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| PRACTICE STORY |
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| Year : 2017 | Volume
: 15
| Issue : 2 | Page : 158-159 |
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The eyes only see what the mind knows
Pravish Bhasuran
Rural Health Training Centre, Believers Church Medical College, Pathanamthitta, Kerala, India
| Date of Web Publication | 18-May-2017 |
Correspondence Address:
Pravish Bhasuran
XII-343, Kochukarimbil H, Vandipetta Junction, Kokkapilly P. O., Ernakulam - 682 305, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_20_17
How to cite this article:
Bhasuran P. The eyes only see what the mind knows. Curr Med Issues 2017;15:158-9 |
In the course of clinical practice, one occasionally comes across a case that defies diagnosis at the first attempt. However, with a little patience and persistence, along with careful practice of the clinical history and examination, the diagnosis may be arrived at eventually. This is once such instance.
A 68-year-old lady presented to our clinic with a history of fever, generalized body pain, abdominal pain, and constipation for 1 week. There were no other symptoms pointing to a possible cause. Except for mild tenderness in the lower abdominal quadrants, there were no other significant signs on clinical examination. Routine laboratory blood parameters and counts for the evaluation of fever were negative. This was a case of undifferentiated fever with an unknown cause. The possibility of dengue was considered, but dengue card test was also negative. The platelet count was 1.5 lakhs/cc.
The patient was kept under observation and was maintained on intravenous fluids and paracetamol for 3 days. Blood counts, renal and liver parameters were monitored regularly. During this period, fever turned high grade and intermittent, and platelet counts dropped to 1.2 lakhs/cc. Serum glutamate pyruvate transaminase level increased to 98 IU/L. The test for leptospirosis was negative. By this time, the patient had had fever for a total of 10 days.
I decided to look into the case afresh and the clinical history was revisited.
A careful physical examination now revealed a small healing eschar.
I decided to look into the case afresh, and the clinical history was revisited. There had been case reports of scrub typhus from North Kerala. The only way to diagnose it is based on clinical suspicion. As the diagnostic kits for scrub typhus were not freely available in all regions, the lesson that was conveyed from the previous reports was to suspect the disease when a fever case presents with features clinically and laboratory similar to a dengue fever, but with a negative dengue serology.
”The eyes only see what the mind knows.” This patient was from Athubumkulam, a Ghat area in Pathanamthitta district, Kerala, which was densely forested. On probing further, her relatives and bystanders gave a history suggestive of tick bite, and the patient herself remembered being bitten by a small black insect, which hung from her lower chest. It had remained at the site for 2 days.
A careful physical examination now revealed a small healing eschar [Figure 1]. The female was started on tablet doxycycline 200 mg stat on the same day (arrow in pic attached) and then followed up with a twice daily dosage. The illness responded avidly, and within 36 h, she was afebrile [Figure 2]. The provisional diagnosis was scrub typhus. | Figure 1: Eschar on the left lower lateral chest - 18 h after doxycycline was started. Fusidic acid cream had been locally applied, following with the central scab fell off.
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 | Figure 2: Doxycycline first dose was started on the 4th hospital (red arrow), following which the fever resolved within 18 hours.
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The District Medical Officer was informed, and they sent a team to visit this female and took a blood sample. Fortunately, the Government General Hospital had a few scrub typhus enzyme-linked immunosorbent assay kits available, and the test turned out to be positive. The diagnosis was now confirmed. This case taught me the importance of revisiting history and clinical examination and looking at a case afresh when at a loss for a diagnosis. Having a knowledge of diseases endemic to the individual's region is crucial to make the appropriate intervention and to do the required tests that can provide a diagnosis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Expert comments: This is an interesting story and it is often the case with scrub typhus where “the eyes do not see what the mind does not know.” It emphasizes the need for careful clinical examination and history-taking in order to diagnose the disease.
The only inconsistent bit is the history of “tick bite.” The tick bite is incidental and is not the cause of scrub typhus. Scrub typhus is caused by the bite of a chigger (larval form of the trombiculid mite) which is only 0.2 mm in size and is not visible to the naked eye. The bite is also painless. Hence, the patient does not know about the bite. Often the patients are not aware of the eschar and which is why a careful examination is required.
Dr. Winsley Rose, Professor, Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India.
[Figure 1], [Figure 2]
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