Just a Fever "I think I'm losing this battle," the fifty-seven-year-old man told his wife one Saturday night nearly a year ago. While she'd been at the theater--they'd bought the tickets weeks earlier--he'd had to crawl up the stairs on his hands and knees to get back to bed. Terrible bone-shaking chills tore through him, despite the thick layer of blankets. The shivering was followed by sudden blasts of internal heat and drenching sweats that made him kick off the covers, only to have to haul them back up as the cycle repeated itself. You really need to go back to the ER, his wife told him. The frustration and worry were clear in her voice. He'd already been to the emergency room three times. They'd given him some intravenous fluids and sent him home with the diagnosis of a viral syndrome. He would start to feel better soon, he was told each time. But he hadn't. This all began nine days before. That first day he called in sick to his job as a physical therapist. He felt feverish, as though he might have the flu. He would drink plenty of fluids and take it easy and go back to work the next day. But the next day he felt even worse. That's when the fevers and chills really kicked in. He alternated between acetaminophen and ibuprofen, but the fever never let up. He started sleeping in the guest room because the sweats soaked the sheets and the chills shook the bed, waking his wife. After four days of this he made his first visit to the Yale New Haven Hospital emergency room. He was already being treated for a different infection. Three weeks earlier he'd developed a red swollen elbow and gone to an urgent care center, where he was started on one antibiotic. He took it for ten days, but his elbow was still killing him. He went back to urgent care, where he was started on a broader-spectrum drug, which he was nearly done with. Now his elbow was fine. It was the rest of his body that ached. But his flu swab was negative. So was his chest X-ray. It was probably just a virus, he was told. The antibiotics he was already taking would kill just about any of the likely bacteria. He should just take it easy till it passed. And come back if he got any worse. The next day his fever spiked to 106. And so he went back to the ER. There he found a mob scene--crowded with people who, like him, felt like they were sick with the flu. It would be hours before he could be seen, he was told. Discouraged, he went home to bed. A nurse from the ER called the next morning. Could he come back now that the ER was more manageable? He was happy to return. He may not have the flu, he thought, but he was sure he had something. But the ER doctor couldn't find it. He didn't have any chest pain or shortness of breath. No cough, no headache, no rash, no abdominal pain, no urinary symptoms. His heart was beating hard and fast, but otherwise his exam was fine. His white blood-cell-count was low--which was a little strange. White blood cells are expected to increase in the setting of an acute infection. Still, a virus can cause white counts to drop. His platelets--the tiny blood fragments that form clots--were also low. That can also be seen in viral infections, but it was less common. The ER staff sent the abnormal blood results to the patient's primary care provider and told the patient to follow up with him. He'd been trying get in to see his PCP, but the doctor's schedule was full. It was the worst flu season in years. When he called again, he was told that the soonest he could be seen was the following week. The office agreed to order blood tests to look for Lyme and other tick-borne infections. This was Connecticut, after all. He dragged himself to the lab and waited for his doctor to call with the results. The call never came. In his mind, he fired his doctor. He'd been sick for over a week and they couldn't see him, couldn't even call him with the lab results he'd asked for. He again went to the ER on Sunday, the morning after his wife returned from the theater and insisted he go back. His previous visits and lab abnormalities caught the attention of the physician's assistant on duty that morning. She ordered a bunch of blood tests--looking for everything from HIV to mono. She ordered another chest X-ray and started him on broad-spectrum antibiotics, as well as doxycycline, an antibiotic for tick-borne infections. He was given Tylenol for his fever and admitted to the hospital. As he prepared to leave the ER, the flu test came back positive. He was pretty sure he didn't have it; he'd never heard of a flu lasting this long. But if he could stay in the hospital, where someone could monitor if he got worse, he was happy to take Tamiflu. The lab called again later that day to say that the test had been read incorrectly; he did not have the flu. But by then other results started to come in. It definitely wasn't his elbow--according to the patient, the orthopedic surgeon who saw him in the ER, and an X-ray. He didn't have HIV; he didn't have mono, or Lyme; he didn't have any of the other respiratory viruses that, along with influenza, had filled up much of the hospital. Yet, after a couple of days, the patient began to feel better. His fever came down. The shaking chills disappeared. His white count and platelets edged up. It was clear he was recovering, but from what? More blood tests were ordered, and an infectious disease specialist consulted. Gabriel Vilchez, the ID specialist-in-training, reviewed the chart and examined the patient. He agreed that it was most likely that the patient had a tick-borne infection. The hospital had sent off blood to test for all the usual suspects in the Northeast: Lyme, babesiosis, ehrlichiosis, and anaplasmosis. Except for the Lyme test, which was negative, none of the other results had come back yet. Vilchez thought that given the patient's symptoms--and his response to the antibiotic--it would turn out that he had one of them. And yet, all the results for tick-borne infections were negative. But there were other tick-borne diseases, less common in the Northeast but still possible. To Vilchez, the most likely was Rocky Mountain spotted fever (RMSF)--though it's much more common in the Smoky Mountains than the Rocky Mountains. The spotted fever part, the rash, was seen in most but not all cases. It's unusual to find the infection in Connecticut, but not unheard of. Vilchez sent off blood to be tested for RMSF and to retest for the other infections. The following day the patient felt well enough to go home. A couple of days later he got a call. He had Rocky Mountain spotted fever. The patient, it turned out, had the misfortune of experiencing fever and flu-like symptoms in the midst of a flu epidemic. Under these circumstances the question quickly becomes not What does he have? but Does he have the flu? Once you get to no, it's hard to go back to the broader question. For the patient, recovery has been tough. Though the doxycycline helped with the acute symptoms, it took months before he could resume his usual patient load at work. He just didn't have the strength or the stamina to get the job done. He feels that the illness brought him as close to dying as he'd ever been. Indeed, RMSF is the most dangerous of all the tick-borne infections, with a mortality rate as high as 5 percent even with current antibiotics. One thing he was certain about, however. He needed a new primary care doctor. And he got one. Excerpted from Diagnosis: Solving the Most Baffling Medical Mysteries by Lisa Sanders All rights reserved by the original copyright owners. 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