The Microbiologist was sat at his desk Boxing Day morning authorising out results and waiting for some further work on the blood cultures before ringing them out when his oncall mobile phone went off.
“Hi, it’s the ED Registrar here; can I discuss a patient with you?”
“Of course, what have you got” answered the Microbiologist.
“We’ve got a chap who has recently been abroad and has presented with a fever and feeling unwell. The basic story is that he returned home from work in the early hours of this morning looking flushed and tired. His wife was worried about him, as his belly was rather distended, so persuaded him to come to the hospital. He insists this is how he normally feels at this time of year but his wife isn’t convinced.”
“Hi, it’s the ED Registrar here; can I discuss a patient with you?”
“Of course, what have you got” answered the Microbiologist.
“We’ve got a chap who has recently been abroad and has presented with a fever and feeling unwell. The basic story is that he returned home from work in the early hours of this morning looking flushed and tired. His wife was worried about him, as his belly was rather distended, so persuaded him to come to the hospital. He insists this is how he normally feels at this time of year but his wife isn’t convinced.”
“So where’s he been; urban or rural? Any contact with animals? What vaccinations has he had? Did he take malaria prophylaxis? Tell me more…” asked the Microbiologist.
“He’s been all sorts of places, developed and developing countries, both urban and rural. He’s been in contact with deer, domestic and street dogs and even rats but didn’t handle them; he got a few licks from cats and even a scratch or two. Apparently he has been extensively vaccinated including all of the normal childhood vaccinations as well as rabies, yellow fever, West Nile Virus, Japanese B encephalitis, typhoid, BCG, etc. He didn’t however take malaria prophylaxis as he was only away for one night but he has a few mosquito bites despite saying he covered up from head to toe and even wore a hat most of the time. He travels a lot so he’s pretty well set up for this type of thing.”
Golly thought the Microbiologist; this guy must be a bit of a pin cushion with all of those vaccinations.
“So tell me more of the presentation. Any distinguishing features, how high is his fever? Any abdominal symptoms or signs? Cough? Shortness of breath? Rashes, etc.”
“He’s a rather large fellow; I’d guess about 150kg or so. He has a tense and distended abdomen; he smells a bit of alcohol, maybe cheap sherry, so he’s probably a bit of a drinker. He’s quite plethoric; his cheeks particularly are very red.”
“Okay, this is what I think you should do…” replied the Microbiologist.
“He needs the normal urine dipstick, microscopy and culture. Send a blood culture as well and swab any broken areas of skin. If he develops any respiratory signs send a sputum and viral throat swab.”
“Given he has had contact with deer we ought to check his Lyme serology; Lyme disease, caused by the bacterium Borrelia burgdorferi is often transmitted from infected deer ticks. The cat and dog exposure is a bit worrying. He ought to have two doses of rabies vaccine, even though he is already immunised, and we could test him for cat scratch disease with Bartonella serology. As for the rat exposure we should do a Leptospirosis PCR on urine and antibody on blood; rats can excrete the bacterium leptospira in their urine, so you can be exposed without necessarily handling the rats.”
“The red cheeks might be a clue. Parvovirus causes a condition known as slapped-cheek syndrome so we should definitely do his Parvovirus serology, and this could also be scarlet fever so a throat swab for Group A Beta-haemolytic streptococcus and an anti-streptolysin O titre on his blood would be a good idea.”
“Food poisoning is also a possibility so a stool sample for Campylobacter, Salmonella, Norovirus and Rotavirus would be wise. Although, if you think his distended abdomen is due to ascites then an ascitic tap for microscopy, culture and sensitivity should also be done in case this is spontaneous bacterial peritonitis.”
“Finally it is always a good idea to rule out malaria, so 3 malaria tests with both the antigen tests and thick and thin films should be done. While you’re at it let’s make sure he doesn’t have any other mosquito borne illnesses such as Dengue, Chikungunya or Zika.”
“Don’t start any antibiotics at the moment. Let’s see how he goes.”
“Okay, did you get all of that?” asked the Microbiologist.
“Yep, got it. I’ll give you a call if anything changes” replied the ED Registrar.
The Microbiologist hung up and went back to his authorisation queues.
An hour or so later the phone rang again; it was the same ED Registrar.
“Sorry to call you back but thought you ought to know. The chap we talked about earlier has elf-discharged. Apparently he insists he’s fine, now a little more sober, and that this is nothing out of the ordinary. He thinks he may have eaten a dodgy mince pie or carrot and that he certainly thinks he drink too much sherry last night but insists that he doesn’t usually drink at any other time of year! He says his cheeks are no more red than usual as he works outdoors a lot and he has always been a bit over weight but hopes to lose it in January as he’s aware that that affects his general elf.”
“He was also concerned that he has left his EHIC (European Health Insurance Card) at home in Finland and doesn’t have elf insurance to cover the cost of an admission and all of the tests we wanted to do; apparently there is some claus in the small print about not having a valid EHIC therefore non-urgent care should not be provided by the NHS unless full payment is received in advance and that in fact the country of origin may actually be responsible for “work-related” healthcare costs. Any how the nurses got him to sign an elf-discharge form before he left so we’re all good.”
“Okay, no problem” said the Microbiologist. “Thanks for letting me know. Can I just take his details, in case he comes back?”
“He’s been all sorts of places, developed and developing countries, both urban and rural. He’s been in contact with deer, domestic and street dogs and even rats but didn’t handle them; he got a few licks from cats and even a scratch or two. Apparently he has been extensively vaccinated including all of the normal childhood vaccinations as well as rabies, yellow fever, West Nile Virus, Japanese B encephalitis, typhoid, BCG, etc. He didn’t however take malaria prophylaxis as he was only away for one night but he has a few mosquito bites despite saying he covered up from head to toe and even wore a hat most of the time. He travels a lot so he’s pretty well set up for this type of thing.”
