Post-Viral Infection

[Cait125]

For the last 3 months I have been having severe joint paint, fatigue, low grade fever, back and neck pain and skin rashes. I spent 4 months in Ghana and another 4 in Tanzania prior to this illness. I have seen many doctors who have concluded that it may be the beginnings of an autoimmune disease or a post-viral infection. I am looking to get some more information on either if these diagnoses or on other possible reasons for the illness, parastic?
Thank you!

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Hi Cait,

Another entity to consider.

Chikungunya virus: http://www.cdc.gov/ncidod/dvbid/Chikungunya/chikvfact.htm

Chikungunya virus causes a febrile illness as the cdc fact sheet describes. There have also been case reports of a post-viral inflammatory arthritis after Chikungunya infection.

Serology testing is available for Chikungunya.

When you said that you had diagnostic tests "confirming" malaria. Exactly what tests were performed? Were blood smears (thick and thin) read by a trained professional?

I ask this because it is quite common in Ghana, Tanzania (and other places where malaria is endemic) for the diagnosis of malaria to be mistakenly made with febrile illnesses.

Just some more thoughts. There are also other possibilities based on your travel history and the length of your stay.

~*~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Hi Cait,

Swampy brings up a possibility that belongs in the list (differential diagnosis) of what might be the cause of your symptoms.

The list of possibilities:
1. Lymphatic filariasis: Disease acquired by getting bitten by mosquitos. In a small percentage of persons, this parasite causes edema and swelling of extremities (legs and arms). And, as Swampy suggests, if your blood smear is drawn in the daytime, the blood smear will likely be negative. Also, here in the U.S. the laboratory might need some special instructions/training/encouragement to identify the parasite. The blood or serologic test may also be falsely negative.
Link: http://www.cdc.gov/Ncidod/dpd/parasites/lymphaticfilariasis/factsht_lymphatic_filar.htm

2. Other filarial parasites: There are dozens of filarial parasites or worms and some of them may only be present in the blood in the daytime, others day and night, some just at night, and others not at all. There is a species that is only found in subcutaneous tissues or skin. So, for diagnosis, skin snips [type of skin biopsy) must be taken (your ID physician should be able to perform this and then tell the laboratory how to stain and analyze the skin specimen).

3. Reactive Arthritis - post-infectious (viral, bacterial, parasitic) arthritis -- or auto-immune (as you have suggested in your postings).

Have any of the physicians performed an ESR (erythrocyte sedimentation rate) or a CRP (c-reactive protein) test? These are non-specific tests for inflammation.

Also, have the physicians told you that your eosinophils (type of white blood cell) are elevated?

Did you take terminal prophylaxis for malaria (Primaquine for 14 days) after your returned from Africa? Do you know what type of malaria that you had? (e.g. p. ovale, p. vivax, p. falciparum, or p. malariae)

Keep the dialogue going and thanks to Swampy for his comment.

~*~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[swampcritter]

Swampy wonders if the blood tests performed so far would have detected lymphatic filariasis. He's heard that you have to draw blood at night to catch it, as the little critters don't come out while the sun it up.

[Cait125]

Thanks for your help. To answer your questions:

1. I had a negative PPD
2. While I was in Ghana, I did briefly wade in Lake Volta. Not for a long period of time but just to wash off some clay. I know I shouldn't have and I am not an entirely naive traveler, I just tried to travel flexibly and without being a "worry wart".
3. When I was diagnosed with malaria, I was given a packet of pills that were in Mandarin. At the time I was so ill I couldnt advocate and find out more information.  I did have a blood test that confirmed the diagnosis both times. The second time I was treated with a drug I believe was called Artemesin and a shot.
4.I have lost a total of 8 pounds since December. I am a healthy person who was at a fine weight prior to this illness. I have not been trying to lose weight.
5. I did have a two week episode of diarrhea in January. I was ill in May with severe diarrhea and again in September.
6.The pain in my chest is in the left and in the upper part of my back when taking deep breaths. Depending upon my positions, sometimes it is worse than others.
7. I occasionaly have a cough. It is not productive. I havent had any coughing for a while now but over the summer was having a cough that occasional made me vomit from the intensity. The cough was only at night. I attributed it to a high level of dust where I was living.
8. I havent established a pattern to the fevers except that they are accompained by the joint pain. I do feel stiff most of the time but when the joint pain is severe, I usually have a vever.
9. No itch from the rash.
10. My cousin has Graves Disease. Other than that, I am unaware of any other autoimmune diseases in my family. Although that is not definite, we are rather spread out and don't keep in close contact.
I did see a rheumatologist who referred me to ID. He thought potentially a reactive arthritis, a post viral thing or early autoimmune. Started me on a tapered dose of steroids but saw little improvement.
Look forward to hearing from you.
-Cait

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Well, it is good that you have been seen by the ID specialist and I can provide more insight as you relay your testing results to me.

