Reacting To Dr. Mike's Weirdest Case Of The Year

[00:00:00]So, Dr. Mike just released a video about the strangest medical encounter he's seen this year, and he challenges the viewer to figure out the diagnosis. So, I immediately paused it and I was like, "Okay, why don't I actually try to react in real time and see if we can get the diagnosis?" I had such a unique patient case to share with you. In fact, it's so unique that my residents and I are doing a full case write up on it. I'm curious at what point you'll know what the diagnosis is. Leave a comment down below if you figure out before me. Let's get started. be whoop a 45year-old gentleman presents for a one-day history of a 101 fever that's Fahrenheit and no other symptoms he's evaluated by >> so immediately in the clinical problem solving realm that whenever we see a fever we immediately think about the I made pneummonic so I is for infectious which is going to be the by far and away reason for a fever uh but M is for malignancy A is for autoimmune disease D is for drugs uh or drugrelated causes and E is for endocrinopathy. So that's kind of the main categories of fever and fever in general is indicating that there's some sort of inflammation that's going on in the body. That's Fahrenheit and no other symptoms. He's evaluated by another member of my staff was found to feel well otherwise have no other symptoms. The doctor that was seeing him diagnosed him with a likely a viral illness. Unclear which one because it was so early in the course. We did a swab for COVID and flu, both which were negative. Explained that likely in the next few days, symptoms would evolve and we would have a better understanding of what's going on. So he was instructed to come back if symptoms were to worsen, change or be prolonged. 2 days.

[00:01:40]>> Yeah. So this is very very classic. A lot of times people will have self-limited illnesses which basically means that the illness will self-resolve over time. So most viral infections are going to be like that. they are going to kind of progress over the course of three to five days, but over that fifth day, it's going to be really tapering off and just resolving or sometimes the symptoms will evolve as is probably what's going to happen in this case. And in that case, it's kind of a diagnostic tool for us. Sometimes we do really need to give more time for patients to uh develop different symptoms that will give us an idea of what's going on or to just declare themselves as having a viral illness that just kind of resolves on its own. So totally appropriate to wait a few days and see what happens later. Same patient comes back and sees me. Now, the patient has a 3-day history of a fever with a T-max, that's a temperature high, of 103.5° F, which is quite a significant fever.

[00:02:43]Whenever a patient has a fever, yeah, 103.5, I'm trying to think about if there are any specific infections that I can think of leading to a very, very high fever. And I'm not really thinking of anything right off immediately off the top of my head. But I'm keeping that data point in mind because potentially later down the line, it's going to trigger an illness script for something that I do recognize. Once I see the other symptoms that are going on and then you add that into the context of a high fever, it may be a very helpful diagnostic clue. You start wondering what is causing their immune system to react by raising the basil temperature of the body. usually. So, the body does this in reaction to an infection, bacterial, viral, in more rare cases, fungal. But really, what you're trying to evaluate in one of these patients is to figure out where is the source of this infection. Because if it's viral, it's more likely to be across a variety of body parts. If it's bacterial, it's usually centered to one organ system. So, you start asking questions, which I did. Do you have >> very much true but if somebody's bactermic then they'll have systemic symptoms as well >> have any respiratory symptoms stuffy nose sore throat cough no interesting not an upper respiratory or even lower respiratory infection so then we start thinking okay perhaps there's a gastrointestinal component to this do you have any upset stomach abdominal pain diarrhea constipation blood in your stool nausea vomiting no no no No, no, no, no. I even started thinking about rashes, asking the patient if they have rash.

[00:04:22]>> So, this is very much where when you are the physician that is trying to diagnose what's going on here, we when you really don't have a clue about what's going on and you need more information. This is where the review of systems comes really in handy. And I remember when I was first being taught about the review of systems, I thought that it was this kind of contrived exercise of just going through every single body part and trying to figure out. But I found actually in real clinical practice, the review of systems is genuinely the most helpful when you do not have a clear picture of what's going on. You know, somebody comes in, they have a fever, cough, they've got fleg coming up, and then they've got an opacity on their chest x-ray. Everything fits with pneumonia. Okay. But somebody comes in with high fever, it's been recurring or persisting, not really clear why. They don't have any other clear symptoms.

