36 yo F with fever and headache

Original case by Brandon Fainstad, MD.
Edits, updates on fever in a traveler and graphics by Yilin Zhang, MD.



A 36 year old previously healthy woman from El Salvador presents with 10 days of fevers and headache. Her fevers come and go, and range up to 40C.  Her headache is mild without associated photophobia, vision changes or neck pain/stiffness. She  otherwise denies sinus pain, congestion, cough, SOB, abdominal pain, diarrhea, dysuria or skin changes. She initially started taking some left over ciprofloxacin for the first 4 days but stopped at the recommendation of her PCP who felt it was likely viral.  After arriving in the US to visit friends, she presented to the ED on day 9 of her fevers. She was discharged from the ED last night and called back for blood cultures positive for GNRs.

She is otherwise healthy except for occasional UTIs. She is on no chronic medications but has been taking APAP as needed for fever and headache. She lives in El Salvador and recently traveled to Guatemala. She denies an substance use.

Physical exam

VS: 39.2C, HR 72, BP 105/65, SaO2 100% on RA
G: comfortable
Neck: supple, full range of motion
CV: 2/6 systolic murmur best at RUSB
Abd: soft, no hepatosplenomegaly
MSK: no CVA tenderness
Skin: warm, no rashes

  • Na 133, K 3.4, Cl 98, CO2 27, BUN 12, Cr 0.6, Glu 100, Ca 8.8
  • WBC 3.7k, Hct 35%, Plt 150
  • AST 300, ALT 300, tbili 0.5, alk phos 300, albumin 3.2, total protein 6.0
  • INR 1.0
  • UA: no bact / no WBC
  • CXR: normal

Give a one liner for this patient.

What is your differential diagnosis and what additional work-up do you want? 




  1. Thwaites, GE & Day, NPJ. Approach to Fever in the Returning Traveler. NEJM. 2017; 376: 548-60.
  2. “Typhoid Fever.” VisualDx. Web. 02 Jan. 2016.
  3. United States. Centers for Disease Control and Prevention.  Typhoid and Paratyroid Fever. By Michael Judd and Eric Mintz. Atlanta, GA:  CDC, 2013. Accessed at: https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/typhoid-paratyphoid-fever
  4. Pramoolsinsap, C & Vikit Viranuvatti. “Salmonella Hepatitis.” J Gastroenterol Hepatol Journal of Gastroenterology and Hepatology 13.7 (1998): 745-50.

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