Case 44: A Bad Bug

“About a year ago,” the obstetrician said,  “I delivered two stillbirths in one week.” The room went silent. We didn’t know what to say as he rubbed his wrinkled forehead. He sighed. He wasn’t usually like this. If I was asked to describe him, I’d have said short and funny, so his first words deflated the morning. “I almost left medicine altogether and I’m not sure I’d survive something like that again.”

The student next to me (who would eventually become an obstetrician) asked why he wanted to quit, considering that he had nothing to do with these deaths, and that they weren’t his fault. He said that although he’d gone through so many years of training and had been a doctor for more than two decades, he’d been helpless and could do nothing to prevent these bad outcomes. That they’d happened so close together made him wonder whether or not they’d keep happening.

He practiced for twenty more years – forty-five in total, and now I’m the one who’s been working for two decades. I’ve had moments when I’ve felt like getting out of the ER, but they’ve been fleeting and infrequent. The sudden and severe run of invasive Group A Strep (iGAS) infections from the spring seems to have subsided. The first case I encountered was my neighbour, a mother of young children who spent almost a week in our ICU after developing flu-like symptoms.

Another was a child I’d seen with a fever and sore throat, one of the dozens I see every month. She returned twice more to our ER before being admitted, and despite treatment, her clinical course spiralled into the worst possible outcome. Shortly after her, I saw another child who’d been vomiting for a week. Each day, her parents thought she’d turned the corner, and then, in the evening, she’d vomit again. By the time I saw her, she was pale and dehydrated, and once admitted, she continued to worsen until she was in an intensive care unit downtown, unable to even stand. I’d heard of several others—even a young man who had died inexplicably a few weeks before the bulk of iGAS cases arrived. “It must have been iGAS,” my colleague later said. “There’s no other explanation.”

Group A Streptococci (GAS) are bacteria most commonly found on the skin or in the throat (ie. strep throat). When GAS becomes invasive (iGAS), it spreads to parts of the body where it’s not commonly found, such as the bloodstream where it can cause Streptococcal Toxic Shock Syndrome (STSS). Approximately 60% of patients who develop STSS die from their illness. Group A Strep can also spread deep into the body’s tissues where it can cause Necrotizing Fasciitis, also known as ‘Flesh-eating Disease.’

Noah Okoro* is 14. He’s wheeled into an assessment room by his mother whose panicked words hit me before I can introduce myself. “You have to help him,” she says, her thick accent suggesting she’s spent most of her life in Africa. “He’s really sick.”

“How long has he been sick?”

“Oh God, I don’t know,” she says, her words quick and loud. Noah lifts himself off the wheelchair and falls onto the exam table. He looks terrible. His dark skin is covered by hundreds of tiny beads of sweat. I look at his vital signs. His heart rate is high, over one-thirty, and his temperature is forty degrees celsius. “How long has it been, Noah, a week?”

“No,” he says, “since the birthday party.”

“Oh right,” she says. She turns to me. “We had a big family birthday, but he just stayed in the car the whole time; he just laid across the back seat.”

“What’s he been sick with? What symptoms does he have?”

“Look at him!” she says. “He’s so weak! He can’t even stand!”

I go back to my original question. “How many days has Noah been sick?”

“When was the birthday party, Noah?” his mother says.

“I don’t know,” he says.

“What day is it now?” she asks.

“It’s Sunday,” I say.

“Almost a week?” she asks her son.

I still don’t know what symptoms he has, other than weakness and fever, and I certainly don’t know how long he’s been sick, so I turn to the triage note. “Fever for two days, treated with Advil, complains of headache, shortness of breath, dizzy, nausea, vomiting.”

“How long has he been vomiting?”

“Just today,” his mother says.

“Is there diarrhea?”

“Oh yes, so many times today.”

“Just today?”

“Yes,” she says, “it’s just been today. All of this is today.”

“So, is today the first day he’s been sick?”

“No, he’s been like this almost all week!”

