Medical CASE 1

A 45-year-old woman presents to the emergency department with bleeding gums and bruises on both forearms for the last 2 days. For the preceding 10 days she had been experiencing a high fever (which has since broken) and rigors. In addition, she complains of a rash over both forearms, but she is unable to further characterize it. She noted severe pain in both legs during the febrile portion of her illness. There was no history of hematuria, melena, cough, or hemoptysis. She is not taking any routine prescription medications or using over-the-counter products or supplements. She has no known drug allergies. She is married with 5 children and is currently unemployed. She does not smoke or drink alcohol and has no history of drug abuse. There is no travel history or any history of sick contacts. She is a resident of Pakistan.

On physical examination, she is alert and apparently well developed and well nourished. The patient has a regular pulse of 90 bpm and a respiratory rate of 14 breaths/min. Her temperature is 98.2° F (36.8° C) and blood pressure is 110/70 mm Hg. The cardiac examination reveals a normal S1 and S2, with no murmur, gallop, or rub. Auscultation of the lungs is normal, and no palpable organomegaly or tenderness is found on abdominal examination. Examination of the extremities reveals large bruises and a petechial rash across both forearms and lower extremities (Figure 1; the image shown is an example of the rash seen). Conjunctival hemorrhages are noted bilaterally. Bruises are also apparent on her soft palate, and minor trauma from oral examination results in gingival hemorrhage.

The laboratory investigation reveals a hemoglobin of 8 g/dL (80 g/L), platelet count of 11 × 10³/µL (11 × 10⁹/L), and a white blood cell count of 1.8 × 10³/µL (1.8 × 10⁹/L). Her serum blood urea nitrogen, creatinine, liver function tests, albumin, and electrolytes are normal. Coagulation studies, including a prothrombin time, activated partial thromboplastin time, fibrin degradation products, and serum fibrinogen, are normal. Blood cultures do not show any growth. Urine analysis and urine culture result negative. Posteroanterior and lateral chest radiographs, as well as abdominal ultrasonography, are unrevealing.

Based on the clinical presentation and physical examination, which of the following is the most likely diagnosis?

Hint: Bruises, conjunctival hemorrhages, and depressed cell lines in a postfebrile patient with a rash.

Leptospirosis

Meningococcemia

Plasmodium falciparum malaria

Typhoid fever

Dengue hemorrhagic fever