Medical Mystery Solved – A Treacherous Course | NEJM

Summary

Mr. M, a 33-year-old Spanish-speaking man, sought emergency care in Massachusetts with severe symptoms including hemoptysis. Initial tests and broad-spectrum antibiotics were inconclusive. His travel from Mexico and arduous journey raised suspicion of leptospirosis, confirmed by a positive serologic test. Despite multiorgan failure, he fully recovered after a 2-week antibiotic treatment, highlighting the importance of thorough patient history in diagnosing rare diseases.

Takeaways

• 🩺 Building trust is crucial in medicine, especially when gathering patient history for diagnosis.
• 🌐 Language and cultural barriers can complicate medical diagnosis and treatment.
• 🏥 Mr. M's symptoms, including hemoptysis, fever, and respiratory distress, indicated a serious medical condition.
• 🔍 Initial tests showed signs of infection and potential liver damage, but the cause remained unclear.
• 💊 Broad-spectrum antibiotics were administered as part of the initial treatment protocol.
• 🔬 Further tests, including bronchoscopy, helped pinpoint the source of bleeding in the lungs.
• 🌿 The patient's travel history was a critical clue to diagnosing leptospirosis, a disease often associated with exposure to contaminated water or soil.
• 🌡 Leptospirosis can mimic other diseases, making it challenging to diagnose without a detailed patient history.
• 💉 Treatment for leptospirosis typically involves a course of doxycycline or penicillin.
• 🌱 Climate change may increase the prevalence of leptospirosis due to more frequent flooding and extreme weather.
• 📝 The importance of a thorough patient history, including travel and social details, is emphasized for accurate diagnosis and treatment.

Q & A

What was the initial complaint of Mr. M. when he went to the emergency room?

Mr. M. complained of nausea, vomiting, abdominal pain, fever, and coughing up blood for two days.

What language did Mr. M. speak and how did the medical staff communicate with him?

Mr. M. spoke only Spanish, and the medical staff used a medical interpreter to communicate with him.

What was the initial physical examination of Mr. M. revealing?

The initial physical examination showed mild respiratory distress, fever, elevated heart rate, and moderate tenderness in the upper abdomen.

What did the chest radiograph and CT scan reveal about Mr. M.'s condition?

The chest radiograph and CT scan showed multifocal, patchy opacities in both lungs, which could indicate an infectious process.

What was the initial treatment given to Mr. M.?

Mr. M. was initially treated with broad-spectrum antibiotics, including intravenous vancomycin and piperacillin–tazobactam.

What were the abnormal lab results for Mr. M.?

The lab results showed low sodium and potassium, mild kidney injury, abnormal liver tests, a high percentage of neutrophils, mild anemia, low platelet count, and a mildly elevated partial thromboplastin time.

What was the presumptive diagnosis after bronchoscopy and bronchoalveolar lavage?

The increasing hemorrhagic return on bronchoalveolar lavage suggested alveolar hemorrhage, leading to a presumptive diagnosis of diffuse alveolar hemorrhage.

What additional information did the patient's family provide that was crucial for diagnosis?

The patient's family provided information about Mr. M.'s recent journey from Mexico to Massachusetts, which included swimming across the Rio Grande and hiking through the wilderness.

What was the final diagnosis of Mr. M.'s condition?

A serologic test for IgM antibodies to leptospira species was positive, leading to a presumptive diagnosis of leptospirosis.

How is leptospirosis typically transmitted and what are the common reservoirs?

Leptospirosis is transmitted through contact with urine of infected animals or contaminated water or soil, with rodents being the main reservoir.

What was the treatment for Mr. M.'s leptospirosis and how long did he require hospitalization?

Mr. M. was treated with a broad-spectrum antibiotic regimen including doxycycline and penicillin for a total of 2 weeks. He was discharged 6 weeks later after making a full recovery.

Why is obtaining an accurate travel and social history important in cases like Mr. M.'s?

Obtaining an accurate travel and social history is important to pinpoint a possible environmental vector, which is critical to making the diagnosis and guiding the treatment, especially for diseases with symptoms common to other conditions.