Clinical Vignette I

Which of the following is the most likely pathogenic cause of this patient’s current medical illness?

For the past week, an 18-year-old male college student football athlete has been complaining to his coach about feeling sick and run down as if he had “the flu.” As a former professional football player with a stellar ten year career in the National Football League, the no-nonsense head coach simply dismissed the young quarterback’s complaints and reassured the 18-year-old athlete that he is most likely experiencing heightened pre-game “jitters”, a phenomenon common to many elite athletes prior to high-stakes competitive sporting events. Despite still feeling sick and weak, the 18-year-old collegiate star quarterback followed the advice of his coach and played in the team’s next game three days later against the number two nationally ranked college football team for a spot in the national championship match. After a devastating team loss and an uncharacteristically poor performance by the star 18-year-old student athlete, the coach now had reason to believe that his player might actually be sick and immediately sent him to the University Health Center to be medically evaluated.

At the University Health Center clinic, the 18-year-old male student athlete is evaluated for ten days of progressively worsening “flu-like” symptoms. The patient reports that the “flu-like” symptoms started approximately a week and half ago but he initially dismissed it all because he thought it was just another simple cold infection that would self-resolve within a few days. After several days of using over-the-counter cold medications, the patient states that his symptoms only became worse with each passing day. He reports daily fevers, night sweats, a painful sore throat, non-productive cough, frequent headaches, loss of appetite, generalized muscle aches, unintentional weight loss of 10 lbs (4.54 kg), and feeling so physically fatigued and sleepy all the time that he is barely able to get out of bed to attend classes and participate in football practices. The patient denies any past history of any similar illness and is not aware of any close friends or relatives with recent illnesses that manifested with similar signs and symptoms. The patient denies smoking, chewing tobacco use, recreational drug use, and alcohol consumption. However, he does report being sexually active with multiple female partners and admits to not always using protection. He also states that he has never been tested for HIV or any other sexually transmitted infections. With the exception of the temporary use of over-the-counter analgesics, antipyretics, antihistamines, throat lozenges, and topical pain relief sports cream, he normally takes no medications. The patient has no known allergies. The remainder of his past medical history, family history, and social history are unremarkable.

On physical examination, temperature is 102.2°F (39.0°C), pulse rate is 91 beats/min, blood pressure is 135/81 mm Hg, respiration rate is 18/min, and pulse oximetry on room air shows an oxygen saturation of 95%. The physician’s methodical physical exam reveals slightly enlarged tonsils with grayish exudates and posterior pharyngeal erythema, diffuse tender lymphadenopathy especially in the posterior cervical lymph nodes, and mild splenomegaly with tenderness to palpation. The remainder of the physical examination is unremarkable.

• Based on the patient’s history of present illness and clinical signs and symptoms, you have already developed a presumptive differential diagnosis with a high degree of certainty. Relying on your clinical acumen and physical diagnostic skills, which of the following is the most appropriate next step in management of this patient?

• Unfortunately, the initial test to confirm your presumptive diagnosis of the patient’s current medical illness yielded a negative result. Provided the clinical circumstances and your high index of suspicion, which of the following is the most appropriate next step in management of this patient?

Initiate antibiotic treatment to cover for gram positive bacterial infection

• Given the patient’s correct diagnosis, current clinical condition, and choice of sporting activity, which of the following complications is the 18-year-old male patient most at risk for developing if he continues to participate as an active player on the college sports team?

Which of the following mechanisms of action best characterizes the antibiotic most likely responsible for the development of the generalized, erythematous, pruritic maculopapular rash in the 20-year-old female college student in this particular clinical scenario?

• A 20-year-old female college student at the same University coincidentally developed a similar acute medical illness as the 18-year-old male college student athlete in the previous clinical encounter. The 20-year-old female college student is being evaluated at the University Health Center clinic for eight days of progressively worsening “flu-like” symptoms. She reports fevers, chills, occasional night sweats, a painful sore throat, non-productive cough, severe headaches, generalized myalgia, loss of appetite, unintentional weight loss of 6 lbs (2.7 kg), and feeling so physically exhausted and sleepy all the time that she is barely able to get out of bed to attend classes. She denies any past history of any similar illness and is unaware of any close friends or relatives with recent illnesses that manifested with similar signs and symptoms. She does not drink alcohol, smoke, chew tobacco, or use recreational drugs. She is currently in a monogamous relationship with the same male partner for the past two years and admits to not always using protection. She states that she has never been tested for HIV or any other sexually transmitted infections. The only medication she takes is prescribed oral contraceptive pills. She has no known allergies and has never had any prior allergy testing. The remainder of her past medical history, family history, and social history are unremarkable.

On physical examination, temperature is 103.1°F (39.5°C), pulse rate is 88 beats/min, blood pressure is 118/76 mm Hg, respiration rate is 18/min, and oxygen saturation is 97% breathing ambient air. The patient’s posterior pharynx is erythematous with grayish exudates and moderately enlarged tonsils. There is diffuse tender lymphadenopathy especially in the posterior cervical region and very mild splenomegaly with mild tenderness to palpation. The rest of the physical examination is unremarkable. 

Based on the patient’s history of present illness and clinical signs and symptoms, the physician developed a differential diagnosis and performed a heterophile antibody test which yielded a negative result. The physician then performed a Rapid G.A.S. Antigen Detection test which yielded a positive result. Given the results of the two tests and the patient’s signs and symptoms, the physician decided to start the patient on antibiotic treatment. Within 48 hours of initiating antibiotic treatment the 20-year-old female patient started to develop a generalized, erythematous, pruritic maculopapular rash. After four days of initiating antibiotic treatment, the rash covered most of the female patient’s body and face while the other signs and symptoms associated with her acute medical illness demonstrated no improvements. Frustrated and still feeling sick and weak, the 20-year-old female patient went back to the University Health Center to confront the physician that prescribed her the antibiotics. Upon seeing the widespread, erythematous, maculopapular rash covering most of the female patient’s body and face, the physician immediately discontinued the antibiotic treatment and ordered a repeat heterophile antibody test which yielded a positive result this time thus confirming the initially suspected diagnosis. Subsequently, the female patient’s rash gradually improved over the next three weeks with complete resolution within five weeks after discontinuing the antibiotic treatment. 

Which of the following anatomic structures typically supplies most of the oxygenated arterial blood to the splenic artery?

• Due to the highly vascularized nature and anatomic location of the organ which enlarges in approximately 50% of patients that develop the same acute medical illness as both the 18-year-old male college student athlete and the 20-year-old female college student, it is not surprising that this particular organ is one of the most commonly injured organs in abdominal trauma.