[00:05:10]That's when the review of systems really has the highest yield. Now, I've had cases before with patients where they said they have no rashes and then we do a physical exam and we find rashes, but in fact, they're a high school gym teacher, so they taught a health class and knew to check for rashes and were so confident they didn't have one. The review of systems was coming up blank on seemingly everything. [music] So, then we start exploring other possibilities. Let's go to the urinary system. Do you have any frequency, hesitancy, burning on urination? No. No.

[00:05:42]No. Do you have any symptoms with your uh genital area? Are you having any discharge, any rashes, any unique issues where you're feeling discomfort down there? No, no, no. We can't forget the neurologic system. I ask about headache, visual changes. I'm trying to think, is there a menitis component here? Rare, but could be. No, no, no. In fact, the patient says they only feel bad when they have the fever. and when they take uh fever-lowering medication, they feel perfectly fine. So now, >> so right now I'm trying to think about, you know, is there some kind of infection that could leave no signature in any organ system in the body and only present with an isolated fever? Or could a malignancy or an autoimmune condition have no other systemic signs and be able to present like this? I feel like in general you're probably going to be seeing some other signs of disease or signature of the disease somewhere else with infections, malignancy or with autoimmune disease. So now I am starting to wonder if this could be something more medication related or endocrine related. Um which potentially uh I'd like to know if there's something that could be causing an isolated fever, but we'll see where the case takes us. We know no travel history, no risk factors, feels well outside of the fever. This has never happened to him before, otherwise healthy, takes no medications, and yet has this fever. I've seen stuff like this happen before, and usually it ends up being some kind of weird viral scenario, like an atypical presentation [music] of mono or EBV. In fact, I tell my patients that I suspect it's that.

[00:07:21]Even then, when I do the physical exam, I feel no lymph nodes, no posterior cervical chain adenopathy. Man, this situation just keeps getting more and more frustrating because this is becoming one of these rare diagnoses called F. Yeah, I was literally just about to say, so F I paused on the FU, but it's FUO, fever of unknown origin.

[00:07:42]And when you really have no idea what's going on, it's a persistent fever. I believe the cutoff is greater than 3 weeks um is really the actual set point for where you can start calling it a fever of unknown origin. That is kind of the flavor of what the patient is presenting with at this time. Now it is still pretty early in the course. So we still may see if some other symptoms arise later on. And also FO is interesting because I think about 50% or a significant portion of FO cases actually never get diagnosed. There's no clear reason for why the patient was having the fever. Yeah. So if I take a look at my Anki card on this, 25% of fever of unknown origin ends up being not diagnosed.

[00:08:23]>> Oh, fever of unknown or unexplained origin where all you have is a fever without a clear explanation for why you have the fever, you have to do an FO workup. Now, >> yeah. So an FO workup once they are reaching that definition of FO, it's a whole litany of tests really just going around looking for any cause of their fever. So, it's autoimmune corologies.

[00:08:46]It's a CT abdomen and pelvis, I believe, CT chest as well. Um, a bunch of like rheumatoid factor, blood cultures, ESR, CRP, inflammatory markers, um, like hepatitis panels. So, you just send off this whole broad array of tests to see if you can find anything. This is an invasive workup in the sense that you have to order a lot of lab work, blood work. you have to get CAT scans of multiple parts of the body thereby radiating the body. So I don't love doing that in patients who are otherwise comfortable and are physically able to withstand having a fever for a few days.

