Name:
A 20-Year-Old with Fatigue and Fever
Description:
A 20-Year-Old with Fatigue and Fever
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/fa032860-3973-4d22-9f55-9411548e89d7/thumbnails/fa032860-3973-4d22-9f55-9411548e89d7.jpg?sv=2019-02-02&sr=c&sig=NCkOKCB5hq%2BhDVaFmeFmzBdJGsOUGPwjXY1kClfdEws%3D&st=2024-05-02T23%3A29%3A09Z&se=2024-05-03T03%3A34%3A09Z&sp=r
Duration:
T00H07M16S
Embed URL:
https://stream.cadmore.media/player/fa032860-3973-4d22-9f55-9411548e89d7
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/fa032860-3973-4d22-9f55-9411548e89d7/18832046.mp3?sv=2019-02-02&sr=c&sig=dMUvY%2Ba52vL8N0OKTHnpNvZDxTRUoCQZZS00kzglK%2FM%3D&st=2024-05-02T23%3A29%3A09Z&se=2024-05-03T01%3A34%3A09Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to episode 64, a 20-year-old with fatigue and fever.
DR. WIENER: A 20-year-old man presents with four weeks of fatigue, fever, headaches, and myalgias. He was previously seen in urgent care for these symptoms and was prescribed a course of antibiotics after ruling out COVID-19 infection. He returns today after completing his antibiotics reporting that his symptoms have persisted, and now he has notable throat pain on trying to swallow solids or liquids, as well as a rash on his trunk.
DR. WIENER: The symptoms have led him to take a leave of absence from his college courses.
DR. HANDY: So what we have so far is the young man who's been ill for about a month based on the time course. He tried a course of antibiotics and it didn't have any clinical improvement. Initially because of that, I think it's reasonable to think that this might be a common viral syndrome, but you would expect the symptoms to resolve at this point. Now I'm not sure exactly what antibiotic he received, but without any response, you have to think that this is either non-infectious in etiology, potentially oncologic, or would be a less common infectious etiology or something not covered by the antibiotics.
DR. HANDY: Can you tell me more about his medical and social history before an exam?
DR. WIENER: Okay, sure. He's a college student and lives in a large metropolitan city. He has no past medical history, takes no medications, he grew up in the suburbs and has had no recent travel. He's up-to-date with all his vaccinations. There is no family history of cancers. He does admit a vigorous and diverse sexual life with men and women, typically characterized by unprotected oral, vaginal, and anal sex.
DR. HANDY: Well, based on that, living in a college dorm and his sexual history would put him at risk for a number of infections. Tell me about his physical examination.
DR. WIENER: Okay, his vital signs are notable for a temperature of 38.5 Celsius, heart rate of 105, blood pressure of 110 over 65, a respiratory rate of 18 and a room air saturation of 97%. His oral exam is notable for a diffusely red and tender pharynx with multiple white plaques on the soft palate and on the posterior pharynx. His tonsils seem diffusely enlarged. He has bilateral anterior and posterior lymphadenopathy with the largest nodes about two centimeters in diameter.
DR. WIENER: His lungs, heart, abdominal exam are normal. His spleen is not palpable, but he does have a diffuse maculopapular rash on his thorax and on his back.
DR. HANDY: Well, based on what you told me with the rash, the lymphadenopathy, the oral exam, his vitals and the social history, acute HIV has to be high on the differential diagnosis.
DR. WIENER: Tell me more about acute HIV.
DR. HANDY: It's estimated that about 50 to 70% of individuals with HIV infection will experience an acute clinical syndrome, that's about three to six weeks after the primary infection. And the period of acute viremia and the syndrome can present similarly to other viral illnesses, such as mono, for example. His presentation would be pretty typical and that includes thrush, which it sounds like he might have on exam.
DR. HANDY: Thrush appears as a white, cheesy exudate often on an erythematous mucosa in the posterior oropharynx. And while most commonly seen on the soft palate, early lesions are often found along the gingival border. You can make the definitive diagnosis by direct examination of a scraping for pseudohyphal elements. The maculopapular rash is also pretty common and is non-specific. It looks like the maculopapular rash of many acute viral syndromes.
DR. HANDY: But patients may also get acute bronchitis and sinusitis with acute HIV infection.
DR. WIENER: So, based on what you've said, you have a high index of suspicion for acute HIV. And in this case, the history really helped. How's the diagnosis confirmed?
DR. HANDY: Because the viremia is acute, you have to measure a viral load directly by PCR. Antibody tests will probably not be positive for a few more weeks, at least.
DR. WIENER: Okay, so let's get to the question. The question asks, the patient is at risk for developing which of the following in the future? And the options are A. encephalitis; B. epiglottitis; C. opportunistic infections; D. postherpetic neuralgia; or E. splenic rupture.
DR. HANDY: So, of these choices, my answer is C. He's at risk of opportunistic infections, if he doesn't receive appropriate therapy. And like I mentioned before, the thrush would be one example of that.
DR. WIENER: Okay, so we're basing that on the presumption that he has acute HIV and will develop HIV. Why are the other options not correct though?
DR. HANDY: The encephalitis in terms of infectious diseases refers likely to the dreaded neurologic complication of measles, which is a subacute sclerosing panencephalitis. Measles is having a resurgence in the U.S. so that should remain on our differential, but the patient does not have the typical rash of measles, that would be red bumps that start on the face and track downwards, plus he reports to being up-to-date on all of his vaccinations.
DR. HANDY: I will say that encephalitis can be a complication of HIV, but opportunistic infections, like thrush would be more common. His examination was not consistent with epiglottitis, and while he did report some dysphagia, it wasn't acute and he didn't report any drooling.
DR. WIENER: And about epiglottitis, we should also add that widespread use of the H. influenza type b vaccine, a major cause of acute epiglottitis has really decreased the frequency or the prevalence of epiglottitis.
DR. HANDY: Yeah, that has significantly improved rates in children where it occurs more commonly. Just to round out the remaining answer choices, postherpetic neuralgia is a complication of herpes zoster or shingles. The rash of zoster is a dermatomal vesicular rash and is not diffusely maculopapular like this patient had. And finally, splenic rupture can be a complication of mononucleosis, which is a good thought here but he has no splenomegaly and it would not explain the thrush.
DR. HANDY: Remember that patients with mononucleosis that receive ampicillin often do develop a maculopapular rash.
DR. WIENER: None of the answers really referred to any oncologic causes, which you had mentioned earlier also.
DR. HANDY: Yeah, we stopped talking about that early on, as the case presented. Lymphomas are common cancers in young adults that can present like this. Solid tumors in a young person like this, I would be thinking of testicular cancer or sarcomas or melanoma, and these can also occur, so initially, your thinking would be broad, but as we learn more about the case we can narrow where to begin our initial evaluation.
DR. WIENER: Okay, great. So the teaching points here are that acute HIV infection may present in a fashion similar to many other acute viral syndromes or even malignancies that are common in young people. The diagnosis may be suggested by the history and diagnosis requires testing for HIV RNA with a PCR test.
DR. HANDY: And you can read more about this in Harrison's chapters on cardinal presentation of disease and on HIV infection. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine, Go to accessmedicine.com to learn more.