Posted by a from IP 188.8.131.52 on December 02, 2013 at 11:58:58:
A 37-year-old man was transferred from an outlying hospital with a two week history of fever, "Flu-like"
symptoms, stiff neck, and a diffuse rash that spared his face but included his hands and feet. His
symptoms had become progressively worse, with the development of mental status changes and a
temperature of 104 degrees F immediately before his initial hospital admission. A work-up was not
revealing. He was treated with ceftriaxone, doxycycline and acyclovir, without resulting changes in his
symptoms. He was unaware of an inciting event precipitating his illness, and he denied knowledge of an
arthropod bite or exposure to any infectious sources. He is a shop foreman in southern Indiana and denies
travel outside of the state. He is without significant past medical history, reports that his immunizations
are up to date, and denies the use of illicit drugs.
A lumbar puncture performed at the outside hospital revealed CSF RBC 7610/mm3, WBC 185/mm3 (Diff:
39% polys, 56% lymphs, 5% mono) with protein 123 mg/dL and glucose 53 mg/dL. Gram stain was
negative with a culture reported as no growth at 24 hours. CSF fungal and viral serologies were also
reported to be negative. Other laboratory studies performed prior to his transfer included a PT of 20.5 sec.
(INR 1.6), PTT 35.9 sec., D-dimer 0.5-1µg/mL , and fibringen of 222 mg/dL
What is the diagnosis?
d.Rock Mountain spotted fever
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