December 2012 Critical Care Case of the Month: Sepsis-like Syndrome in a Returning Traveler

Eric Chase, MD

Eric Ong, MD

John Bloom, MD

University of Arizona

Division of Pulmonary and Critical Care Medicine

Tucson, AZ

History of Present Illness

The patient is a 56 year old male with a past medical history that is significant only for well controlled hypertension presenting with acute onset of fever, hematuria, jaundice and fatigue. He had been hospitalized in Mexico for the last 5 days. When he failed to improve his friends chartered an airplane and brought him to the U.S. Prior to his hospitalization in Mexico he had traveled to Sierra Leone related to his work as a geologist.

PMH, SH, FH

Past Medical History: Hypertension, gastroesophageal reflux disease

Past Surgical History: Vasectomy

Medications:  Omeprazole, Lisinopril

Social History:  Works as a geologist with recent travel to Sierra Leone, no history of alcohol abuse, intravenous drug abuse, or HIV

Physical Examination

Vital signs: Temperature 97.5° F, Pulse 87 beats/min, Respiratory Rate 18 breaths/min, Blood Pressure 111/84 mm Hg, and SaO2 89% on room air. 

The patient was initially alert, oriented and appropriate.

His pulmonary examination revealed faint bibasilar rales. 

His abdomen was obese, soft, non-tender and non-distended. 

His skin had obvious jaundice and his sclerae were icteric. 

He later decompensated, became altered and developed significant tachypnea.

Admission Laboratory Studies

Significant initial laboratory studies are as follows:  Hemoglobin 11.5 g/dl, Hematocrit 35%, Platelet Count 25,000/uL, Chloride 115 mMol/L, CO2 17 mMol/L, BUN 35mg/dL, Creatinine 1.6 mg/dL, Albumin 1.5 g/dL, Total Bilirubin 13.2 mg/dL, ALT 38 IU/L, AST 97 IU/L, INR 1.7, Fibrinogen 270 mg/dL, D-Dimer 8.37 ug/ml, Venous Lactate 3.9 mMol/L, Urinalysis: Small Blood, 2 RBCs/HPF, Moderate Bilirubin, Urobilinogen 2.0 mg/dL.                    

As part of the workup for possible hemolysis a peripheral blood smear was obtained (Figure 1).

Figure 1. Peripheral smear of the patient’s blood.

Which of the following is the diagnosis?

1. Malaria
2. Babesosis
3. Ehrlichiosis
4. Relapsing fever
5. American trypanosomiasis (Chagas disease)

Reference as: Chase E, Ong E, Bloom J. December 2012 critical care case of the month: sepsis-like syndrome in a returning traveler. Southwest J Pulm Crit Care 2012;5:279-85. PDF