After trip, college student falls deathly ill

One in an occasional series on attempts to solve a medical mystery.

The plan was to have a relaxing family vacation, then return to college invigorated for the spring term. But nearly two weeks after returning from the trip, just as class work was escalating, the 19-year-old student began to feel awful. It started with fever and aches in his muscles. Then came head pain that grew into what he called "the worst headache of my life."

That was early January, the heart of flu season, and his symptoms - fever, headache, and muscle aches - were classic for influenza. His inclination was to stay in bed and sleep it off, but he didn't have the strength to eat or drink, and within a day, he was too weak to stand. His parents rushed down from New York, took one look at him, and dragged him into a cab heading to the emergency room.

His heart was racing, and his blood pressure was low when he arrived. He was confused and had a hard time following directions and cooperating. The ER team placed an intravenous line in his arm, drew off some blood for testing, and began infusing antibiotics and fluids.

While flu was still possible, the first order of business was to consider the most rapidly fatal illnesses, whose rule is: "One strike and you're out."

In this case, with severe headache and fever, the concern was bacterial meningitis. Meningococcal meningitis in particular can kill in a few hours. The disease can strike college students in the close quarters of dormitories. The patient had received meningococcal vaccine before the school year began, but the vaccine didn't hit every strain, and the ER doctors were not going to take chances.

As fluids to bring up the patient's low blood pressure were flooding into him with antibiotics, the ER team told the patient and his anxious parents a spinal tap was needed to look for bacterial meningitis. The test involves a needle placed into the back to drain off a bit of the normally clear fluid that bathes the spinal cord and brain. The test is quick and safe, and if the lab doesn't see anything abnormal, bacterial meningitis can be ruled out.

In his confusion, the patient refused the procedure, and his parents did not want to overrule him. The patient was admitted to the intensive care unit, and without the results of a spinal tap, the ICU team felt it had to continue aggressive antibiotics to treat meningitis.

Meanwhile, as the patient was restless and writhing in muscle pain, the teams homed in on the vacation. It was a luxury Caribbean cruise to several islands. Not the type of adventure travel that puts a vacationer at risk for exotic diseases. After such a trip, the sick returning traveler often has an illness that could readily be acquired at home. The doctors knew they had to go through possible causes systematically and shouldn't be too blindsided by the trip.

Just the same, after looking at the patient in detail and examining the initial lab results, there were some unusual diseases to consider. He had severe muscle pain, particularly in his calves, and an abnormal lab result suggesting his muscles were inflamed and leaky.

His platelet count was very low - these are the blood cells involved in clotting, and without them, people can bleed where they shouldn't - and in him, this manifested as small dots on his lower legs where he'd bled into the skin.

The infectious-diseases doctors asked more questions. What exactly did he do on Monday, Tuesday . . . and in Aruba, Antigua, Barbados? They asked his family, too.

There was a snorkeling adventure in a freshwater cave in Barbados with his siblings, but all were doing fine. No, he did not swallow much water, but he did cut his elbow on a rock in the cave. That raised the possibility of exposure to leptospirosis, which could explain his fever, headache, inflamed muscles, and abnormal blood counts.

Leptospirosis is a bacterial disease that can infect many animals, including dogs, rats, livestock, and wild animals, often without the animal's being sick. The bacteria can grow in their kidneys so any water or mud that might be contaminated by animal urine presents a risk. Moreover, the organism can live in freshwater or soil for months. But it does not grow easily in the lab, so specific testing must be done if an infection is suspected.

In the United States, farm workers are at risk for the disease. Cases have been seen among triathletes swimming in lakes, and among homeless people diving for food in Dumpsters where rats have been. The typical traveler with leptospirosis is an adventurer returning from white-water rafting in Costa Rica or Thailand.

A quick Google search revealed that leptospirosis cases were being seen in Barbados. Travelers and locals alike were being advised to wear waterproof clothing, avoid ingesting fresh water, and clean water-contaminated wounds.

As he improved, the patient was sent home and given a few days of antibiotic pills to finish off his care for presumed leptospirosis.

It was not until his follow-up visit a few weeks later that blood testing confirmed the diagnosis. By then, he was back to himself - a well-spoken, grateful, and thoughtful young man who recalled very little of his delirious days in the hospital after a peaceful holiday trip.

Valerianna Amorosa and John Stern are infectious-disease doctors in the University of Pennsylvania Health System. He practices at Pennsylvania Hospital. She practices at the Hospital of the University of Pennsylvania, as well as the Philadelphia VA Medical Center.