[00:09:25]I >> right because if you think about it um you're exposing the patient to a lot of radiation and a lot of phabbotomy where you're drawing their blood they may have some false positive results on there that causes a lot of anxiety. So it is kind of a risk benefit ratio, you know, that needs to be weighed. And I think that's one of the reasons that we define it as like 3 weeks duration before you start, you know, thinking about fever of unknown origin if they're otherwise healthy. I feel like it's much easier to order some lab work, see if we get some information, also see how the symptoms evolve in the patient and then make the diagnosis or make uh a change to the diagnostic plan and get the CT scans then because that always remains an option. But you have to make sure your patient is on board with that plan. My patient happened to be on board with that plan. So I said, "We're going to order this lab work. I'll call you back in a couple of days and we'll decide a treatment plan." Order the lab work.

[00:10:17][music] Initial results come in.

[00:10:19]Inflammatory markers. CRP, ESR, feritin elevated. CBC all over the place.

[00:10:26]Multiple things off. No clear pattern.

[00:10:29]White counts a little bit down.

[00:10:31]Platelets a little bit down. Lymphosytes a little bit up. Still possibility that this is a viral picture, but we don't.

[00:10:38]So, with the CBC abnormalities, I am starting to think about some more autoimmune conditions. He doesn't really fit the age range for it, but I'm wondering if we're going to start going down that route.

[00:10:46]>> Don't have the viral results yet. Later that day, we get the results. Just as I expected, monucleiosis positive, EBV, somewhat positive. And I asked the patient, he swore that he had mono in the past. So this is interesting because when I ordered these EBV titers, the way that you are able to analyze them to understand what you're looking at is based on a few factors. So you have EBV, IGM, EBV, IGG. Now if the IGM is positive and the IGG is negative, odds are you have an acute first time infection of monucleiosis. If on the flip side, your IGM is negative and your IGG is positive, that likely means in the past you've had mono, overcame it, and now have immunity to it, which most people have because mono is a pretty common condition. But then there's a third option, IGM negative, IGG positive, and then early antigen IGG positive, signaling that the person was infected with EBV in the past, fought it off, developed immunity, but now has reactivation of the illness just like shingles is a >> so interesting. I actually did not know about the early antigen IGG, >> reactivation of chickenpox, which is caused by variceloser. It's the same infection. So I said, "Great. We have an answer. My patient has mono reactivation.

[00:12:17]That is why this is happening." I call the patient.

[00:12:20]>> We still got 6 minutes of the video, so there's more to come. It sounds like I tell him the good news. He's very grateful, very happy, and he says, "What should be my expectation here, doc?" And I explained that it's very likely he'll have a fever for the next 5 days or so and then it should just the fever curve should go down and down and down, meaning that the highest temperature of the day should be lower and lower each following day. And I said, "If that does not go according to plan, please let me know." 5 days goes by, I hear from the patient. He says, "Doc, you were right.

[00:12:51]I don't have a fever anymore. Tomorrow I'm going back to work. I'm ready to hustle and bustle. No issues. Thank you for making a great diagnosis. I feel so much better. No fever, etc. I'm great.

[00:13:02]And I'm like, wow. Okay, that worked.

[00:13:04]>> I'm curious about the twist.

[00:13:06]>> Yeah, totally. I'm still telling you the story because it's about to get more complicated. 5 days after on a Friday, early evening, patient reaches out and I specify Friday early evening because it's a really crappy time to hear from a patient that something's not going well because you have very few options of how you can help them out.

[00:13:26]>> Yeah. If you're a PCP, the Friday e evening at late afternoon call is the worst because you can't find any way to like get them labs ordered to get them done over the weekend or have them get x-rays or other imaging very, you know, quickly other than sending them to potentially an urgent care or most often if you're concerned the emergency department. So, uh, that's always the PCP's biggest dread is the Friday afternoon emergency or or urgent issue >> of sending them to an ER. So, he kind of handcuffs you into what you can do to help your patient out. I hear from my patient and he says, "Doc, bad news.

[00:14:03][music] Fever is back since yesterday.

[00:14:05]What do you think I should do?" I said, "Well, how high is your fever?" And he says, "Oh, yeah, 103." I'm like, "What?

