Hearing Hoofbeats

It is critical for physicians to share unusual patient diagnoses that present to clinic with routine type symptoms. In a hospital setting, these are cases for discussion and debate at Grand Rounds. In a primary care setting, we do case reviews when we can with informal sharing for the purpose of teaching and learning. The bottom line, whether in a formal academic setting, or an informal setting around the lunch table: clinicians need to always be thinking of the possibility of a zebra hiding in camouflage among the many ponies in the primary care setting.

After twenty two years working as a physician in college health and seeing two or three extraordinary cases every year, suddenly I’ve seen three “once in a career” patients in the last three months.

Several weeks ago I saw an otherwise healthy student with an unusual rash and history of nightsweats for two weeks. The well circumscribed large erythematous lesions matched photos I looked up of erythema marginatum which can occur with rheumatic fever from Group A strep infection. The student had never had a sore throat but did have a positive rapid strep test that day as well as a markedly elevated streptozyme and sed rate, and met other clinical criteria of rheumatic fever. The infectious disease consultants agreed. Thankfully the student was diagnosed and treated early enough that echocardiogram was normal. The rash and sweats disappeared within 48 hours on Penicillin VK. This is believed to be the only case of rheumatic fever in our state this year.

Last week I saw an otherwise healthy student with a history of a pet rat having bitten an index finger a week before. The bite healed without intervention but the student was feeling generally unwell with headache, nausea, fever, chills and muscle and joint aches, as well as a new macular rash of discrete erythematous lesions on palms and soles, extending to the dorsum of the feet. All symptoms appeared classic for rat bite fever, a rare infection by Streptobacillus moniliformis with a 25% mortality rate if left untreated. Blood cultures remain negative but must be kept at least three weeks for this particular bacteria. The patient has finished a week of IV antibiotics while remaining in school and all symptoms have improved. There are apparently very few cases in the U.S. annually but since it is not reportable, the incidence is unclear.

Also last week an otherwise healthy student was hospitalized in septic shock after being seen twice in emergency rooms while home over Thanksgiving break–fever, sore throat, nausea, muscle aches that appeared viral to the evaluating clinicians. The student came back to school still sick, went to the local emergency room when feeling so lightheaded that walking was difficult, ended up in ICU on a ventilator due to incipient respiratory failure. It took several days of touch and go clinical management for the diagnosis to become clear: Lemierre’s Syndrome–septic thromboembolism to the lungs that results from a gram negative infection in the throat and causes deep pharyngeal abscesses, with a jugular vein that becomes infected with septic emboli. The student was initially placed empirically on three antibiotics by the infectious disease specialist so was being appropriately treated even before the diagnosis was obvious, and will likely be on IV antibiotics at home for up to eight weeks due to the persistence of the emboli. Lemierre’s is something that is reported two or three times a year in young adults nationally and carries a significant mortality rate.

These three patients have survived these devastating infections. I’m very humbled by the fact that presentation of routine symptoms in a young adult primary care population should never leave the clinician complacent about what the potential cause might be.

The zebra just might be hiding in the bushes, right in the middle of a herd of horses.