A 22 year old man has just returned from a surfing trip to Timor. While away he developed a fever, headache and generalised aches and pains. The fever settled for a day or two but has now returned and he has developed a rash. The aches and pains continue unabated. He feels miserable.
- Given the history and clinical photograph what is the most likely diagnosis?
- What investigations should be performed in the ED?
- How should this patient be managed?
Reveal the ICE answer
The most likely diagnosis is Dengue fever, colloquially known (because of the major symptoms) as “backbreak” or “breakbone” fever. This is caused by a mosquito borne flavivirus endemic in tropical regions and returned travellers suffering from it regularly present to healthcare practitioners in Australia. Typical symptoms are fever, headache, intense muscle and bone pain and a maculopapular or measles-like rash obvious on the trunk.
A diagnosis of dengue can be made on clinical grounds, however fever in a returned traveller who has been to a malaria endemic area (such as Timor) would mandate taking blood for malaria smears. This patient should also have blood taken for an FBE & U&E/LFTs. A lowish WCC and mild thrombocytopaenia are common in dengue. The uncommon (in travellers) severe form of dengue known as dengue haemorrhagic fever will show more marked FBE changes and clotting abnormalities as well as other clinical signs of severe illness. In this patient also take blood for serology so that later convalescent specimens can show rising antibody titres to confirm dengue or other viral diagnoses. A PCR test is also available.
Most cases of dengue can be managed as an outpatient or in a short stay ward. The treatment is symptomatic with regular paracetamol (not NSAIDs) & fluids. Severe cases need admission under an ID physician.
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