[00:14:11]We had full resolution of symptoms, a window of you feeling normal, and now again, you're feeling terrible. Nothing makes sense. Luckily for me, I was working on Saturday, the next day in [music] the morning with my residents.

[00:14:24]Patient comes in, vital's normal, looks comfortable, no changes to physical exam, no new symptoms, no new history added. My residents tried to ask questions, [music] and we're all at a loss. So, I called my ER friend, Dr. Donald Pettit, who you've seen on the channel. And luckily for me, he was driving with another ER doctor in his car and he put me on speaker phone and I was able to present this case to ask for a curbside cons.

[00:14:51]>> Yeah. So, always really great to be able to rely on other colleagues to solicit a second or even third opinion in this time. Honestly, the collective brainstorm in medicine is one of the reasons we can provide really good patient care is really relying on co colleagues and consultants and things like that. And uh I think here he's asking does this patient warrant going to the ED? Now I am curious to see what they're gonna say because this patient otherwise is completely stable. Um really I think probably he could continue outpatient monitoring, but I could very well be wrong. I'm I'm very curious what they're going to say here and if they're just going to be able to make the diagnosis right off the bat right here. Um I don't I certainly don't have enough information here to be able to make the diagnosis.

[00:15:32]>> From two established ER doctors, they heard the case. They're all equally as confused as me. They started thinking really outside the box and saying, "He's having a fever. Odds are he has an infection. Why don't you just treat him with doxy?" And I said, "Well, look, like I see what you're saying, but I tested him for lime. Lime was negative.

[00:15:50]This isn't a true fever of unknown origin." Yeah. So, this is very common on the east coast, not very much uh on the west coast, but there's so much tick born diseases there. And when people are not able to figure out what's going on, a lot of times people just give empiric treatments for doxycycan which basically treats all of the Lyme diseases or a lot of the tickborne diseases. Um they actually call this in the literature a doxycyc deficient state and it's just so common to have patients get so much better after it. Um and it's hard to make a diagnosis of tickborn diseases sometimes that empiric treatment is often advised. So uh that's definitely something we don't see here. So the location very much plays a role in the context of this patient's care >> because I have a positive mono test.

[00:16:33]It's just an atypical mono presentation.

[00:16:35]Maybe it's that. I thank them for their help and I decide against the doxy for two reasons. Reason one, my patient is comfortable. My patient has normal vital signs. He can withstand a fever. Second, this isn't a true fever of unknown origin. I know he has mono. I know he has EBV due to these blood tests. So I'm still going off of that diagnosis and I decide not to treat with Doxy. Instead, we decide to broaden the blood work, check for more rare conditions. Really chase those zebras as if I am house MD reincarnated. I order a tickborn panel.

[00:17:07]I order CMV. I order autoimmune tests that I haven't ordered in a long time. I said, "Look, [music] we're going to send all of these tests and simultaneously get you in with an infectious disease doctor early in the week. Patient is on board. We have a good line of communication." I say we're going to do this. We send out the blood tests right away. We get our answer. Patient had >> Okay, what are we going to land on? So, the other blood test that he sent was tick diseases, tickborn diseases. And also he had uh sent out some autoimmune stuff. He said I'm going to go with it is going to be a tickorn disease. Uh he had some abnormalities on his white blood cell count with a lucopenia thrombocytoenia.

[00:17:51]So, when I think about a tick born disease that I don't know when exactly this patient presented, but they're on the east coast, they're exposed to ticks and they're already kind of considering that. Um, and the ones that can cause CBC abnormalities are the ericchiosis and the anoplasmosis kind of diagnoses, which I have never seen in my career because I don't work on the East Coast, but we learn about these because they are still conditions that we need to know about and could potentially see.

[00:18:18]So, I'm going to go with maybe he had this mildly positive EBV tighter, but actually he did have a tickorn exposure.

