A 49-year-old woman presents to the emergency room complaining of a two-day hist
ID: 140823 • Letter: A
Question
A 49-year-old woman presents to the emergency room complaining of a two-day history of fever. She had been well until two months ago when she presented to her primary care physician with palpitations and heat intolerance. She was diagnosed with hyperthyroidism. Her palpitations and heat intolerance symptoms improved with treatment, and one week prior to presentation, she reported no significant symptoms. Two days ago she noted the onset of a sore throat with fatigue. Yesterday she developed a fever to 100.8° F (38.2° C). She took acetaminophen with resolution of her fever. Today she developed a temperature of 101° F (38.3° C) with associated chills and lightheadedness. She therefore came to the emergency room. Vitals: Temp 100.5° F (38.1° C) BP 101/68 HR 105 O2 sat 98%. She is a thin woman, appearing fatigued but in no acute distress.
CBC
Patient Results
Normal Range
WBC
3.6 K/ul
3.5 – 11 K/ul
Hb
11.5 g/dL
11.5 – 15.5 g/dL
Hct
37%
36 – 47%
MCV
86 fL
81 – 99 fL
MCH
30.1 pg
26 – 33 pg
RDW
12.74%
< 15%
Platelets
157,000/ul
150,000 – 450,000/uL
Cell type
Patient Results
Normal range
Granulocytes (%)
2
39 - 75
Lymphocyte (%)
86
16 - 47
Monocyte (%)
7
4 - 12
Eosinphil (%)
2
0 – 7
Basophil (%)
3
0
1. Based on her lab results, what do you suspect is causing her fever? Support your answer with the abnormal lab results and the vital signs that she presented.
2. Do you expect to find any abnormalities in her lymphocyte population? Why or why not? If so, what specific abnormalities?
3. Would you expect someone in her demographic to be susceptible to the cause of her fever? Why or why not?
CBC
Patient Results
Normal Range
WBC
3.6 K/ul
3.5 – 11 K/ul
Hb
11.5 g/dL
11.5 – 15.5 g/dL
Hct
37%
36 – 47%
MCV
86 fL
81 – 99 fL
MCH
30.1 pg
26 – 33 pg
RDW
12.74%
< 15%
Platelets
157,000/ul
150,000 – 450,000/uL
Explanation / Answer
1. The fever pattern presented by the patient is possibly due to a bacterial infection, since the basophils, lymphocytes are elevated and the granulocytes are low. When the basophils are increased, it is usually due to the fact that these cells are struggling with some type of infection and they have not been able to do more, that's why they increase. Basophils are usually increased by diseases of the respiratory tract, so the sore throat may be present. The decrease of granulocytes specifically of the neutrophil type is mainly due to bacterial infections since they are the first cells to detect the attack to the organism and the first to reach the infection center, however, it can also be low due to the hyperthyroidism presented by the patient .
The increase in lymphocytes is usually indicative of viral or bacterial infections.
The patient's palpitations may be due to hyperthyroidism or the low pressure displayed by the patient and is accompanied by symptoms such as weakness, fatigue, sweating, excessive heat, fever or chills. While these symptoms are typical for hyperthyroidism, sore throat and fever may indicate some type of bacterial infection.
2. If possible, during an infectious or autoimmune process, morphological abnormalities such as uncommon chromatin, very basophilic cytoplasm or larger lymphocytes, which are typical of an active immune response, may occur.
3. If it is a viral or bacterial infection, the most susceptible groups would be children, the elderly and pregnant.
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