2.1 Case history/examination
A 46-year-old married man without any known medical conditions was admitted to Civil Hospital, Karachi, via emergency due to complaints of fever for nine days, loose stools and blackish discolouration of the tip of the nose, fingers and toes for eight days. The patient presented with a high-grade, abruptly onset fever that was recorded up to 104°F, intermittent and relieved by antipyretics, associated with rigours, chills and loose stools. The loose stools had an acute onset eight days back. There were five or six episodes per day. The stools were watery and lacked any mucus, smell or blood. There was no complaint of tenesmus. The stools were easily flushable and had no association with food intake or abdominal pain. The patient’s malaria test was positive, for which he was prescribed antimalarials, after which his fever subsided. He then developed blackish discolouration of the tip of the nose, fingers and toes. The onset of this discolouration was acute and painful. There was reddish discolouration initially, which later turned black and progressively involved the dorsum and soles of both feet. The patient denied any other symptoms. His past medical history was significant for hepatitis B, which was discovered upon routine testing ten years ago. He never consulted any doctor for this. Past surgical, transfusion, drug and personal histories are insignificant.
The physical examination revealed a man with average build and height, a BP of 135/80 mmHg, a pulse rate of 90 bpm, a regular and average volume, a temperature of 98.6°F and a respiratory rate of 18 breaths/min. He had anaemia, and blackish discolouration was visible on the tip of the nose, hands and feet (fig 1. A, B, C). The peripheries were cold to the touch. His pulses were palpable except for the dorsalis pedis on both feet, which were feeble. The rest of the examination was insignificant.