A 72-year-old man, living in Miranda (50 km from Cali, Colombia), with no morbid history, consulted a local health institution for a six-day picture of fever, post-quantified asthenia, polyarthritis
She complained of severe pain and swelling in her wrists and ankles that limited her mobilization.
Because it is an epidemiological nexus with similar cases, the diagnosis of CHIK-V infection was suggested.
The patient was managed as outpatients with nonsteroidal anti-inflammatory drugs.
Due to symptom progression, vomiting and hypogastric pain secondary to urinary retention, she consulted again two days later in a primary care center, where she was managed with bladder catheterization.
Laboratory tests showed a leukocyte count of 55.17 cells/mm3, neutrophils 49.000 cells/mm3, leukocytes count 300 cells/mm3, platelets 160,000 cells/dL 3, hemoglobin 217,800 cells/mm3.
The urine test was normal.
The patient was referred to our institution after 8 days of evolution due to rapid hemodynamic instability with hypotension and altered state of consciousness.
Physical examination revealed a hard edema in the ankles.
The patient was hypoperfused, with agonic respiration, blood pressure 86/41 and mean of 56 mmHg, heart rate 96 per min, respiratory rate 26 per min, capillary refill 84%, decreased breath sounds 2 °C.
Electrotechnical recording identified picu waves suggestive of hyperkalemia.
In the Intensive Care Unit (ICU) energy resuscitation with intravenous fluids was continued.
A renal failure (creatinine 3.3 mg/dL), sodium 131 meq/L, hyperkalemia of 6 meq/dL, albumin level 17 mg/dL, and albumin 3 g/dL were observed.
Blood count and leukocyte count were 36,400 cells/mm3, neutrophils 90%, hemoglobin 22.1 g/dL, hematocrit 62.5%, platelet count 120,000 cells/mm3, and hematocrit 0.45.
The initial chest X-ray showed increased vascular network and aortic arch elongation, with no evidence of pulmonary consolidation or pleural effusion.
The initial partial thromboplastin time (PTT) was 46.8 sec and the INR was 0.99.
In the following hours, the patient presented progressive clinical deterioration, with signs of respiratory failure, requiring orotracheal intubation and mechanical ventilation.
Despite the management instituted, the patient persisted with severe haemodynamics.
The patient remained with fever up to 39.7 °C and metabolic acidosis.
With a diagnosis of secondary shock with unknown focus, management was initiated with vasopressive drugs, invasive mechanical ventilation, broad-spectrum antibiotics and hemostasis.
On the second day the patient continued to show a clear clinical deterioration.
A transthoracic echocardiogram showed a preserved ejection fraction, with no other important findings; abdominal ultrasound showed a fatty liver and linear calcifications in the right kidney.
Despite dialysis therapy, the patient developed progression of renal failure, with severe metabolic acidosis, very high lactic acid (13.6 mmol/L), and severe coagulopathy.
The hemoglobin levels decreased to 4.1 g/dL, requiring blood product transfusions.
The patient finally died on the third day (60 h) of his admission to the institution.
1.
Microbiological tests
A viral load was performed by RT-RPC for CHIK-V, which resulted in 5,000,000 copies/mL of viral material (LightMix® kit Chikunguncler Diagnostics, Light).
After the death, the results of positive RT-RPC for DENV-3 serotype were received at the Laboratory of Microbiology of Valle del Valle (University of Permissible G Dengue Screening and Certificate) National Institute of Dengue Ig.
From a urine culture taken through the bladder catheter, Enterococcus faecalis sensitive to ampicillin was isolated.
Two hemocultives were also performed, one of which was positive for Staphylococcus epidermis at 37 h, which was interpreted as contamination.
IgM tests for leptospira, thick smear for malaria, and HIV serology were negative.
Since there are no reports of circulation of fever virus in southern Colombia, this virus was not included in the study.
