28. The Summer Fever

‘Oh my God! She’s the cutest, just like her mom.’

On a rare slow morning in the ICU, I decided to stop by Jane’s floor before rounds. Jane was the nurse I had worked with for most of my intern year and also one of my first friends in residency. She had been out on maternity leave for a while and had just returned to work.

‘I know, right?’ Jane answered. ‘I still don’t know how she came out of me.’ She smiled proudly as she went through little Ellie’s photos. 

I remember I was thinking about how radiant and joyful Jane looked that morning when my pager went off. I had a new admission before rounds. 

‘Sorry, Jane, I gotta go! Will catch up with you later.’

‘Sure, Lisa, don’t worry about it.’ She said without even looking up from her phone but her smile was still full as she was watching a video of Ellie giggling.

I rushed through the hospital to get back to the ICU. It was almost time for rounds already, so I had to pick up the pace and check her chart.

Mia Santos, 25 years old. She had gone to the ER that day after a history of 5 days of headache, body aches, fever, and vomiting. That morning she was still feeling terrible and had started with abdominal pain and bloody vomits. They stabilized her in the ED and started Ms. Santos’ workup which showed 15.000 platelets, leukopenia, and increased AST and ALT.

Interesting. I quickly glanced at her previous history but there was nothing there so I walked to her bedside.

‘Good morning, Ms. Santos. I am Dr. Diaz, I will be taking care of you today, alright?’

‘Hi.’ She smiled weakly. ‘Alright, thank you.’

‘So how are you doing right now? Is there something bothering you?’

‘I still feel very weak. But the body pains and nausea improved a little after I got these medications in the ER.’ She pointed to the IV in her arm.

‘I see.’ I nodded. ’I already read a little about what’s going on with you in your chart, but I would love to hear it from you as well. Do you mind telling me from the start?’

‘Not at all. I’ve been feeling sick for maybe 5 days now.’ She tried to straighten up on the bed. ‘It started with the chills and a lot of body pain and headache. I felt like staying in bed all day long. And the fevers were rough, tylenol and ibuprofen were not helping. I thought I was catching a cold or something. But no cough or anything like that. Just pain and fever, and lots of vomiting.’

‘Right.’ I nodded.

‘The fever finally broke a couple of days ago.’ She continued. ‘But the vomiting worsened. I had some gum bleeding, and then today I had all this bloody vomiting which brought me here.’

‘Ok. Anything else?’

She scratched her head. ‘Oh yes! I also had a pink rash.’ She pulled up her sleeves. ‘It’s fading now but it started on my hands and then it spread everywhere.’

‘I see.’

‘But now that the rash is almost gone there are some dark spots appearing randomly.’ Mia pointed to the petechiae on her left forearm. Yep, I thought to myself, 15.000 platelets can do that to you. 

Going forward with our conversation, I found there was really nothing of note in her previous medical history. However, suspecting something infectious was going on with her, I decided to dig a little deeper.

‘And what do you do?’

‘I’m a mom.’ She answered with a smile just like Jane’s. ‘I also work at a department store, but being a mom is definitely my proudest accomplishment.’

‘Congrats!’ I said smiling back. ‘Sounds like someone I know.’

‘Thank you.’ She winked. ‘But anyway I’m on vacation right now.’

‘Bummer.’ I said. ‘I’m sorry you got sick on your vacation.’

‘Right?’ She laughed playfully. ‘But it’s okay, I got to enjoy most of it, I went to see my grandparents in Brazil.’

‘Really?!’ Jack-pot. ‘When did you come back?’

‘A week ago.’

I felt like asking her more questions. Even though Mia looked very ill, she was so warm and easy to talk to. I checked my watch again, no more time at all, rounds were about to start. Honestly, I didn’t even have time to perform a proper physical on her. What I could tell from our brief encounter was that she was ill-appearing, dehydrated, with petechiae and a fading rash. That would have to do it. I excused myself and told her I would be back later that day.

I don’t remember much about the other patients we discussed that day, but I do remember presenting Mia’s case to the team.

‘Interesting case.’ Dr. O’Brian, the ICU attending that day, said when I finished. ‘So what are you thinking?’

‘I am thinking Ms. Santos has an acute febrile illness, probably a tropical infectious disease.’

‘I agree.’ He said and tapped his fingers at the table. ‘And what’s the bug here? We could call ID to discuss this one.’

‘Yes! I can call them right away.’

‘Great. But before that. Any thoughts, people? What do you guys think this is?’ Dr. O’Brian asked everyone in the multidisciplinary rounds. 

After a moment of silence, he continued. ‘It’s not a tricky question. I have some ideas, but I am really not sure. It’s actually the first time I see a case like this. I would love to hear it from you.’

Laura, an intern from another resident, raised her hand shyly.  

‘Yes, Dr. Mendes.’ O’Brian said and frowned. ’Aren’t you from Brazil, Dr. Mendes?’

‘Yes, I am.’ Laura smiled more confidently. ‘I have actually seen many cases like this one back when I practiced in my country.’ We all turned to her, both curious and surprised, as we waited for her to finish her thoughts.

‘It’s Dengue Fever. In her case, the hemorrhagic kind. And the timing fits as well. It’s winter here which means it is summer there, when all the mosquitoes come alive. We have surges every year around this time in Brazil.’

‘Very good, Dr. Mendes. I think you may have given us the answer, so go on, how would you treat her?’

‘Well, it’s mostly supportive, but all our protocols tell us to hydrate well and keep an eye out for hemoconcentration which usually precedes shock. Is her hematocrit elevated?’

I looked at my notes and quickly found what she wanted to know. ‘Yes.’ I said surprised. ‘It actually is.’

‘So she’ll definitely need fluids. Lots of it.’

‘Let’s get this moving then! Dr. Mendes, you help Dr. Diaz discuss the case with ID and tell them your impressions, alright? Send labs to confirm the diagnosis as well.’ Dr. O’Brian got up to leave. ‘Great work everyone. Keep me posted.’

‘Oh my God, that was so badass, Laura.’ I whispered to her as the rounds team was leaving the room.

She laughed. ‘You have no idea how many patients I saw with this. I call it the Summer Fever.’

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SS: signs and symptoms; Tt: treatment.

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