Fever In Collegiate Athlete With Recent Travel

HISTORY: A 20-year-old college lacrosse player presented with 2 days of high fevers after returning from recent travel to the Dominican Republic. She had associated symptoms of chills, myalgias, polyarthralgia, nausea, headache, retro-orbital pain, and transient rash on chest. She had been backpacking through the Dominican Republic approximately 1 week prior. She reported numerous mosquito bites and had not received any prophylactic vaccinations or medications for travel. She was seen at a student health clinic and sent to the ER for further evaluation. PHYSICAL EXAMINATION: General: Well appearing, no distress | Skin: Warm, clammy, multiple erythematous bug bites on bilateral legs | Eyes: PEERL, EOMI, clear conjunctiva | Ears: Canals / TMs clear | Oropharynx: moist mucous membranes, throat clear | Neck: Supple, FROM, no adenopathy | Lungs: CTAB | Cardiovascular: rrr, no m/r/g; no peripheral edema | Abdomen: Soft, non-tender, no rebound or guarding | Neuro: AOx3, CN II-XII intact, strength and sensation normal throughout | Psych: Cooperative, appropriate mood and affect DIFFERENTIAL DIAGNOSIS: 1) Dengue Fever. 2) Chikungunya Fever. 3) Zika. 4) Malaria. 5) Meningitis. TEST AND RESULTS: Dengue PCR: Positive | Zika PCR: Positive | Rickettsia panel: neg | Chikungunya PCR: neg | Covid/Flu/RSV: neg | UA: neg; Ucx: No growth | Blood Cx: No growth | Peripheral smear: normal | HIV 1/2 Ag Ab: neg | Hep A/B/C: neg | Mono: Neg | Lumbar puncture: not successfully collected. CXR: Clear. CTAP w/con: Small fluid within left adnexa and cul-de-sac; abscess unlikely. Mild bilateral inguinal lymphadenopathy. Pelvic US: Left ovarian simple cyst. Small amount of free fluid in cul-de-sac. CTH w/, w/o: No evidence for acute intracranial pathology. No pathologic enhancement identified within the brain. FINAL/WORKING DIAGNOSIS: Concomitant Dengue fever and Zika virus infection. TREATMENT AND OUTCOMES:1) Initially empirically treated with Ceftriaxone and Vancomycin for possible bacterial meningitis; Doxycycline for possible rickettsial disease. 2) With negative initial labs and imaging, she was treated supportively with acetaminophen and ondansetron. 3) Send-out tests eventually returned positive for Dengue and Zika. 4) Patient was discharged and able started return to play progression and conditioning the following week.