The possibility of typhoid or paratyphoid in particular is possible
given a relatively low efcacy of the vaccine (5570%) and the history of ice consumption. Examination Observations are as follows: blood pressure 90/60 mmHg, pulse 60 beats/min, temperature 38.9C, respiratory rate 20 breaths/min, oxygen saturations 98% on air. On general examination he appears unwell and lethargic with a greyish pallor. He is not jaundiced; there is no evidence of anaemia, lymphadenopathy, clubbing or cyanosis. There are a couple of blanching, pink maculae on his ank, but otherwise no evidence of rash on his skin. There are ne crackles in both lung bases. His JVP is not visible. Heart sounds are normal, with no ankle oedema. His abdomen is soft but generally tender. The tip of the liver can just be felt, but no other organomegaly or masses are palpable. Bowel sounds are present. He is neurologically fully intact with a Glasgow Coma Score of 15/15. Fundoscopy is normal and he has no neck stiffness. Question: Given the history and examination ndings what is your principal working diagnosis? Principal working diagnosis enteric fever Malaria is still possible. Hypotension and his lethargic, unwell appearance point to this, but the absence of jaundice, pronounced pallor or hepatosplenomegaly casts doubt. Meningitis is unlikely as the headache is not accompanied by meningism. Septicaemia of some type is still possible. Amoebic liver abscess might be a possibility, although one would expect more pronounced right upper quadrant pain and tenderness. The lack of respiratory symptoms or signs makes pneumonia unlikely. Enteric fever is much more likely given the presence of pink macules (possible rose spots), accompanied by diffuse abdominal tenderness, mild anaemia and mild hepatitis, and a heart rate of 60 in a febrile patient. Management This patient requires urgent uid resuscitation and oxygen. Investigation includes full blood count, renal and liver function tests, ESR, CRP and chest X-ray. Three thick blood lms specically for malaria parasites and haemolysis should be sent urgently. Blood, urine, and stool should be cultured. If these do not yield a result, bone marrow aspirate culture should be considered. Do not request a Widal test for typhoid; it has been abandoned by most laborato- ries in the UK due to difculty in the interpretation of results. Your laboratory may have the newer rapid antigen tests available. Urinary antigen testing should be performed if Legionella is suspected. If meningitis is suspected in the absence of a classic meningococ- cal rash, a lumbar puncture should be performed to conrm the diagnosis and identify the organism unless contraindicated. If the history and examination point to pneumococcal meningitis a dose of steroids with the rst dose of antibiotics can improve outcome. As enteric fever is likely, treatment with i.v. ceftriaxone or cefotaxime should be initiated whilst awaiting the microbiological Figure 4.5 Pulmonary tuberculosis. Image kindly provided by Dr Andrew McDonald Johnston, www.doctors.net.uk Figure 4.6 Rose spots in the context of typhoid. Image courtesy of the Health Protection Agency via Doctors mess, www.doctors.net.uk Box 4.1 Non-infective causes of fever Malignancy Autoimmune diseases Drug reactions allergic reactions to, or metabolic consequences of the drug Seizures Environmental fever (due to very high external temperatures, or excessive exercise) Hyperthyroidism Thrombosis Infarction of myocardium, kidney, or lung (auto-immune element) Blood transfusion reaction Atmospheric pollution (e.g. nitrogen dioxide) Factitious fever (Munchausens syndrome/Munchausens by proxy) High Fever 17 results and sensitivity testing. The patient may require inotropic support. Management in an infectious diseases unit is appropriate. Outcome This patients investigations showed negative malaria lms, mild anaemia, lymphopaenia, mild abnormalities of liver function and a normal chest X-ray. His ESR was 87 and CRP 264. Salmonella Typhi subsequently grew on stool culture. He was managed in an infec- tious diseases unit with uids and intravenous ceftriaxone, and was monitored for development of ileal perforation by measuring girth size. He made a full recovery. Further reading Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infectious Diseases 2005; 5:623628. Cook GC (Ed.). Mansons Tropical Diseases, 21st Edition. Saunders, London, 2003. Felton JM, Bryceson AD. Fever in the returning traveller. British Journal of Hospital Medicine 1996; 55:705711. Health Protection