Breathtaking Journey

A CLINICAL PROBLEM-SOLVING article by David Rhee, from Brigham and Women's Hospital, Boston.
A 48-year-old man came to the emergency department in early August with a 3-day history of influenza-like symptoms and profound dyspnea on exertion, which had started 3 days after his return to Boston from a vacation in California. On his return flight, subjective fevers, headache, myalgias, and nausea developed, and the patient had one episode of vomiting. Over the next 2 days, a nonproductive cough and profound exertional dyspnea developed. The patient said that he did not have a rash, neck stiffness, visual changes, diarrhea, dysuria, or joint pain.
Three weeks before admission, the patient hiked and camped in the Catskill Mountains for 9 days. On the first night, he slept on the floor of a lean-to, where he observed mice. Two weeks before admission, he removed an attached tick. Then he flew to California and spent 4 days hiking and camping in the San Joaquin Valley.
The evaluation of illness in a returning traveler should include determination of whether events on the trip are causally associated with the illness. A thorough review of the patient's itinerary and activities on the trip is critical for identifying human, animal, or environmental exposures that might explain the patient's presentation. Because potential pathogens associated with travel have different incubation periods, establishing the temporal sequence of events is essential. In this case the relevant documented exposures, in addition to those involving domestic air travel, include tick, mouse, and possibly mosquito and dust exposure. [Original Article]

該当記事は、"Health care providers should be aware of the association between mouse exposure and cardiopulmonary illness in wilderness travelers to facilitate early diagnosis of the hantavirus pulmonary syndrome and initiation of supportive therapy."で締め括られている。もともと朝鮮戦争で出血熱が発生し、後に韓国の医師により漢灘江（한탄강）の鼠からこのウイルスが同定され、名前もそこに由来することやアメリカ合衆国では南西部のfour corners地域のwhite-footed mouseに保有率が高く、そこのウイルスは、米墨戦争における割譲地故にSin Nombre virus（名前なしウイルス）とスペイン語で名付けられていることを知っておくと、記憶に残りやすいかも。NOW@NEJMも参照。