Tick Borne Bacteria
Application Questions
Open case one
Case One
- HPI: A fifteen year old boy was in his usual state of health in November when he developed a fever, which lasted several days. He's brought to you for evaluation by his parents.
- ROS: No acute S/S other than fever and fatigue. Vaccinations up to date. History of mild asthma, well-controlled on montelukast and prn albuterol. Otherwise healthy.
- FH/SH: Parents, two siblings A&W. Paternal GF died in MVA prior to birth; other grandparents still living, maternal GM s/p breast CA, dx at age 56. Lives in Madison, CT. Does well in school; runs on the cross-country team.
- MEDS: montelukast 10 mg daily; albuterol, 1 puff prn wheezing / SOB
- PEx: T 101.2F, P 80, BP 105/70, RR 15
- Thin, well-developed young man in NAD
- PEx negative except for rash (picture)
- Labs: normal CBC
Open case two
Case Two
- HPI: A 10 year old girl from North Carolina presents in May with two days of sore throat, malaise, and a low-grade fever. She is initially seen by her pediatrician, who suspects a viral URI. She returns 2 days later with a history of a day of emesis, diarrhea, increased fever, and rash.
- ROS: Occasional tick exposures; plays outdoors, household has several dogs; tick removed 10d ago. Vaccinations up to date. No prior medical problems other than colds and such.
- FH/SH: Only child, parents A&W. Repeated 2nd grade; doing well since. Loves animals, has trained one of her dogs for local shows.
- MEDS: Tylenol used for fever in age-appropriate doses.
- PEx: T 103.3, P 104, BP 100/60, RR 24
- HEENT with injected conjunctivae and red spots on palate
- Skin with rash (see picture). These lesions are non-blanching, predominantly on the distal upper and lower extremities, but beginning to spread to the trunk. Extremities are cool, with weak pulses.
- Chest clear. Heart RRR, no m/r/g. Abdomen soft without tenderness, no masses.
- Labs: Chemistries include sodium 125 mmol/L, Co2 15, otherwise normal
CBC WBC 14,900, differential includes 78% neutrophils, Hgb 8.8, plt 26,000, PT/PTT greatly prolonged.
Open case three
Case Three
- HPI: A 38 year old man from Guilford presents in September with a 4 day history of fever, chills, and malaise. His condition has gradually deteriorated, but because of a lack of health insurance he delayed seeking care. His girlfriend had difficulty awakening him, called an ambulance, and he presents to the ER.
- ROS: No significant health problems according to his girlfriend, but she doesn't know his history well.
- FH/SH: He is a professional gardener, divorced, with one child who doesn't live with him. No significant family history, girlfriend is well.
- MEDS: ibuprofen prn pain, perhaps 2x/week.
- PEx: T 102.2F P 108 BP 60/40 RR 16
- Labs: normal chemistries, a hematocrit of 42, WBC of 2.2K with 32 segs, 52 lymphs, 12 monos, 3 eos and 1 baso, and no other abnormalities noted on the smear. Platelet count is 32K. You get a call from the laboratory.
Open case four
Case Four
- HPI: John D., a 42-year-old male, presents nic with a 7-day history of high fever, severe headache, myalgias, and malaise. He reports the fever spiking up to 104°F (40°C). Along with the fever, he has been experiencing chills and rigors, profound weakness, and anorexia. Two days ago, he noticed a diffuse maculopapular rash starting on his trunk and spreading to his extremities. He also complains of nausea and a mild non-productive cough.
- SH: The patient is a humanitarian aid worker who recently returned from a 3-month mission trip to a refugee camp in a war-torn region of Eastern Europe (The camp had poor sanitary conditions and very crowded living environments.
- PEx: T 103.5°F (39.7°C), BP 120/80, HR 110 , RR 20
- General: The patient appears toxic and is diaphoretic.
- HEENT: unremarkable.
- Cardiovascular: Tachycardic, no murmurs, regular rhythm.
- Respiratory: Clear to auscultation bilaterally, no rales or wheezes.
