3. Travel and Infectious History

Travel and Infectious History

  • Ten days before admission, the patient returned from 2 months of
    travel in Asia
  • He prepared his own food, used only boiled water, and did not swim
    in any river or lake
  • He was in his usual state of good health on return to the US
  • He received Japanese encephalitis vaccine prior to the trip
  • Outdoor cats at home, no scratches on patient
  • No tick or mosquito bites and no sick contacts reported
  • Japanese encephalitis usually demonstrates bilateral thalamic lesions,
    especially hemorrhage on MRI
    (Kumar S et al. Neuroradiology 39:180, 1997)

Physical Exam

  • afebrile, vital signs stable
  • lethargic, but oriented to time and place
  • no rash
  • no facial asymmetry or focal neurologic deficits
  • increased tone in the left leg but 5/5 strength in all extremities
  • Babinski reflex downgoing, no Brudzinski’s sign
  • no lymphadenopathy

Admission Labs

Na+134(135-145 mmol/L)
K+3.8(3.5-4.5 mmol/L)
Cl-98(96-106 mmol/L)
C0226(22-30 mmol/L)
BUN11(8-18 mg/dL)
Cr1(0.5-1.2 mg/dL)
Ca ++8.8(8.8-10.2 mg/dL)
Mg + +3(1.8-3.0 mg/dL)
PO4-2.2(3.1-4.5 mg/dL)
Phenytoin9(10-20 mg/mL)
WBC7.1(4-10K/mL)
Hb15(14-18 g/dL)
Hct45(40-52%)
PLT265(150-350K/mL)
Seg76(38-81%)
Lymph14(14-46%)
Mono10(2-15%)

Breakpoint #3

  • How would you proceed at this point?