human transmission or of airborne transmission of HPAI A(H5N1) to humans. In almost all cases, those infected with H5N1 had extensive physical contact with infected birds. Still, around 60% of humans known to have been infected with the current Asian strain of HPAI A(H5N1) have died from it, and H5N1 may mutate or reassort into a strain capable of efficient human-to-human transmission. [45] [46] [ </li></ul>