A 13-Year-Old Girl With Fever After Travel

Colleen Mathis, MD; Kimberly Monroe, MD, MS

Disclosures

January 26, 2018

Editor's Note:

The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 13-year-old girl presents to the emergency department (ED) with 2 months of worsening shortness of breath, malaise, fever, and loose stools. She traveled to Mexico approximately 10 weeks ago; after her trip, she had nonbloody, frequent, loose stools for 2 weeks. She then began having general malaise, with intermittent fevers every 2-3 weeks and dyspnea upon exertion. She reported sporadic shakiness, dizziness, diaphoresis, and tachycardia at rest. She also developed intermittent "burning" head pain and recurrence of loose stools.

She was evaluated by her primary care physician for dyspnea and was prescribed an albuterol inhaler, which had no effect. She had unremarkable pulmonary function testing and chest radiography findings. Inhaled ipratropium, intranasal fluticasone, and omeprazole had no effect. Allergy and otolaryngology specialists believed that her shortness of breath was secondary to vocal cord dysfunction.

Two weeks before her ED presentation, the patient experienced daily fevers for 1 week, with continued loose stools. Her pediatrician obtained stool studies for Salmonella, Shigella, Campylobacter, and Clostridium difficile, which were all negative. No growth on blood and urine cultures was noted, Epstein-Barr serology was negative, and a tuberculin skin test was nonreactive.

The patient was started on amoxicillin for 10 days for presumed sinusitis. Her fever ceased on day 2 of antibiotics but returned, with a temperature as high as 103°F on day 8 of antibiotics, 3 days before her ED presentation. She continued to have up to four loose stools per day. Her headache became more severe and began to awaken her from sleep. She denied upper respiratory infection (URI) symptoms, cough, rash, night sweats, or persistent weight loss. She presented to the ED owing to worsening symptoms and persistent fevers.

Her family history is significant for a paternal grandmother with a rheumatologic disorder and a father with a resected thyroid mass; the etiology of both is unknown. Her social history is unremarkable, other than her recent travel to Mexico and exposure to a dog at home.

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