Agency website: www.hpa.org.uk Heyderman RS on behalf of the British Infection Society. Early management of suspected bacterial meningitis and meningococcal septicaemia in immunocompetent adults. Journal of Infection 2005; 50:373374. Also www.meningitis.org Lalloo DG, Shingadia D, Pasvol G et al. UK malaria treatment guidelines. Journal of Infection 2007; 54:111121. Ledingham JG, Warrell DA. Concise Oxford Textbook of Medicine. Oxford University Press, Oxford, 2000. Spira AM. Assessment of travellers who return home ill. Lancet 2003; 361:14591469. www.britishinfectionsociety.org www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/ DH_4097254. Immunisation against Infectious Disease the Green Book. www.wrongdiagnosis.com/f/fever/causes.htm 18 CHAPTER 5 Vaginal Bleeding Sian Ireland and Karen Selby ABC of Emergency Differential Diagnosis. Edited by F. Morris and A. Fletcher. 2009 Blackwell Publishing, ISBN: 978-1-4051-7063-5. Question: What differential diagnosis would you consider from the history? The differential diagnosis of heavy vaginal bleeding is listed in Box 5.1. This woman could be pregnant as she has not had a period for 8 weeks. Bleeding in early pregnancy is most often due to a mis- carriage, but ectopic pregnancy is the other important diagnosis to consider. Miscarriage Spontaneous miscarriage is the loss of a pregnancy before 24 weeks gestation. It is thought that around 1020% of pregnancies result in spontaneous miscarriage. The majority are due to embryonic abnormalities with a small percentage attributable to maternal health factors such as diabetes, renal disease, autoimmune dis- orders, trauma and infections, or structural abnormalities of the reproductive tract (see Figure 5.1). Threatened miscarriage. This is vaginal bleeding during 1 early pregnancy without the passage of tissue. The cervi- cal os remains closed and a viable pregnancy is seen in the uterus. About half will progress to an actual miscarriage. The bleeding and accompanying pain is not usually severe, and on vaginal examination the os is closed and there is no cervical excitation. Inevitable miscarriage. There is dilatation of the cervical canal 2 and bleeding is usually more severe. Incomplete miscarriage. Vaginal bleeding is more intense and 3 accompanied by abdominal pain. On vaginal examination the os is open and tissue is being passed. The presence of tissue in the os itself can cause cervical shock low blood pressure accompanied by bradycardia due to vagal stimulation. If the tissue is removed with sponge forceps the shock will usually resolve. Complete miscarriage. This is said to have occurred when the 4 fetus and the entire placenta have been passed. There is a his- tory of vaginal bleeding and pain which has usually subsided. Ultrasound scan reveals an empty uterus. Delayed or missed miscarriage. This can only be diagnosed by 5 ultrasound scan when a gestational sac with a mean diameter of more than 20 mm is seen but there is no fetal pole, or a fetal pole greater than 6 mm is present but no fetal heart pulsation is detected. These may present with slight vaginal bleeding. Ectopic pregnancy This occurs when a fertilised ovum implants at a site other than in the uterus. Most often it occurs in the fallopian tubes but also occur within the abdomen, cervix or ovary (see Box 5.2 and Figure 5.2). CASE HISTORY A 36-year-old, obese, diabetic woman presents with a 5-day history of heavy vaginal bleeding. She is passing clots and using more than 10 pads per day. The bleeding is accompanied by right-sided lower abdominal pain that is constant and becoming more severe. She has not vomited but has lost her appetite. In her early twenties she was treated for a sexually transmitted infection. She has a long history of irregular periods attributed to polycystic ovary syndrome (PCOS), and has previously tried clomiphene in order to try to become pregnant. Her last menstrual period was 8 weeks ago but given her menstrual irregularity she is not overly concerned by this. She is sexually active and is not using any contraception. She has no other medical problems and there is no family history of a tendency to bleed. Box 5.1 Causes of vaginal bleeding Non-pregnant Dysfunctional uterine bleeding Cervical erosion Cervical polyps Infection Malignancy Early pregnancy Spontaneous miscarriage Ectopic pregnancy Late pregnancy Placental abruption Placenta praevia
Serum Ferritin and Iron/TIBC of Pregnant Women Attending Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria: A Longitudinal Study