A report describes a case of a 32-year-old man with no antecedent comorbidities who presented with an acute onset high-grade intermittent fever with chills and rigors, headache, myalgia, abdominal pain, and vomiting. He took oral anti-malaria medications, oral ciprofloxacin, and antipyretics with no improvement. 

The patient was an agricultural research fellow and routinely spent much time outdoors in farms and fields. Physical examination revealed an acutely ill-looking febrile patient with a temperature of 38.9°C, blood pressure of 120/70mmHg, a pulse of 92 beats per minute, and a respiratory rate of 24 cycles/minute. No other significant findings were present. 

His laboratory evaluation revealed a leukocyte count of 7,090/μl, of which 84.7% were neutrophils, hemoglobin of 14.5g/dl, and platelet count of 89,000/μl, along with prolonged Activated Partial Thromboplastin Time (APTT) and prothrombin time, slightly elevated INR and markedly elevated D-dimer. The significant renal biochemical finding was creatinine of 1.5mg/dl, and the liver biochemical finding was an AST of 223 IU/l and an ALT of 70IU/l. Urinalysis revealed microscopic hematuria. He thus received Intravenous ciprofloxacin, metronidazole, and parenteral artesunate.

In the following review, he showed the temperature as 39.2°C, pulse as 102 beats/minute, and tenderness on the right iliac fossa as well as suprapubic areas. He then received ceftriaxone instead of ciprofloxacin and additional metoclopramide to control the vomiting that had continued since admission. 

On the fourth day of admission, the patient complained of rhinorrhea, which appeared as a mildly inflamed pharynx with no significant regional lymph node enlargement on examination. His displayed pulse as 82 beats per minute, blood pressure as 110/70mmHg, respiratory rate as 32 cycles per minute, and reduced breath sounds in the middle and lower zones. Chest X-ray revealed perihilar patchy opacities worsening on the right with few patchy opacities on the right upper and lower zones. Suspecting a sub-optimally treated community-acquired pneumonia, he received an addition of azithromycin for atypical pathogens. The next day, his body temperature remained at 40.5°C despite regular antibiotics, along with a pulse of 100 per minute, blood pressure of 130-170/60-100mmHg, respiratory rate of 62 cycles per minute, and SpO2 of 79-81% while breathing ambient air. Percussion notes stood dull on the right lower zone, and breath sounds were vesicular, combining coarse crackles and rhonchi on the right lower zone.

A repeat laboratory evaluation revealed worsening microscopic hematuria, thrombocytopenia, and leukocytosis of 11,720/μl. Blood film for malaria parasite detection remained repeatedly negative. The patient then received supplemental intranasal oxygen at 4L per minute, Loratadine, and amlodipine, and was transferred to the Intensive Care Unit (ICU) for respiratory support, where his dyspnea improved with oxygen therapy by face mask. SpO2 on oxygen therapy remained between 93% and 97%, Respiratory rate as 26 cycles/minute, Pulse as 88 beats per minute, and blood pressure as 135/76mmHg. However, the patient remained with a high-grade fever and tachypnea and developed diarrhea with dark-colored stools over the next three days. 

On the 10th day of admission, he obtained a positive result for viral hemorrhagic fever screening detecting the dengue virus. He continued to receive supportive management. After 16 days of conservative management, the patient recovered uneventfully and received a discharge. He described normal blood pressure with no medication after a year of follow-up.

Pan Afr Med J. 2019 Oct 5;34:74. doi: 10.11604/pamj.2019.34.74.20373. PMID: 31819790; PMCID: PMC6884723.