Case history
Case history #1
A 16-year-old boy presents to the emergency department two days after his return to the US from a trip to the Amazon. He complains of fever, headaches, vomiting, diarrhoea, and myalgias, which have persisted for 24 hours. On arrival at the emergency department, a physical examination reveals an elevated temperature (39.1°C) and mild tachycardia (heart rate: 110 bpm). FBC, urea and electrolytes, LFTs, a rapid malaria antigen test, and serum for arboviral serologies are drawn. These tests reveal mild leukocytosis (WBC count 12.5 x 10^6 cells/mL) and transaminitis (aspartate aminotransferase and alanine aminotransferase twice the upper limit of normal). The rapid malaria test is negative, and serologies are pending. He is given some intravenous fluids and sent home with paracetamol. His parents bring him back to the emergency department three days later. At home, he had become disoriented and had a generalised seizure. He is admitted and given intravenous fluids, lorazepam, and phenytoin. A lumbar puncture is performed and he is started on intravenous vancomycin, ceftriaxone, and aciclovir. Cerebrospinal fluid analysis reveals a mild pleocytosis with lymphocytic predominance, normal chemistries, negative Gram stain, and negative herpes simplex virus polymerase chain reaction. A head CT and brain MRI are carried out. The head CT is unremarkable, but brain MRI shows subcortical white matter enhancement. A repeat serum sample is sent for arboviral serologies. He has no further seizures, and his mental status improves over the course of the following week. His initial serologies come back negative for dengue virus, St. Louis encephalitis virus, Eastern equine encephalitis virus, and VEEV. His repeat serologies are positive for VEEV immunoglobulin M. He has some persistent fatigue for a month following discharge but recovers fully.
Case history #2
An 8-year-old girl, native to Darién Province in Panama, develops acute onset fevers, chills, severe headaches, and myalgias. She lives with her family in a wooden house without any screening or windows and washes her clothes in a nearby river. Her older brother had similar symptoms one month prior. She visits the local clinic where a clinician sees her. On physical examination, she is noted to be febrile; the remainder of her examination is normal.
Other presentations
Patients may also present with haemorrhage (e.g., epistaxis, haematuria, haematemesis, melaena), jaundice, or hepatomegaly.[3][4]
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