86 year old man with GI upset and a fever that refuses to go away.
In medical school we were taught: 90%of the diagnosis are made by taking a good history.
An 86 year old man was admitted with GI upset (intermittent nausea and vomiting) that was unrelenting. He had been feeling sick for about 2 weeks. He had been to his primary doctor already and had been told that he probably had "viral gastroenteritis" - essentially the stomach flu. When after 5-6 days he wasn't feeling better he decided to see a Gastroenterologist. He underwent a battery of tests... stool studies, blood tests, colonoscopy, endoscopy... however nothing was found.
In all of this his platelet count had been running low and he had been advised to see a hematologist. Because the GI issues seemed more pressing he hadn't seen one yet.
Then he developed a fever.
This is when doctors get worried. Until a fever develops someone's problem is a "chronic condition" but, with fever it's an acute one. He was advised to go to the hospital immediately by his primary care doctor.
As this was a "new" development patient underwent a whole new fever work up. First we looked for the common things: no urinary tract infection, no pneumonia, no skin infection and no obvious blood infection. His physical exam wasn't consistent with meningitis and this wasn't during flu season so no point in checking for that.
As we weren't finding anything we decided to broaden our thinking.
Me: Have you ever been diagnosed with Lyme's disease?
Patient: No never.
Daughter (who was in the room): Why are you asking about that?
Me: We have to start looking for other things that could be causing your dads fever because the work up so far hasn't turned up anything.
Patient: I mean I have been bitten by ticks but I have always taken them off ASAP.
Me: Oh? Has anyone ever checked you for Lyme after those tick bites?
Patient: Yes each time and it has always been negative.
Me: (Ageism taking over) But I have to imagine this was a while ago?
Patient: No, no...I was just checked like 2 weeks ago.
Me: You got a tick bite 2 weeks ago?!?
Patient: Well 4 weeks ago - my doctor wanted to wait a bit before checking...but yea? Why do you seem so surprised?
Me: I mean, you have to be outside to get a tick bite as in, go into a wooded area where mice or deer are...I can't imagine at your age you are doing much of that?!?
Daughter: Haha - he hikes practically every other day in the summer!
Me: (Incredulous) Like..you are outside walking around and, going up and down trails?
Patient: (Laughing at me) Sonny I go camping with my friends every summer and yes I am out in the woods all the time...It's this fever that's got me down!
Me: (starting to accept that maybe some older people are very active) Okay Okay...so you have been checked for Lyme though?
Patient: Yes and I was told everything was fine.
Me: (light bulb goes on) Okay...in that case, I am gonna check you for the other diseases that travel with Lyme...I think I know what's going on.
Patient: What are you thinking??
Me: The tick that gives you Lyme can be co-infected with three other bugs: Babesia, Anaplasma and Ehrlichia - besides the Lyme. I wonder if you have one of these three but not the Lyme?
Patient: Wouldn't they have picked it up when they checked me for Lyme's disease?
Me: No, not at all...first of all you have to specifically check for these bugs - which your doctor might not have done because they are a lot less common than Lyme. Secondly, just like Lyme they give you fever which you really haven't had until now - so honestly speaking if you came to my office after a tick bite but no symptoms I wouldn't have checked you for them either.
So I send off for the three diseases and what do you know - he's got Babesia. In hindsight it was probably why his platelet count was so low.
Simple question might have caught this earlier: "Sir, do you go out for walks in woods or do you do a lot of yard work?"
Until next time!