16 ABC of Emergency Differential Diagnosis

The possibility of typhoid or paratyphoid in particular is possible

given a relatively low efcacy of the vaccine (5570%) and the
history of ice consumption.
Examination
Observations are as follows: blood pressure 90/60 mmHg, pulse
60 beats/min, temperature 38.9C, respiratory rate 20 breaths/min,
oxygen saturations 98% on air. On general examination he appears
unwell and lethargic with a greyish pallor. He is not jaundiced; there
is no evidence of anaemia, lymphadenopathy, clubbing or cyanosis.
There are a couple of blanching, pink maculae on his ank, but
otherwise no evidence of rash on his skin.
There are ne crackles in both lung bases. His JVP is not visible.
Heart sounds are normal, with no ankle oedema. His abdomen is
soft but generally tender. The tip of the liver can just be felt, but
no other organomegaly or masses are palpable. Bowel sounds are
present. He is neurologically fully intact with a Glasgow Coma Score
of 15/15. Fundoscopy is normal and he has no neck stiffness.
Question: Given the history and
examination ndings what is your
principal working diagnosis?
Principal working diagnosis enteric fever
Malaria is still possible. Hypotension and his lethargic, unwell
appearance point to this, but the absence of jaundice, pronounced
pallor or hepatosplenomegaly casts doubt. Meningitis is unlikely
as the headache is not accompanied by meningism. Septicaemia
of some type is still possible. Amoebic liver abscess might be a
possibility, although one would expect more pronounced right
upper quadrant pain and tenderness. The lack of respiratory
symptoms or signs makes pneumonia unlikely. Enteric fever is
much more likely given the presence of pink macules (possible rose
spots), accompanied by diffuse abdominal tenderness, mild anaemia
and mild hepatitis, and a heart rate of 60 in a febrile patient.
Management
This patient requires urgent uid resuscitation and oxygen.
Investigation includes full blood count, renal and liver function
tests, ESR, CRP and chest X-ray. Three thick blood lms specically
for malaria parasites and haemolysis should be sent urgently. Blood,
urine, and stool should be cultured. If these do not yield a result,
bone marrow aspirate culture should be considered. Do not request
a Widal test for typhoid; it has been abandoned by most laborato-
ries in the UK due to difculty in the interpretation of results. Your
laboratory may have the newer rapid antigen tests available. Urinary
antigen testing should be performed if Legionella is suspected.
If meningitis is suspected in the absence of a classic meningococ-
cal rash, a lumbar puncture should be performed to conrm the
diagnosis and identify the organism unless contraindicated. If the
history and examination point to pneumococcal meningitis a dose
of steroids with the rst dose of antibiotics can improve outcome.
As enteric fever is likely, treatment with i.v. ceftriaxone or
cefotaxime should be initiated whilst awaiting the microbiological
Figure 4.5 Pulmonary tuberculosis. Image kindly provided by Dr Andrew
McDonald Johnston, www.doctors.net.uk
Figure 4.6 Rose spots in the context of typhoid. Image courtesy of the
Health Protection Agency via Doctors mess, www.doctors.net.uk
Box 4.1 Non-infective causes of fever
Malignancy
Autoimmune diseases
Drug reactions allergic reactions to, or metabolic consequences
of the drug
Seizures
Environmental fever (due to very high external temperatures, or
excessive exercise)
Hyperthyroidism
Thrombosis
Infarction of myocardium, kidney, or lung (auto-immune
element)
Blood transfusion reaction
Atmospheric pollution (e.g. nitrogen dioxide)
Factitious fever (Munchausens syndrome/Munchausens by proxy)
High Fever 17
results and sensitivity testing. The patient may require inotropic
support. Management in an infectious diseases unit is appropriate.
Outcome
This patients investigations showed negative malaria lms, mild
anaemia, lymphopaenia, mild abnormalities of liver function and a
normal chest X-ray. His ESR was 87 and CRP 264. Salmonella Typhi
subsequently grew on stool culture. He was managed in an infec-
tious diseases unit with uids and intravenous ceftriaxone, and was
monitored for development of ileal perforation by measuring girth
size. He made a full recovery.
Further reading
Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet
Infectious Diseases 2005; 5:623628.
Cook GC (Ed.). Mansons Tropical Diseases, 21st Edition. Saunders, London,
2003.
Felton JM, Bryceson AD. Fever in the returning traveller. British Journal of
Hospital Medicine 1996; 55:705711.
