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A Host in Puerto Rico

Posted by Dr. Sushrut Jangi  February 8, 2013 07:00 AM

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This is the case of a real patient. After reading the description of the case, I invite you to guess the patient's diagnosis. The answer will be posted Friday.

Mr. G's photograph of the El Yunque Forest in Puerto Rico

On December 5th, Mr. G and his wife left the cold and snow-caked city of Worcester to celebrate their wedding anniversary in balmy Puerto Rico. After landing in San Juan, they met their host family, who lived right in the city. The cordial hosts -- D and M -- had offered Mr. and Mrs. G a spare room at the far end of the house. The accommodations were comfortable and secure. However, Mr. G soon noted that one of the hosts, the man, appeared ill. 

"When we first arrived, [M] looked pale and leaned heavily on the wall for just a few moments, not saying much," he said. The man's wife, D, seemed unaffacted. She was gracious and talkative, and soon, Mr. and Mrs. G were settled into their new home. 

The next day, Mr. and Mrs. G stepped out into the city. They strolled down the Plaza del Mercado de Rio Piedra, a busy marketplace that bustled with natives and tourists. Vendors hawked cigars, old books, candles; food stalls sold cut coconut, giant avocadoes, and meat smoked on the open flame. 

On December 7th, the couple traveled to the slopes of the Sierra de Luquillo mountains, descending into the tropical rainforest called El Yunque [see photo that Mr. G took]. "The weather was gorgeous," Mr. G recalled. The air was moist, but not humid; the sky threatened rain, but none fell. The river that ran through the rainforest stood still.  Ferns and palms grew alongside the path, some reaching a height of 50 feet; the canopy was thin enough to make out crescents of blue sky and the wings of colored birds. A few giant snails clung to the underside of the sparse underbrush. 

 By noon, the couple had descended deep into the rainforest, where they broke for lunch. "We sat in an open-air pavillion built by Boy Scouts. She ate sardines. I had a banana, dried dates and some nuts," Mr. G said. During that hour, he remembered, something had bit him, four or five times. He guessed it was a mosquito. "I thought the bites pretty weird at the time. It wasn't very buggy around there." On the trip, they hadn't seen many bugs or animals at all -- just clouds of gnats, little lizards that scampered underfoot, and the birds in the trees. 

 The couple hadn't forgotten the health of their host. Between trips to old San Juan, a swim at Guanica, and a hike through the Dry Forest nearby, they saw that M's condition was improving. One evening, he joined them on the veranda in conversation. The illness he had seemed to have passed. 

But just as M had recovered, on December 10th Mr. G awoke in the middle of the night in a profuse sweat. Although he had no thermometer, it was evident that he had broken out in a fever. As the night pressed on, strange and recurring dreams occupied his mind. "A dream replayed over and over and into the day -- some delusion about a mass I had in my stomach, with little hairy projections I had to snip," he said, without laughing, as though remembering the potency of the dream. The delusions and fevers were persistent. 

Even a short trip to a botanical garden with his wife exhausted him. Moreover -- he had developed a wincing headache that came and went nearly every minute -- unusual in a man who never had headaches at all.

Mr. and Mrs. G left the host family in a rush, growing concerned about his sickness. They flew back to Boston on the night of December 12th. The flight was uncomfortable. "I had a flare-up of pain on the crown of my head, as though someone had struck me with a small hammer every 30-60 seconds," he said. 

Back in the cold of Worcester, the couple's troubles did not end. On December 16th, Mr. G awoke with a rash that covered his legs and arms, his feet nearly purple. "My skin is usually unblemished," he reported. "The capillaries on my feet broke and everything started to swell. I was purply up through the ankles. The rash looked fissured -- like a fishnet." [See image of his legs].

Purpura and petechiae along Mr. G's lower legs

When he went to see Dr. Jeremy Golding, a family practioner in Worcester, the doctor was most impressed by the rash. "What really startled me was the purpura and petechiae (bleeding under the skin) from the knee down," he said, referring to the skin findings on his legs. By December 20th, Mr. G received an e-mail from the hosts in Puerto Rico. Both Mr. G and M, he found to his surprise, shared the same diagnosis.

(2) If you were to travel to Puerto Rico or another Carribean country, would you:

(a) Visit a travel clinic before your trip (b) Visit a specific web site, like the CDC (c) perform a google search to research diseases in the country (d) Do none of the above and hope for the best

Post your answer by clicking on the comment link below.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »

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