CDC Unknown Infectious Disease Case Surveillance Report

Transcription

1 Case Surveillance Report State Case No: 397 CSID No: 337 Case No: Patient name (last, first): Berger, Timothy Date of symptom onset of this attack: (mm/dd/yyyy): 8/30 Date of Birth: 11/04/1970 Is patient pregnant? Y N Sex: Male Female Unknown Physician name (last, first): Smith, M. Height: 5 ft. and 7 in. Weight: 179 lbs. State reporting case: Los Lunas, NM County: Valencia County Patient admitted to hospital: Yes No Unknown Hospital: University of New Mexico Hospital Date: 9/4 Has patient traveled or lived outside the U.S. during the past 2 years? Yes No Country: Date returned/arrived in U.S.: Duration in country: Did the patient reside in U.S. prior to most recent travel? Principle reason for travel for most recent trip: Yes Tourism Visiting friends/relatives Military Airline/ship crew No, (specify country): Business Missionary/dependent Peace Corps Refugee/immigrant Unknown Student/teacher Other Blood transfusion/organ transplant within last 12 months: Yes No Unknown If yes, Date:

2 Name: Timothy Berger Phone # N/A D.O.B. 11/04/1970 Height 5 7 Weight 179 Date of Visit 09/04 Address 1000 Rivas Rd, Los Lunas, NM Reason for visit: Dizziness, body aches Personal Medical History Medication allergies: None Reaction: None Latex Sensitivity Yes No Pregnant Yes No Heart Problem Yes No Breast Feeding Yes No High blood pressure Yes No Smoker Yes No Valve replacement Yes No Breathing problems Yes No Pacemaker/AICD Yes No If Yes, explain Stroke Yes No Sleep Apnea Yes No Diabetes Yes No Alcohol Use: Yes No Kidney Problems Yes No Cancer: Yes No Seizures Yes No If Yes, type: Liver Problems Yes No

3 Family History of illness: History of debilitating arthritis, sciatica, right femur misaligned due to injury across the growth plate as a child Recent travel (local and abroad): None Treatment: Given broad spectrum antibiotics and antiviral agents via IV, along with supportive treatment in the form of fluids and steroids. He succumbed to the infection on 09/04 of this year.

4 Full Background Timothy Berger was a disabled and unemployed resident of Los Lunas, New Mexico. He lived in a small home maintained by the local churches. He experienced extreme pain in his joints on a regular basis, and often had trouble simply walking around the house. He spent most of his days sitting outdoors on the porch, talking to friends and neighbors. He was well liked by most of the community, and he was known to help anyone and everyone when he could. He relied on the church and other charity organizations to survive. He received visits from organizations on a regular basis that checked on his welfare, got his meals from Meals on Wheels, and received discounted medical care when the mobile clinic was in town. He knew that many of his neighbors were in the same boat, and when his injuries allowed, he would walk with his neighbors to the local food bank or discount stores and help them purchase food. He often ate with his friends and neighbors, and attended church on a regular basis. He did not own a car, and had to walk wherever he needed to go. He could most often be seen sitting on his porch during most of the day and evening. His house was small, but it suited him fine. It did not have air conditioning, which made sitting inside uncomfortable during the heat of the summer. He tended to leave the windows and doors wide open all day and all night in an effort to catch a breeze. He suffered numerous bites from blood feeding insects, and every once in a while members of his church or the doctors from the mobile clinic would supply him with insect repellant to keep the insects away. Once he ran out of this, though, he was always uncomfortable asking for more, and simply did his best swatting the bugs. His disability meant that Mr. Berger was in pain for most of his days. He was unsure when the symptoms of this last illness began, since he only noticed he might be sick when his muscles began to hurt worse than usual, and he found that he was very dizzy when he tried to rise. A passing neighbor noticed that Timothy was sleeping in an outdoor chair late one night, and asked Mr. Berger why he hadn t gone to bed. Timothy replied that he was unable to rise from the chair, and thought he would just sleep outside until he was able to get up. The neighbor summoned the mobile clinic, which transported Mr. Berger to the hospital on 9/4 of this year. The admitting doctor ascertained that Timothy began to feel the first of his symptoms on 8/30. Soon after giving his background, Mr. Berger slipped into a coma. A blood test indicated the presence of an unknown agent. Attempts to identify the infecting agent were unsuccessful. IV antiviral agents were administered, along with steroids and fluids. His condition worsened, and he succumbed to the infection on 09/04 of this year. Tissue and fluid samples were saved and are awaiting testing instructions.

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