As the specialist likely discussed with you, the list of possible explanations is rather lengthy because of the non-specific nature of your symptoms (low grade fever, low back and neck pain, rash, and joint pain).

In the meantime, while you are awaiting your testing results, I will try to offer some assistance. However, first, more questions than answers.

1. Have you had a tuberculosis skin test (also called a PPD test)? This test involves the injection of purified protein derivative underneath the skin of your forearm. The test is "read" at 48-72 hours. If the test is positive (the area where you had the injection becomes hard or indurated), then this tells us that you have been exposed to tuberculosis. A positive test can occur in people who do not have symptoms. Your chest x-ray result will be helpful as well. For the most part, your symptoms do not sound like classic TB symptoms.
2. Did you swim in rivers, streams, or lakes when you were in Africa?
3. What treatment did you have for the malaria that you "had twice"?
4. Have you experienced weight loss during the course of your illness?
5. Are you having abdominal pain, diarrhea, or blood in your stool?
6. Where is your chest pain that you are having when you take deep breaths? Center of your chest, right, left, etc?
7. Do you have a cough? If so, is it productive?
8. Is there a pattern to your fevers? For example, do the fevers occur at the same time every day (night) or every couple of days?
9. Does the rash that you have itch?
10. Does anyone in your family have a history of an autoimmune disorder (lupus, polymyositis rheumatica, rheumatoid arthritis)?

Lots of questions from me.

Also, if infectious causes are ruled out, it will likely be helpful for you to be seen by a rheumatologist (specialist in autoimmune disorders).

~*~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[Cait125]

Hi

Just had an appt. today--still no direction. More blood, chest x-ray. Unsure of what this could be because the symptoms are non-specific. However, it is really causing me great difficulty. Theres a chance, I was told, that it is some response to a virus that just needs to run its course be it 3 months, 5 months, 10 months. Then there was talk of early autoimmune, also TB or a tick-borne disease. Have a new strange rash on upper back...about the size of silver dollar and all small red bumps. Not raised.
Any thoughts or suggestions? I am overwhelmed with this illness!!

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Any news on your condition after the ID consultation?

~*~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case

[Cait125]

Thanks for your response. I am living outside of Boston. They have done a lot of blood work and have found nothing that alarms them. The only findings thus far are blastocystis and  parvovirus. I was tested for Lyme and Malaria. I have not had a lumbar puncture or any imaging. I am now having some lower back pain and chest pain when taking deep breaths. I spoke with my doctor and she is not sure what to do with me so has not taken any of this further and is sending me to ID.

When I was away, I did have malaria twice that I know of and was sick another time but was unable to seek medical attention. I was working on a research project in both countries. I was taking a prophylaxis and tried to be mindful of the daily pill. I missed a few here and there but did take the meds regularly. Avoiding malaria is much harder than most believe especially when living with host families and not staying in A/C hotels where there are little to no bugs!

I will keep you posted. I am seeing an ID dr at the end of the week at the Brigham!

[Philip D Parks, MD, MPH, MOccH, FACOEM]

My apologies regarding the posting.

I am reassured that you will be seeing an Infectious Disease physician next week who will be able to comprehensively review your medical, travel, occupational, and domestic history.

Where do you live now? Have tick borne illnesses been ruled out?
Has malaria been ruled out?

What diagnostic work-up has been completed and what were the results?
Blood tests, imaging, lumbar puncture, etc..?

What were you doing in Ghana and Tanzania? Did you take malaria prophylaxis (or was it recommended? If so, what medication? If so, did you take the medication consistently?

I would agree that blastocystis may not be all of the story here.

Please keep your questions and comments coming.

Link to information from the CDC on blastocystis: http://www.cdc.gov/NCIDOD/DPD/PARASITES/blastocystishominis/factsht_blastocystis_hominis.htm

~*~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[Cait125]

I cant seem to find your posting. Sorry for the double post but your reply is not under the first post...?

I just returned from the dr.s and was told I have blastocystis but could this be causing the other symptoms? I am going to see an I.D. doctor next week since this dr did not know much about the parasite. She did not prescribe any treatment yet.
Thanks

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Your posting was posted twice. See the other posting for my answer.

~ Dr. Parks