[00:18:28]I would have loved to hear if he did have some sort of outside exposure history to ticks. Was he hiking recently? He does work as a gym teacher or a PE teacher. So, maybe if they were running around and there were some woods nearby or some trees, maybe a tick jumped on him or something. Um, but yeah, let's go with the tickborn disease just because they can cause these weird relapsing remitting fevers, can be kind of difficult to diagnose, and can cause these CBC abnormalities. That's what I'm going to put my nickel down on in this very limited set of data.

[00:18:59]>> As anoplasmosis, let's go. We did it. Anoplasmosis is an infection that is spread by the very same tick that spreads Lyme disease.

[00:19:11]It's just a different bacteria. And I'm so glad we checked because if anoplasmosis goes untreated early on, it can become quite problematic. But because we caught it, right away I sent my patient a prescription for doxycycline, which is exactly what Dr. Donald Pettit told me to do. The patient was very grateful. The next day he had his appointment with infectious disease doctor. They confirmed that this is the treatment. In fact, I think I ordered doxy for 10 days. The infectious disease doctor extended it to 2 weeks. [music] Just a few days of antibiotics. patients fevers go away. Two weeks later, get all his lab work back. All pristine, all good, no issues, liver enzymes down.

[00:19:51]>> Yeah, I love this one. Oh, and I forgot I did he mentioned that the livers enzymes were up too because definitely all those tickborn diseases can cause all those liver enzyme elevations as well. So I I think uh very very classic case, a very classic morning report or board's favorite because these tickborn diseases always present in interesting ways and they are always hard to diagnose and so I love that he highlighted this case and it's a very satisfying conclusion where the patient is going to have a great outcome.

[00:20:18]>> Inflammatory markers down CBC is complete normal. There's also an important takeaway here. Tickspread illnesses are on the rise in the US.

[00:20:29]Why? Summers are hotter, are longer, springs are earlier, winters are milder, so there's less tick die off, so ticks are more present and are spreading more readily. Part of this is due to climate change because of this weather cycle that we're experiencing. There's also obviously differences based on how often people get this diagnosed, how much we're looking for it, deer and mouse population, all these vectors that we have to think about. But it's important [snorts] that when you're in a tick disease endemic area like >> Yeah. So just take a look at this map.

[00:21:02]You know, very very few tickborn diseases out where we are uh out in California or on the west coast, but just crazy amounts in the east coast and in the Midwest. I practice in in the Northeast. You think about these diseases right away because they're very easy to miss. In a situation like this, if we were to miss them, there could have been true harm done to the patient.

[00:21:26]If you enjoy hearing about my patient account, All right, fantastic case. Thank you for sharing that one, Dr. Mike. I really enjoyed it. I feel like it highlighted a very, very great aspect of medical care that we provide to patients because these are very difficult diagnoses to make and a lot of times it does require time and repeated, you know, encounters to fully elucidate what's going on with the patient. And there is always this risk of doing over diagnosis, ordering too many tests all at once. You know, patients always come in all the time and they're asking, "Why can't I get an MRI and a CT and all this stuff?" Well, you're going to spend a million- dollar workup when eventually the diagnosis is something that is just going to be treated with oral antibiotics, right?

[00:22:05]So, I think the way that he approached this case was really good in a step-wise fashion. He also triaged the severity of the situation on whether the patient was sick enough to need more urgent or emerent evaluation. And in this case, he deemed that it was not the case. And the patient ended up doing really well. So very interesting case. The lay people are really going to love this one because it is a bit of a zebra diagnosis. You know, not the most common bread and butter that we see every single day. And it is a very very popular morning report kind of case because of all of these reasons. So that was a ton of fun. I'm actually very happy that I was able to get the diagnosis myself. Uh so put your nickel down whenever you're trying to make a diagnosis before you get that final aloquat of information. If you're listening to a podcast or a morning report or something, try to guess and put your nickel down on what the di final diagnosis is. That way, you get instant feedback and you're going to learn better for next time. So, thanks again for watching. I hope you guys enjoyed. I'll see you guys in the next video and until then, good luck and have fun.

[00:23:02][music] [music]