Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention (CDC) or the US Public Health Service.
Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
Background
Four patients present to a small emergency department (ED) in a suburb of Pittsburgh with cough, dyspnea, fever, and other symptoms described in further detail below.
Patient 1 (32-year-old male) presents with a chief complaint of subjective fevers and cough since yesterday. He reports coughing up frothy, bloody mucus in the past few hours and worsening malaise. His past medical history and family history are both unremarkable. He has not traveled recently but notes attending a Major League Baseball game 2 days ago with his wife.
Patient 2 (35-year-old female), wife of patient 1, complains of trouble breathing and a headache for the past 24 hours. She is 24 weeks pregnant and has been receiving regular prenatal care for an uncomplicated pregnancy thus far. She also reports a fever and worsening cough that began this morning. Past medical and family history are unremarkable. She has not traveled recently due to concern about COVID-19 impacting her pregnancy; her only recent outing was to a major league baseball game with her husband 2 days prior to presentation. She and her husband have a 3-year-old son who stayed with his grandmother during the baseball game and is currently asymptomatic.
Patient 3 (74-year-old male) presents with a cough, headache, and fever since yesterday. He also complains of dyspnea and hemoptysis. He has hypertension, type 2 diabetes mellitus, and rheumatoid arthritis, for which he takes methotrexate. He has not traveled internationally but returned from visiting his brother in Arizona 1 week prior to presentation.
Patient 4 (10-year-old female, granddaughter of patient 3) presents with high fever, cough, and trouble breathing. She reported feeling very weak and is carried into the ED by her mother. She has a history of asthma and uses an albuterol inhaler as needed.
All four patients present to the ED on the same afternoon. Upon further questioning, you discover that patients 3 and 4 also attended the same summertime baseball game 2 days ago.
Physical Examination and Workup
Upon physical examination, patient 1 (32-year-old male) is ill appearing and has a temperature of 102.4 °F (39.1 °C), pulse 108 beats/min, respiration rate 20 breaths/min, blood pressure 118/76 mm Hg, and oxygen saturation 89% on ambient air. Physical examination is notable for regular tachycardia, coarse breath sounds bilaterally with scattered rales, and mild generalized abdominal tenderness. Capillary refill is < 2 seconds, and he has strong pulses bilaterally.
Patient 2 (35-year-old female) appears uncomfortable. Her temperature is 101.4 °F (38.6 °C), pulse 116 beats/min, respiration rate 24 breaths/min, blood pressure 122/78, and oxygen saturation 92% on ambient air. Examination is notable for decreased breath sounds in the right lower lung field, regular tachycardia, and a fundal height of 24 cm. Fetal heart tones are present, with a rate of 168 beats/min.
Patient 3 (74-year-old male) is ill-appearing and lying on the gurney in pain. His temperature is 102.1°F (38.9 °C) with a pulse of 105 beats/min, respiration rate 24 breaths/min, blood pressure 98/62 mm Hg, and oxygen saturation 86% on ambient air. He is alert and oriented to person and place only. He has decreased breath sounds over both lung bases bilaterally.
Patient 4 (10-year-old female) is lying in her mother's arms and coughing. She responds to questions with grunts and withdraws from painful stimuli. Her temperature is 104.2 °F (40.1 °C), heart rate 145 beats/min, respiratory rate 30 breaths/min, blood pressure 100/64 mm Hg, and oxygen saturation 90% on ambient air. She is taking short, shallow breaths and there are scattered rhonchi. Her abdomen is diffusely tender to palpation and capillary refill is delayed (4 seconds). Her extremities are cool.
Public Information from the CDC and Medscape
Cite this: CDC Case Challenge: Four People With Cough and Dyspnea After Attending a Baseball Game - Medscape - Oct 07, 2021.
