Case of a 58 year old woman with a skin ulcer, fever, and lymphadenopathy

Ming Fung, Ella Park, Jane Lee Case Presentation

Patient Symptoms: - Skin ulcer - Temperatures over 40°C - Headache - Chills - Myalgias - Malaise - Cervical lymphadenopathy Case Presentation

Patient Symptoms: Cervical lymphadenopathy Final Symptoms

- In no distress - Temperature of 38.0°C - Ulcer at the hairline - Left cervical lymphadenopathy - Systolic murmur Case Background: Lifestyle

- Monogamous life with her husband - Wooded area in Coastal New England - Frequent exposure to the outdoor environment - Owns a pet dog - Does not smoke or use illicit drugs Case Background: Medical History

- Medication: - Acetaminophen - Clindamycin - Cesarean section Diagnosis

Differential Diagnosis Approach

● Fast Thinking Diagnosis ● Slow Thinking diagnosis ● Final diagnosis Diagnosis

Fast Thinking process:

● Lived in forested area of New England ● Ulcerated skin lesion ● Lymphadenopathy ● Fever ● Possible exposure to animal vectors Diagnosis

Slow Thinking process:

● Heart murmur ● Endocarditis? ○ (most common cause: infection associated with oral surgery) ● Glomerulonephritis ● Rareness

Diagnosis

What could explain ulcerated skin lesions and lymphadenopathy?

Bubonic plague

- Endemic southwestern U.S.A - Incubation period 2-8 days

Patient perspective: - Traveled months before symptoms -No septic shock Diagnosis

● Rickettsialpox - Poxlike lesion with central eschar - Papulovesicular rash on appendages Patient perspective: - No rash - Typically transmitted by mites - Commonly reported by in urban areas Diagnosis

● Cutaneous anthrax (Anthrax infection) - Associated with bioterrorism

Patient perspective:

- No reported bioterrorism activity - No international travel/exposure to places where disease is endemic Lab Results: Serological Test

- Test: - F.tularensis Antibodies must be present in a higher titer than 1:80 after 14 days - Patient: - First few days: Negative results - After 4 weeks: 1:640 titer Final Diagnosis

● Rule out other possible diseases/infections ● Positive Serological test

Unanimous Conclusive diagnosis: Ulceroglandular Tularemia Treatment Medications

● Acetaminophen (inflammation) ● Streptomycin (3 days) ● Vancomycin (3 days) ● Ciprofloxacin (11 days) ○ enthesopathy ● Doxycycline (3 days) F. tularensis

● Transmission: ○ Contact with infected animals ○ Arthropod bites ○ Consumption of contaminated meat

Symptoms of Tularemia

● Suppuration (pus formation) of lymph nodes ● Abscesses (pustules) ● Facial cellulitis (bacterial skin infection) ● Chronic otitis (ear infection) ● Meningitis (CNS inflammation) ● Acute encephalitis (Brain inflammation) ● Lymphangitis of upper limb (inflammation of lymph vessels) Prevention

● Similar to Lyme ● Avoid tick bites ○ Treated clothing ○ Repellent Thank you Questions? Citations

● Baggett MV, Gonzalez RG, Bhattacharyya RP, Mahowald MA. Case 4-2016. New ○ England Journal of Medicine [Internet] 2016 [cited 2019 Jan 15];374(6):573–81. Available from: Case 4-2016. A 58-year-old woman with a skin ulcer, fever, and lymphadenopathy.

● Maurin M, Pelloux I, Brion JP, Bano J-ND, Picard A. Human Tularemia in France, 2006-2010. ○ Clinical Infectious Diseases [Internet] 2011 [cited 2019 Jan 15];53(10). Available from: https://academic.oup.com/cid/article/53/10/e133/332757