A History Is Worth a Million Dollar Workup

1University of Miami, Miami, FL

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 204

Case Presentation:

A 79‐year‐old female with a history of hypolhyroidism presented with recurrence of her symptoms within days of discharge. On her last admission she presented with a 2‐week history of recurrent high‐grade fevers, headache, and flulike symptoms. Laboratory analysis was significant for anemia, thrombocytopenia, abnormal LFTs, and elevated LDH and CRP. A Coomb's test was positive for complement and urine for hemoglobinuria. She was treated with multiple antibiotics with no response. Results of a bone marrow biopsy, cultures, and CT scans were negative. She received solumedrol with resolution of her fevers and was discharged on tapering steroids with a presumed diagnosis of autoimmune hemolytic anemia. She was readmitted with a working diagnosis of fever of unknown origin. Her examination was remarkable for a temperature of 102.5°F. Laboratory analysis was significant for hemoglobin of 8.2 g/dL, platelet count of 94,000, ESRof 112 mm/h, bilirubin of 2.8 mg/dL, and AST/ALT of 189/251IU/L. Hematology, rheumatology, and infectious disease consults were obtained, and extensive specialty‐based studies were ordered. Persistent headaches, fever, and elevated ESR raised concerns for Temporal arteritis. She was started on steroids and underwent a temporal artery biopsy. All her studies including the temporal artery biopsy did not lead to a diagnosis. On the third hospital day, she underwent a liver biopsy and hepatitis workup. The etiology of her symptoms remained unclear until the sixth hospita day when further questioning revealed that she had recently traveled to Cape Cod, Massachusetts, for 2 weeks. 3 weeks prior to her first admission. Tests were then performed for Lyme disease, babesiosis, and ehrlichiosis. Her serologies and thin blood smear confirmed the diagnosis of babesiosis. Tests for Lyme disease and ehrlichiosis were negative. She was treated with atovaquone and azithromycin and discharged home asymptomatic

Discussion:

Travel history is vital in making the diagnosis of babesiosis, a tick‐borne illness. It develops only in patients who live in or travel to endemic areas of the northeastern and northwestern United States. Symptomatic infections are characterized by fevers, headaches, and lethargy. In severe cases, hemolytic anemia, thrombocytopenia, abnormal LFTs, and hemoglobinuria may occur. Infections can be fatal in 5%–10% of cases. The definitive diagnostic test for babesiosis is the identification of parasites on a Giernsastained thin blood smear. Serology and polymerase chain reaction tests are useful when blood smear examinations are negative.

Conclusions:

This case clearly sends hospitalists a strong message that failure to obtain a complete history often results in a missed and delayed diagnosis, thereby potentially leading to inappropriate testing including invasive tests, prolonged hospitalization, unjustifiable cost, and added risk. Cost‐effective and evidence‐based medicine starts with a complete history, including a travel history.

Author Disclosure:

S. Abbas, none.

To cite this abstract:

Abbas S. A History Is Worth a Million Dollar Workup. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 204. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/a-history-is-worth-a-million-dollar-workup/. Accessed September 19, 2019.

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