Twenty some year old Japanese man presented with three week history of watery diarrhea. (wax and wane) Did NOT take any antimicrobial agents.
Presenters(Drs.Tani and Takakura) were well prepared to give me extremely hard time blocking variety of my way of analysis.
I explained that three weeks is too long for the "ordinal" diarrhea.
Explained three axis when you are dissecting diarrhea which are
1)Chronic vs. Acute, 2)small vs. large intestine, 3) Health care related vs. unrelated.
This case fits into the category of subacute~chronic, small intestine, and healthcare unrelated diarrhea.
I listed possible, viral, bacterial, parasitic etiologies. Chronicity should also help me to narrow down etiologic agents.
Turns out patient had been everywhere including, Asia, Africa, to name a few eating everything. Most recent trip had been to India.
In terms of travel/tropical medicine,I could not narrow down possible agent based on 1)destination (patient had been everywhere), 2)incubation time (illness of waxing and waning nature made it difficult to calculate latent period), 3)Exposure regarding food, insect/animal, sex, and so on.
So I was pushed into the corner of physical examination, imaging and laboratory test. (= Bad sign)
These were significant for followings
1)relative bradycardia
2)generalized lymphadenopathy
3)diffuse tenderness of abdomen with somewhat decreased peristaltic movement.
4)CBC with diff. WBC:11000 WITHOUT left shift.
5)Diffuse swelling of colonic wall by CT especially around the cecum and ascending colon.
I was able to pick up follwings.
1)Bradycardia⇒Intracellular pathogen / general lymphadenopathy
ぶるせらずれおち
2)leukocytosis WITHOUT left shift⇒ increase in mononuclear cell
(This was backed up further by mononuclear cell dominant stool later)
3)Most recent travel was to India⇒ Asian Big Five (Malaria, Dengue, Typhoid, Leptospira, Tsutsugamushi)
These 5 ID's have peculiar region of origin. Malaria(≒Africa), Dengue(≒SE Asia), Typhoid(≒India)
Blood culture grew GNR. 4 bottles out of 4 !!
Enteric fever it was !
Sadistic presenters: Drs. Tani and Takayama.