Golly thought the Microbiologist; this guy must be a bit of a pin cushion with all of those vaccinations.
“So tell me more of the presentation. Any distinguishing features, how high is his fever? Any abdominal symptoms or signs? Cough? Shortness of breath? Rashes, etc.”
“He’s a rather large fellow; I’d guess about 150kg or so. He has a tense and distended abdomen; he smells a bit of alcohol, maybe cheap sherry, so he’s probably a bit of a drinker. He’s quite plethoric; his cheeks particularly are very red.”
“Okay, this is what I think you should do…” replied the Microbiologist.
“He needs the normal urine dipstick, microscopy and culture. Send a blood culture as well and swab any broken areas of skin. If he develops any respiratory signs send a sputum and viral throat swab.”
“Given he has had contact with deer we ought to check his Lyme serology; Lyme disease, caused by the bacterium Borrelia burgdorferi is often transmitted from infected deer ticks. The cat and dog exposure is a bit worrying. He ought to have two doses of rabies vaccine, even though he is already immunised, and we could test him for cat scratch disease with Bartonella serology. As for the rat exposure we should do a Leptospirosis PCR on urine and antibody on blood; rats can excrete the bacterium leptospira in their urine, so you can be exposed without necessarily handling the rats.”
“The red cheeks might be a clue. Parvovirus causes a condition known as slapped-cheek syndrome so we should definitely do his Parvovirus serology, and this could also be scarlet fever so a throat swab for Group A Beta-haemolytic streptococcus and an anti-streptolysin O titre on his blood would be a good idea.”
“Food poisoning is also a possibility so a stool sample for Campylobacter, Salmonella, Norovirus and Rotavirus would be wise. Although, if you think his distended abdomen is due to ascites then an ascitic tap for microscopy, culture and sensitivity should also be done in case this is spontaneous bacterial peritonitis.”
“Finally it is always a good idea to rule out malaria, so 3 malaria tests with both the antigen tests and thick and thin films should be done. While you’re at it let’s make sure he doesn’t have any other mosquito borne illnesses such as Dengue, Chikungunya or Zika.”
“Don’t start any antibiotics at the moment. Let’s see how he goes.”
“Okay, did you get all of that?” asked the Microbiologist.
“Yep, got it. I’ll give you a call if anything changes” replied the ED Registrar.
The Microbiologist hung up and went back to his authorisation queues.
An hour or so later the phone rang again; it was the same ED Registrar.
“Sorry to call you back but thought you ought to know. The chap we talked about earlier has elf-discharged. Apparently he insists he’s fine, now a little more sober, and that this is nothing out of the ordinary. He thinks he may have eaten a dodgy mince pie or carrot and that he certainly thinks he drink too much sherry last night but insists that he doesn’t usually drink at any other time of year! He says his cheeks are no more red than usual as he works outdoors a lot and he has always been a bit over weight but hopes to lose it in January as he’s aware that that affects his general elf.”
“He was also concerned that he has left his EHIC (European Health Insurance Card) at home in Finland and doesn’t have elf insurance to cover the cost of an admission and all of the tests we wanted to do; apparently there is some claus in the small print about not having a valid EHIC therefore non-urgent care should not be provided by the NHS unless full payment is received in advance and that in fact the country of origin may actually be responsible for “work-related” healthcare costs. Any how the nurses got him to sign an elf-discharge form before he left so we’re all good.”
“Okay, no problem” said the Microbiologist. “Thanks for letting me know. Can I just take his details, in case he comes back?”
Ho, Ho, No! Bottom on show!!!
“Certainly, his name is Mr S. Claus, I’ve not got a date of birth but his address is just The North Pole, Finland… strange address!”
“Oh, I know this fellow” said the Microbiologist. “He comes in every year. As you say, big chap, red cheeks, white beard and smells slightly of sherry and damp deer. Tends to hang around for a bit until he feels better and then elf-discharges, walking out saying Ho Ho Ho. Merry Christmas…!”
“That’s the bloke” replied the ED Registrar. “Well he’ll probably be back next year.”
“I expect so” said the Microbiologist, “hope the rest of your day is quiet, … Merry Christmas!”
“Yeh, Merry Christmas and a Happy New Year to you too!” replied the Registrar.
How long did it take you to work this case out? …Our fever in a returned traveller wasn’t actually investigated but if a large chap in a red and white suit turns up complaining of a fever, at least you now have an initial microbiology plan! Have a great Christmas and a Happy New Year, back blogging week of the 7th Jan. David, Jenny & Prof. Hoops (The Nuts & Bolts Team)
“Oh, I know this fellow” said the Microbiologist. “He comes in every year. As you say, big chap, red cheeks, white beard and smells slightly of sherry and damp deer. Tends to hang around for a bit until he feels better and then elf-discharges, walking out saying Ho Ho Ho. Merry Christmas…!”
“That’s the bloke” replied the ED Registrar. “Well he’ll probably be back next year.”
“I expect so” said the Microbiologist, “hope the rest of your day is quiet, … Merry Christmas!”
“Yeh, Merry Christmas and a Happy New Year to you too!” replied the Registrar.
How long did it take you to work this case out? …Our fever in a returned traveller wasn’t actually investigated but if a large chap in a red and white suit turns up complaining of a fever, at least you now have an initial microbiology plan! Have a great Christmas and a Happy New Year, back blogging week of the 7th Jan. David, Jenny & Prof. Hoops (The Nuts & Bolts Team)
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