Fever in returning traveler

You are asked to review a 35-year-old lady who has presented with a history of fever and bodyache. She was admitted 2 days ago and has been stable on the ward. You have been asked to see her overnight as she reports severe breathlessness, which is worse on lying down. The nurse reports that her oxygen saturation has dropped over the past couple of hours. How would you approach this case?

I would start by taking a focused history from the patient with appropriate input from the nursing team, if the patient is unable to present a coherent history. I would review the medical notes, blood investigations, medical imaging and drug chart to identify any obvious precipitating cause of the desaturation.

I would then perform an A to E examination:

• A – Airway: I would ensure that the airway is patent and take corrective measures if necessary.
• B – Breathing: I would assess the breathing, specifically the respiratory rate, oxygen saturations and calculate the FiO2. If there are signs of respiratory distress, such as tachypnoea, low saturations, use of accessory muscles, orthopnoea etc, I would arrange for an urgent arterial blood gas to assess PO2, PCO2, lactates and pH. I would initiate supplemental oxygen to maintain O2 saturations above 96% and ask for an urgent portable X-ray chest. I would auscultate the chest to look for wheeze/crepts or conducted sounds.
• C: I would check the blood pressure, heart rate and CRT and initiate appropriate measures. If the patient is hypotensive, a fluid bolus should be given unless there is clinical evidence of pulmonary oedema. I would ensure a patent cannula and send blood for septic screen, including blood cultures. I would ask for a 12-lead ECG.
• D and E: I would check temperature, blood glucose and look for other causes of acute shortness of breath such as features of acute blood loss.

You are informed that the patient has recently returned from a camping trip in sub-Saharan Africa, has polycystic ovarian syndrome and was diagnosed with Gilbert syndrome by her GP three years ago.

On clinical examination, there are widespread crepitations and the respiratory rate is 40 per min with an oxygen saturation of 85% on high-flow oxygen.

Arterial blood gas shows hypoxia, high lactates and hypocapnia. ECG shows sinus tachycardia while the X-ray chest shows bilateral fluffy shadows with clear costo-phrenic angles.

Fever with acute respiratory distress could be a manifestation of various tropical diseases such as Malaria, leptospirosis and dengue. Sending specific investigations would be essential for diagnosis and would need input from the Microbiology team/senior colleagues. I would also urgently discuss with the ICU team as she is likely to deteriorate and need mechanical ventilation.

While you are discussing with the ICU team, the patient reports to the nursing team that she has missed her last two menstrual cycles, but has not been tested for pregnancy. She also starts coughing up blood and her saturations drop further despite the high flow oxygen.

This lady appears to be in acute respiratory distress syndrome and will need NIV/mechanical ventilation. I would fast-bleep the ICU team to convey this and ask for an urgent review.

I would keep the patient and family updated throughout regarding the diagnosis and plan of management.