Majority of the cases at the hospital are common cases and so they come with common symptoms but when these patients come and the medical team are on the note that they have a common symptom, it can become a challenging situation to recognize when common symptoms becomes uncommon.
This is the case of a 20 year old lady who went to her pediatrician with complains of having had 3 days of cough, malaise, throat pain, and chills. The doctor requested for her vitals which were normal just like it is usually like for most patients that come to report their symptoms unlike emergency cases. The doctor performed physical examination and noticed she had tender, and enlarged lymph nodes in her neck. She had a red throat and swollen tonsils.
A strep test was done on her and it came back negative, so the doctor performed a throat culture, prescribed Ibuprofen and advised her to take more fluids. She went home but was back the next day with worse pain than the previous day, and difficulty swallowing (dysphagia), and she had a muffled "hot potato" voice even when she could speak properly. On this day, her vitals were normal with no fever but still had enlarged lymph nodes and tonsils.
The doctor question her and she mentioned that her roommate just suffered from a respiratory infection. Back to her history, she ones suffered MRSA cellulitis as a child and a left carotid body resection for a benign tumor, and although she had all her routine vaccinations she had not been on any long-term medication. In other to understand what was going on, the physician ordered a complete blood count and mononucleosis spot test but they both came back negative. The doctor prescribed a dose of Oral dexamethasone, and Acetaminophen. The following day, Serologic testing for IBV IgG antibody to Early IgG Antigen returned negative while EBV IgG, IgM, and EBV IgG antibody nuclear antigen came back positive.
On the third day, case became worse as patient returned to the Emergency department with shortness of breath, muffled voice, pain swallowing, and extreme throat pain. She was not in any obvious distress but had a faster than normal heart rate. She was given 1 liter of IV fluid which helped with her heart rate she was also given Benzocaine spray after a blood work showed a slightly reduced platelet count. She went for home but was back 3 days later with worsen situation including foul-smelling breath, secretion in her respiratory tract, worsening cough, throat pain, and also reported that she vomited three times within the past 3 days.
At this time, the patient looked ill and anxious, she had a fever as well as rapid heart rate and respiration. The patient experienced pain on the left side of her neck when she turned her head to the right. Blood work done on her showed elevated white blood-cell count, anemia, low platelet count, metabolic acidosis, and sign involving kidney dysfunction. She was then given acetaminophen about 1000mg but over the next 2 hours, she became more agitated, temperature rising, and increased heart rate.
A chest x-ray was done and abnormalities in the lungs were seen as the lungs were filled with fluid and solid material which were most likely infection. CT scan showed blood clot in the left lingual vein of the neck. The patient was then placed on broad spectrum antibiotics. The patient was transferred to the ICU and was helped with her breathing as she was placed on oxygen. She was given vancomycin, cefepime, and metronidazole, also Dexamethasone was administered for the fullness of the tonsils. CT showed there was seeding of bacteria to the lungs and small pocket of air in the right clavicle. Cultures from the patient showed gram negative bacilli and the culture showed Fusobacterium Necrophorum.
The patient was treated with Piperacillin-tazobactam, and the clavicular tissue that was damaged was removed surgically. The patient became well post-surgery but still continued on Daptomycin, Ceftriaxone, and Amoxicillin-clavulanate for the next 6 weeks. Her signs were similar to mononucleosis but the result didn't give that. The doctors treated her for just the common symptoms and it led to the deterioration of her case.
Post Reference
https://www.nejm.org/doi/full/10.1056/NEJMcps2100980
https://www.nejm.org/doi/full/10.1056/NEJMimc2103214
Image Reference
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