A 39-year-old woman presented to the emergency department (ED) four days after returning from a 5-day-long trip to The Gambia in West Africa with complaints of fever, nausea, anorexia, and fatigue. The onset of symptoms started two days after her return to the United States. The patient recalled being bitten by mosquitoes daily during her trip, did not take any malaria prophylaxis, and had heard that several of her travel mates tested positive for SARS-CoV-2 upon return to the United States. The patient had a positive COVID-19 antigen test confirmed using a rapid home antigen test 2 days before presentation to the ED, despite being triple vaccinated against SARS-CoV-2 (a booster was given 10 weeks before presentation). She had no significant past surgical history and a past medical history of asthma, for which she did not need any rescue inhalers. The patient’s self-reported high-grade fevers, ranging from 101 to 104 ˝F, were associated with rigors and chills for the 4 days before admission. The only other complaint included multiple small petechiae on the abdomen that resolved within 24 h of returning from the trip abroad. The patient denied having a sore throat, chest pain, shortness of breath, or diarrhea and had stable vital signs besides slight tachycardia (HR 105 bpm). Upon physical exam, she was oriented to person, place, and time. Laboratory baseline findings in the ED were within reference ranges except for a low WBC of 1.92 ˆ 109/L (with a differential that included an absolute neutrophil count of 1200, platelet count of 145,000 ˆ 109/L) and elevated liver function tests (highest AST 148 IU/L, ALT 199 IU/L, alkaline phosphatase 111 IU/L). The Infectious Disease service was consulted, and empiric antibiotic therapy was started with ceftriaxone 2 grams IV daily and doxycycline 250 mg PO twice daily. The patient was admitted to a COVID-19 isolation room for a workup of malaria, DENV fever, and CHIKV. Serological evidence was positive on enzyme-linked immunosorbent assay (ELISA) for dengue-specific IgM with a value of 5.66 (IgG 1.04) and positive for chikungunya-specific IgM with a value of 4.28. All other blood cultures, HIV antigen screening, malaria smears, and Leptospira IgM antibodies were negative. The patient was treated with acetaminophen 650 mg every 6 hours as needed for fever and with a one-liter infusion of normal saline at 83 mL/hour. On the third day of admission, the Hematology service was consulted as the platelets count was 107 ˆ 109/L and the PTT was elevated, for which mixed studies were ordered. There was a subsequent clinical improvement, and the patient was discharged with normalized blood counts and laboratory findings. Two days post-discharge, laboratory findings showed a WBC of 4.68 ˆ 109/L (ANC 900) and a platelet count of 210 ˆ 109/L. The patient reported developing an itchy rash on the palms of her hands and soles of her feet and severe bilateral hip joint pain, which resolved within 48 h of discharge. The only other symptoms occurring during the week post-discharge included headache, retro-orbital pain, and diarrhea, which all resolved within seven days. The patient had sacroiliac joint pain that started in week 3 post-discharge and required NSAID therapy, physical therapy, and a short course of methylprednisolone. Two weeks after the initial presentation, follow-up laboratory findings showed the resolution of platelet counts (584 ˆ 109/L) and liver function enzymes (AST 64 IU/L, ALT 96 IU/L, alkaline phosphatase 106 IU/L).
This case highlights the need for a high index of suspicion for infection with multiple viruses in returning travelers. Several viral infections present with similar clinical manifestations and timelines. Measures should ensure appropriate, timely diagnosis for the best patient outcomes. Further epidemiological studies on returning travelers are needed to assess the magnitude of co-infections, including triple viral infections.
Conceptualization C.H. and S.S.; methodology S.A.; original draft preparation S.A., M.M.; review and editing S.S., C.H., M.M., S.S. All authors have read and agreed to the published version of the manuscript.
Conflicts of Interest
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