I turn to Noah and ask him about his symptoms, head to toe, although the first thing I ask is whether or not he has a sore throat. He’s so sick that Group A Strep is at the top of my list. He doesn’t have a sore throat, but that doesn’t rule it out. Two of our sickest iGAS patients had come in with shoulder pain and fever. The vomiting child I’d seen also didn’t have a sore throat.

Noah has a headache, he’s weak, he feels short of breath and light-headed, and as of today, he’s had vomiting and diarrhea. His stomach is uneasy, and he has cramps, but his abdomen is only minimally tender and soft to palpation. He denies pain anywhere else in his body. There’s no cough, no urinary symptoms, no neck stiffness or tenderness, and no other obvious source of infection. And before this, he’d never had any medical issues.

Other than the high fever, high heart rate, and borderline-low blood pressure, the rest of his physical exam is normal. I consider asking his mother a few more questions, but, before I can come up with a question, she speaks. “Can you please help him, he’s so weak. I can’t take him home like this.”

I tell her that I’m not planning on sending him home just yet and order a septic workup—blood tests, urinalysis and a chest X-ray. “We’re going to run some tests,” I say, “and we’ll get him feeling a little better.” I aggressively re-hydrate him with IV fluids and order an anti-nauseant and Tylenol. With iGAS at the forefront of my thoughts, I consider intravenous antibiotics, but for now, I hold off. Maybe it’s just a bad stomach bug; perhaps he’ll feel better after a liter of saline.

Three hours later, his tests are back. He’s been moved to a hallway stretcher where he can rest. He’s had a liter of fluid and his pulse has come down from one-thirty to one-ten, but his blood pressure is still low. He still has a fever so I order ibuprofen on top of the acetaminophen he’s already had. I ask if he feels any better, and he says no. He still feels awful, and even lying down, he feels like he could throw up or even pass out.

The blood tests don’t tell me much—or at least I think they don’t. His creatinine is a little high, indicating dehydration, as he’s been losing fluid through his gut and skin all day. His hemoglobin (red blood cell count) is a little low, and his platelets (responsible for blood clotting) are down too, about half normal. The urine is clear, and his chest X-ray is normal. It has to be Group A Strep, I think to myself. The blood culture won’t return until tomorrow, but what else could it be? We’ve seen other kids who look almost exactly like this.

His mother is sitting at the end of the bed. She’s calm now and has brought Noah food, but he doesn’t have an appetite. “What’s next?” she says.

I consider taking a more thorough history from the beginning, but he’s in no shape to go home and he’ll have to see the pediatrician for admission. The pediatrician on call is one of my favourites—easy to talk to, knowledgeable, always willing to help. I call and tell her the story.

She’s down within minutes and gathers a similar history, although she’s able to add some detail. A few weeks earlier, Noah had been on antibiotics for a lower-body skin infection, and this course of antibiotics had been given just before returning from a family trip to Nigeria. She orders more IV fluid, and tells me that he is sick enough that she’s going to initiate transfer to the children’s hospital downtown.

An hour later, at home, I log in to follow up on Noah. I skim the pediatrician’s consultation note. “Clinical picture is concerning for sepsis of unclear source. Need to consider iGAS.” She’s seen the worst of our iGAS cases and to be safe, she’s already given Noah three different intravenous antibiotics to cover invasive Group A Strep.

As I continue to skim the note, my phone goes off. It’s the intra-hospital messaging system. “Malaria,” the note says. “Our patient has malaria.” The bad bug in Noah’s case wasn’t Group A Strep, it was a mosquito.

Having taken a better history than I had, the pediatrician connected Noah’s trip to Africa to his symptoms and blood test results, particularly his low hemoglobin. With his travel history, she’d also considered a pulmonary embolus as the source of Noah’s shortness of breath and rapid heart rate, but the malaria smears that she’d ordered were the key to diagnosis.

“Amazing,” I text back. “Cool case.” I wish I’d tried harder to get a better history and realize that while medicine can be hard, very hard, and tragic to the point of hopelessness, it is at the same time challenging, interesting, surprising, and most of all, incredibly gratifying. After a week of treatment in hospital, Noah is back to baseline and discharged home.

*name and all identifying features have been changed

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