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.