Health Protection Agency website: www.hpa.org.uk
Heyderman RS on behalf of the British Infection Society. Early management
of suspected bacterial meningitis and meningococcal septicaemia in
immunocompetent adults. Journal of Infection 2005; 50:373374. Also
www.meningitis.org
Lalloo DG, Shingadia D, Pasvol G et al. UK malaria treatment guidelines.
Journal of Infection 2007; 54:111121.
Ledingham JG, Warrell DA. Concise Oxford Textbook of Medicine. Oxford
University Press, Oxford, 2000.
Spira AM. Assessment of travellers who return home ill. Lancet 2003;
361:14591469. www.britishinfectionsociety.org
www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/
DH_4097254. Immunisation against Infectious Disease the Green Book.
www.wrongdiagnosis.com/f/fever/causes.htm
18
CHAPTER 5
Vaginal Bleeding
Sian Ireland and Karen Selby
ABC of Emergency Differential Diagnosis. Edited by F. Morris and A. Fletcher.
2009 Blackwell Publishing, ISBN: 978-1-4051-7063-5.
Question: What differential diagnosis
would you consider from the history?
The differential diagnosis of heavy vaginal bleeding is listed in
Box 5.1.
This woman could be pregnant as she has not had a period for
8 weeks. Bleeding in early pregnancy is most often due to a mis-
carriage, but ectopic pregnancy is the other important diagnosis
to consider.
Miscarriage
Spontaneous miscarriage is the loss of a pregnancy before 24 weeks
gestation. It is thought that around 1020% of pregnancies result
in spontaneous miscarriage. The majority are due to embryonic
abnormalities with a small percentage attributable to maternal
health factors such as diabetes, renal disease, autoimmune dis-
orders, trauma and infections, or structural abnormalities of the
reproductive tract (see Figure 5.1).
Threatened miscarriage. This is vaginal bleeding during 1
early pregnancy without the passage of tissue. The cervi-
cal os remains closed and a viable pregnancy is seen in the
uterus. About half will progress to an actual miscarriage.
The bleeding and accompanying pain is not usually severe,
and on vaginal examination the os is closed and there is no
cervical excitation.
Inevitable miscarriage. There is dilatation of the cervical canal 2
and bleeding is usually more severe.
Incomplete miscarriage. Vaginal bleeding is more intense and 3
accompanied by abdominal pain. On vaginal examination the os
is open and tissue is being passed. The presence of tissue in the os
itself can cause cervical shock low blood pressure accompanied
by bradycardia due to vagal stimulation. If the tissue is removed
with sponge forceps the shock will usually resolve.
Complete miscarriage. This is said to have occurred when the 4
fetus and the entire placenta have been passed. There is a his-
tory of vaginal bleeding and pain which has usually subsided.
Ultrasound scan reveals an empty uterus.
Delayed or missed miscarriage. This can only be diagnosed by 5
ultrasound scan when a gestational sac with a mean diameter
of more than 20 mm is seen but there is no fetal pole, or a fetal
pole greater than 6 mm is present but no fetal heart pulsation is
detected. These may present with slight vaginal bleeding.
Ectopic pregnancy
This occurs when a fertilised ovum implants at a site other than in
the uterus. Most often it occurs in the fallopian tubes but also occur
within the abdomen, cervix or ovary (see Box 5.2 and Figure 5.2).
CASE HISTORY
A 36-year-old, obese, diabetic woman presents with a 5-day
history of heavy vaginal bleeding. She is passing clots and using
more than 10 pads per day. The bleeding is accompanied by
right-sided lower abdominal pain that is constant and becoming
more severe. She has not vomited but has lost her appetite. In her
early twenties she was treated for a sexually transmitted infection.
She has a long history of irregular periods attributed to polycystic
ovary syndrome (PCOS), and has previously tried clomiphene in
order to try to become pregnant. Her last menstrual period was 8
weeks ago but given her menstrual irregularity she is not overly
concerned by this. She is sexually active and is not using any
contraception. She has no other medical problems and there is no
family history of a tendency to bleed.
Box 5.1 Causes of vaginal bleeding
Non-pregnant
Dysfunctional uterine bleeding
Cervical erosion
Cervical polyps
Infection
Malignancy
Early pregnancy
Spontaneous miscarriage
Ectopic pregnancy
Late pregnancy
Placental abruption
Placenta praevia