- Abdomen: Soft, non-tender, no hepatosplenomegaly.
- Skin: Diffuse maculopapular rash on the trunk and extremities, sparing the palms and soles. No eschars or petechiae.
- Neurological: Alert and oriented, no focal neurological deficits.
- Laboratory:
- CBC: WBC: 3,500 Hgb: 12.5 g/dL Plt: 120K
- BMP: normal
- Liver Function Tests: mildly elevated
- CRP: Elevated
- Blood cultures: collected
Open case five
Case Five
- HPI: Sarah T., a 29-year-old female, presents with a 5-day history of high fever, severe headache, myalgias, and chills. She reports that the fever spikes up to 102°F (38.9°C) with associated night sweats. She also notes that her muscles, particularly in her calves and lower back, have been unusually painful. In the past 48 hours, she has developed a nonpruritic rash and noticed her urine has become dark. She has had nausea but denies vomiting or diarrhea. She also mentions some redness in her eyes without any associated vision changes.
- SH: Sarah works as an outdoor adventure guide and recently returned from a 2-week trip leading a kayaking expedition in Costa Rica. During the trip, she and her group frequently swam in freshwater rivers and lakes. She describes the conditions as very rustic and mentions that they did not always have access to clean drinking water, at times relying on untreated river water.
- PEx: T 101.5°F (38.6°C), BP 110/70, HR 105, RR 18
- General: The patient appears moderately ill and fatigued.
- HEENT: Conjunctival suffusion (redness of the eyes without purulent discharge), no jaundice, no scleral icterus.
- Cardiovascular: Tachycardic, no murmurs, regular rhythm.
- Respiratory: Clear to auscultation bilaterally, no rales or wheezes.
- Abdomen: Soft, mildly tender in the right upper quadrant, no hepatosplenomegaly. Skin: Diffuse erythematous, non-pruritic maculopapular rash primarily on the trunk and extremities.
- Neurological: Alert and oriented, no focal neurological deficits.
- Laboratory:
- CBC: WBC: 10,500 Hemoglobin: 13.0 g/dL Platelets: 90K
- BMP: normal except for BUN: 28 Creatinine: 1.5 mg/dL
- Liver Function Tests: mildly elevated
- Urinalysis: Color: Dark yellow Clarity: Clear Protein: 1+ Blood: 2+ Leukocytes: 5-10 /HPF
- CRP: Elevated
- Blood cultures: collected
Open case six
Case Six
- HPI: Michael R., a 38-year-old male, presents with a 1-week history of fever, fatigue, and a headache. He describes the headache as dull and persistent, located at the back of his head. He also notes that over the past 3 days, he has developed weakness and drooping on the right side of his face. He denies any recent trauma or previous episodes of facial weakness. He reports his symptoms have been progressively worsening.
- SH: Lives in Connecticut, spends time outdoors. No recent tick bites. He denies any recent travel outside the state.
- PEx: Temperature 100.5°F (38.1°C), BP 120/80 mmHg, HR 82 bpm, RR
16 breaths/min
- General: The patient appears slightly fatigued but is in no apparent distress.
- HEENT: No erythema or exudate in oropharynx, no scleral icterus, no lymphadenopathy.
- Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
- Respiratory: Clear to auscultation bilaterally.
- Abdomen: Soft, non-tender, no organomegaly.
- Skin: No erythema migrans lesions observed.
- Neurological:
- Cranial Nerves:
- Cranial Nerve VII (Facial Nerve): Right-sided facial weakness, including inability to raise the eyebrow, incomplete closure of the eyelid, drooping of the mouth on the right side.
- Cranial Nerve II-XII: Other cranial nerves intact.
- Motor: Normal strength in all extremities.
- Sensory: Intact to light touch and pinprick sensation in all extremities.
- Reflexes: 2+ reflexes throughout; plantar reflexes are down-going.
- Laboratory:
- CBC: normal
- BMP: normal
- CSF Analysis: WBC: 50 cells/μL (lymphocyte-predominant) Protein: 75 mg/dL (elevated)
- Glucose: 55 mg/dL