A Traveler’s Fever
Background
A 17-year-old man presents to the emergency department (ED) complaining of a headache that has lasted for the past 2 days. The patient states that he returned to the United States 2 days ago after spending 3 weeks in Nigeria. According to the patient, he felt well when he initially arrived in the United States, but he developed a severe headache soon after. The headache is constant and throbbing, is lasting throughout the day, and is relieved with ibuprofen. He complains of subjective fevers and intermittent sweats, especially at night, but he has not taken his temperature.
Today, while preparing to board a plane, he developed a worsening headache, bilious emesis, palpitations, and sweats. He decided to delay his trip and is now presenting to the local ED for further evaluation. The patient denies having any trauma, seizures, abdominal pain, stiff neck, or photophobia. He has no significant past medical history, and his only medication use is the ibuprofen that he has taken over the past 2 days.
On physical examination, his temperature is 103.0° F (39.4° C), his pulse is 83 bpm, his blood pressure is 120/70 mm Hg, his respiratory rate is 16 breaths/min, and his oxygen saturation is 96% while breathing room air. The patient is generally well-appearing, alert, and oriented. The examination of the head, eyes, and pupils is unremarkable. The neck is supple, without any lymphadenopathy. On auscultation, the lungs are clear; additionally, the patient's heart has a regular rate and rhythm, without any murmurs.
The examination of the abdomen reveals normal bowel sounds, with mild tenderness to palpation in the right and left upper quadrants. The spleen is noted to be 3 cm below the costal margin. The neurologic examination is unremarkable.
The patient is treated with intravenous fluids. An electrocardiogram (ECG) shows a normal sinus rhythm, with a QTc of 390 msec. Serum laboratory tests are done, and they are significant for the following values: creatinine, 1.2 mg/dL (106.08 µmol/L); magnesium, 1.2 mg/dL (0.49 mmol/L); alanine aminotransferase (ALT), 110 U/L (normal range 0-35 U/L); aspartate aminotransferase (AST), 159 U/L (normal range 0-35 U/L); total bilirubin, 2.7 mg/dL (46.17 μmol/L) (normal range <1.20>
What is the diagnosis?
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