What is the diagnosis for a patient with fever, normal Human Immunodeficiency Virus (HIV) status and CD4 count, headache, negative Computed Tomography (CT) scans of the head, abdomen, pelvis, and chest, recently released from county jail, born in Vietnam, with a history of residence in Hawaii and California, no exposure to animals, negative QuantiFERON (Interferon-Gamma Release Assay) test, and elevated International Normalized Ratio (INR)?

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Last updated: February 10, 2025View editorial policy

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Differential Diagnosis

  • Single most likely diagnosis
    • Viral hepatitis: The patient's elevated INR and fever, combined with a negative Quantiferon test and normal CD4 count, suggest a possible diagnosis of viral hepatitis. The patient's history of living in Vietnam and Hawaii, where hepatitis is more prevalent, also supports this diagnosis.
  • Other Likely diagnoses
    • Tuberculosis (despite negative Quantiferon): Although the Quantiferon test is negative, it is not 100% sensitive, and TB is a significant concern in immunocompromised patients or those from high-prevalence areas like Vietnam.
    • Endocarditis: The patient's fever and elevated INR, combined with a history of incarceration (which may increase the risk of IV drug use), raise the possibility of endocarditis.
    • Viral infections (e.g., influenza, COVID-19): The patient's symptoms of fever and headache, combined with a negative workup for other conditions, suggest a possible viral infection.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Meningitis: Although the CT head is negative, meningitis can present with non-specific symptoms like fever and headache, and is a medical emergency that requires prompt diagnosis and treatment.
    • Sepsis: The patient's fever and elevated INR, combined with a history of incarceration and possible exposure to infectious diseases, raise the possibility of sepsis.
    • Toxoplasmosis: Although the patient has a normal CD4 count, toxoplasmosis can still occur in immunocompetent individuals, and is a significant concern in patients with a history of exposure to undercooked meat or contaminated water.
  • Rare diagnoses
    • Melioidosis: The patient's history of living in Vietnam and Hawaii, where melioidosis is more prevalent, combined with symptoms of fever and headache, raise the possibility of this rare but serious infection.
    • Leptospirosis: Although the patient has no known exposure to animals, leptospirosis can still occur through contact with contaminated water or soil, and is a significant concern in patients with a history of living in tropical or subtropical regions.
    • Brucellosis: The patient's symptoms of fever and headache, combined with a history of living in Vietnam and Hawaii, raise the possibility of this rare but serious zoonotic infection.

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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