Case Report
Volume 2 Issue 1
Abstract
Acute onset febrile illness is one of the most challenging disease to physician. It can occur in various infective, inflammatory, neoplastic diseases. Sometimes it is very difficult to find the cause and sometimes it is also difficult to treat.
Clinical Presentation
A 50 years old non diabetic, non-hypertensive male patient presented with acute onset fever for past 5 days and persistant hiccough and drowsiness for last 1 day. Fever was intermittent (twice daily), not associated with chill and rigor. It was associated with generalised weakness and myalgia. There was no history of cough and cold, dyspnea, abdominal pain, dysuria, headache, nausea, vomiting.
On examination, patient was drowsy, GCS 14/15. Neck rigidity was absent. Chest examination revealed mild inspiratory crepitations over left lower zone.
Investigations
Complete hemogram shows Hb 11.5, TLC 3500 (N58L40E1M1), platelet 75000. LDH 780.
Liver function test showed total bilirubin 0.8, SGOT 170, SGPT 44, ALP 92, albumin 3.1, total protein 6.
Renal function test showed urea 51, creatinine 1.5, serum sodium 125, potassium 3.6.
C reactive Protein was 75.5.
Urine examination was normal.
Chest x ray was normal.
USG whole abdomen showed liver 14 cm, spleen 14 cm.
2 D echocardiography- Normal.
Malarial parasite and Dual antigen Negative.
Dengue IgM Negative, Typhidot IgM negative.
Leptospira IgM-positive (titre-1:80).
Scrub typhus IgM-positive (titre-1:80).
Clinical Course
Patient was managed conservatively with Ceftriaxone, Doxycycline and 3% Nacl, But didn't improve. He developed dyspnea and progressive drowsiness.
CSF analysis showed protein 72mg/dl, sugar 54mg/dl.cell count 3, all lymphocytes.
Further examination revealed Triglyceride was 613mg/dl, ferritin was 14540mg/dl.
Bone marrow examination revealed Haemophagocytes.
Management
The patient was diagnosed with Macrophage Activation Syndrome secondary to Scrub typhus and Leptospirosis. He was treated with intravenous dexamethasone along with antibiotics. Patient improved dramatically from third day and he was discharged with oral antibiotic and oral steroid for total 14 days.
Learnings
We have to keep Macrophage Activation Syndrome in our mind while treating a febrile patient who was not responding to antimicrobial therapies rather who was gradually deteriorating because antimicrobials without immunosuppresion in these cases can lead to fatal consequences.
Reference