The Missing Test: A Case of Delayed Diagnosis

1Lutheran Medical Center, Wheatridge, CO

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 408

Case Presentation:

A 57‐year‐old man with diabetes mellitus, hypertension and hyperlipidemia presented to the emergency department (ED) with fevers, rigors, and malaise for 72 hours. In the ED, vitals were normal except for temperature of 102.7 °F. He was in no distress. Labs were normal except Na 128, AST 61, and ALT 70. Urinalysis was normal except for glucose 50‐70. A right upper quadrant ultrasound showed only biliary sludge without evidence of cholecystitis. A chest x‐ray was normal. The patient was admitted. There had been no recent travel and no history of tuberculosis exposure. There were no pets at home. His ezetimibe + simvastatin was held, and he was observed off antibiotics. High spiking fevers would persist in paroxysms (up to 104.1 °F) for the next 48 hours. CT scan of the chest, abdomen, and pelvis would show a 5‐mm area of ground‐glass opacity in the lung, fatty liver, prostatomegaly, and adrenal nodule (likely adenoma). A CT of the sinuses was negative. He would feel well except when bouts of fevers, sweats, and rigors would overcome him, usually twice a day. On hospital day (HD) 3, Zosyn and vancomycin were started. His liver function tests (LFTs) would continue to show mild elevations: (ALT, 50‐180s; AST, 70‐170s), but all previous lab abnormalities would normalize. Cultures of urine and blood would remain negative. On HD 6 a liver biopsy showed granulomatous hepatitis. Serologies for West Nile, Brucella, Q fever, HIV, influenza, Yersinia enterolcolitica and Y. pseudotuberculosis, Mycoplasma pneumoniae, Chlamydia psittaci, Epstein‐Barr virus, toxoplasmosis, rapid plasma reagin, and cytomegalovirus did not reveal evidence of acute infection. Acute viral hepatitis panel was negative, as was a protein purified derivative. A transthoracic echocardiogram showed no vegetations. Rheumatologic markers were negative. Antibiotics were stopped on HD 6. On HD 8 he was feeling better, and fevers were running lower than on admit (∼100.5°F). He was released for close outpatient monitoring. Just 5 days after discharge, he was readmitted with worsening fevers. His abnormal labs on admit were hematocrit 30, platelets 555, and Na 132. His LFTs had normalized. Antigen and/or antigen testing for Cryptococcus, histoplasmosis, Coccidiodes immitis, tularemia, and Trophyerma whippeli were negative. Biopsy of a temporal artery, colonoscopy, and bone marrow biopsy were unrevealing. On HD 7, it was discovered that Coxiella brunetti testing previously done had revealed positive IgM and negative IgG to both phase I and phase II antibodies. The patient was released on doxycycline therapy, and his symptoms resolved.

Discussion:

Q fever is a rare zoonotic infection caused by Coxiella brunetti. It is most often a self‐limited flu‐like illness. However, its next most common manifestations are hepatitis and pneumonia. Hepatitis characteristically reveals granulomatous inflammation. We postulate that our patient acquired Q fever by eating unpasteurized cheese from Mexico.

Conclusions:

Persistence is key in diagnosing fever of unknown origin. Securing the correct diagnosis requires not only the correct differential but also close attention to each test result.

Hospital Medicine 2011 Abstracts S257

Disclosures:

J. Strohecker ‐ none; N. Fujita ‐ none

To cite this abstract:

Strohecker J, Fujita N. The Missing Test: A Case of Delayed Diagnosis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 408. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/the-missing-test-a-case-of-delayed-diagnosis/. Accessed July 21, 2019.

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