LEAPING INTO PANAMA

INTRO

Holmes and I were enjoying a quiet cup of Earl Grey when the clinic door blew open with a crash and in strode a bedraggled middle-aged man.  His blood-shot eyes, his tremulous hands, and occasional spasm of pain produced in my heart an instant compassion and in Holmes, an instant curiosity.

“I deduce from your faded camouflage shirt that you have been a soldier-of-fortune, and have recently fallen from whatever fortune that line of work once brought you.  You smell of Café Boquete, a coffee only found in Panama, bringing me to the conclusion that you have recently spent time in that country, where you have fallen in with a bad crowd or into a bad disease.  Your deep tan suggests you have been out of doors for months, without using sunscreen, I might add.  And your well developed pectoralis muscles suggest that you are an avid swimmer.  The way that you are holding your head tells me that you have had a vicious headache for days. ”

“Indeed,” our weary guest slumped into a chair, “You are absolutely accurate on every count.  I am at the end of my physical reserve Mr. Sherlock Holmes.  That’s why I have come to see you.  Can you help me?”

“Mr. Watson, would you be so kind as to check his vital signs and perform one of your admirable and thorough physical examinations.”

EXAM

BP: 170/110

Temp: 103.5 F

Pulse: 120

RR: 20 Pulse Ox 96% RA

Eyes: bilateral conjunctival suffusion (figure #1)

Oral : no lesions

Neck : no LAD, supple

Lungs: scattered rhonchi

Heart: no murmur

Abd: soft, nontender, no organomegaly

Skin: no rash

Neuro: intact

Joints: normal ROM

RESULTS

“Well done, Watson.  Your results have proved my preliminary hypothesis.  Our soldier-of-fortune has been swimming in rat urine infested ponds in Panama and contracted Leptospirosis. 

“Remarkable, Holmes, the acute serologic titre is > 1:800.  You hit it right on the head.”

“Elementary, Watson,” Holmes flashed a smile of satisfaction, “fever, rigors, chills, severe headache, and a conjunctival injection in a fellow recently back from slopping around in Panamanian ponds, in the hot season…the diagnosis of Leptospirosis is hardly a strain for my brain.”

DISCUSSION

“Let us walk through the facts of the case.  Never allow your compassion for the patient to distract you from the facts, Watson.”

“A little compassion never hurt anyone, Holmes.”

“It clouds the active work of reductive reasoning, my sentimental friend.  Now, to business.  Let us rule out the other possibilities that could explain his story, but fall out with closer scrutiny.  Chikungunya has been described in the Americas, but he had a paucity of arthritis and arthralgias.  Malaria is a possibility of course in Panama, but he lacked the typical predictable fever.  Typhus?  Endemic in that part of the world.  His fever and headache are certainly suggestive, but the telling eye finding points away from Typhus as the cause of his trouble.  Typhoid fever likewise has no eye finding and has a more telltale rash than Typhus and virtually no rash in Leptospirosis.  Dengue or Break-bone Fever has remarkable boney pain, which our patient completely lacked.”  Holmes took a deep breath.

“Our patient had the clinical features of Leptospirosis and the laboratory support including the relative leukopenia, thrombocytopenia, hyponatremia, elevated liver enzymes, proteinuria, rhabdomyolysis, and the very high acute serologic titre, which clinched the diagnosis.

CONCLUSION

Holmes and Watson admitted their patient to the hospital for three days of IV hydration and IV Doxycycline.  The patient’s myoglobin cleared nicely with Normal Saline at a rate to keep the patient urinating an average of 100cc an hour.  By day three he was switched to PO Doxycycline, had been afebrile for 48 hours and was discharged in excellent condition.  Even his conjunctivitis was resolving by that point.  The Sodium corrected with fluid rehydration and treatment of the spirochete.  His liver enzymes were trending down and his platelets were coming up.  Surprisingly, he never developed the common pulmonary problems seen with Leptospirosis, including pulmonary hemorrhage and ARDS.  The diagnosis is solidly a clinical one, with acute and convalescent serologic titers lending support.  New ELISA and PCR tests are becoming more readily available, but, as Sherlock Holmes would say: engage your neurons, Watson, they need the exercise.”

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