Think Like a Doctor
Solve a medical mystery with Dr. Lisa Sanders.
On Thursday, we challenged Well readers to take on the case of a 36-year-old woman with several weeks of fever, fatigue, diarrhea and chest pain along with an ugly sore on the back of her leg. The correct diagnosis is …
Tularemia – ulceroglandular type
Almost 400 readers sent in their diagnosis, and 23 of you nailed it. The first reader to send in the correct diagnosis was Louise Gilmer, who is just finishing up her second year of medical school in London, Ontario.
Last year Ms. Gilmer had a bite that looked a lot like the one in this woman had. At the time she thought she might have been bitten by a spider, but her doctor gave her a quick tutorial on what spider bites look like — usually much better than the one this patient had, but occasionally much worse. Once she moved away from the spider diagnosis, she recalled that there were diseases spread by ticks that could cause both local injury and a systemic illness. She looked around on the Internet and found what she was looking for. And she posted it less than an hour after the article went up. Strong work, Ms. Gilmer.
The Diagnosis
Tularemia is a bacterial infection that is carried by rabbits, squirrels and other small mammals. Also known as rabbit fever, it can be transmitted to humans either through direct contact with an infected animal or, more commonly, through the bite of a dog tick that has fed on an infected animal. The bacterium is transmitted at the site where the tick bites its human victim.
From there the bug causes a purulent lesion and then spreads through the blood and lymph nodes to cause all the symptoms this patient had over the past few weeks: fever and chills, nausea, vomiting and diarrhea, chest pain and splenomegaly.
Treatment is two weeks of an antibiotic known as ciprofloxacin. None of the antibiotics she had already been given were effective against Francisella tularensis, the official name of the tularemia bacterium.
A Rare Diagnosis
Tularemia was named for Tulare County, Calif., where it was first described in 1911. Although initially seen in squirrels, it has been known to infect over a hundred species of mammals, especially rabbits, as well as birds and reptiles. It has been found in all states except Hawaii.
It is rare in humans — only 100 to 200 cases are reported each year in the United States. It most commonly occurs in the summer, when it is usually passed on through ticks. Transmission also occurs in the winter, often during rabbit-hunting season.
This patient had the most benign form of the disease, the ulceroglandular form transmitted through the skin. The sore on her leg appears to have been from an infected tick. When the bacterium is inhaled it can cause an infection in the lungs that can be deadly.
How the Diagnosis Was Made
Dr. Heather Sateia, the Hopkins internist who saw this young woman, had felt certain that the patient had some kind of tick-borne illness. And so when all the results came back negative, she was surprised and a little stumped. It wasn't Lyme disease; it wasn't ehrlichiosis; it wasn't babesiosis. What other diseases could be transmitted by ticks?
She read more, she talked with a colleague in infectious disease, and came up with a few more possibilities. Then she sent the patient for what she hoped would be her last visit to the lab.
Bunny Fever
"Are there rabbits where you live?" Dr. Sateia asked the patient after the test results came in.
Yes, the patient told her. She and her husband often watched the wild rabbits run around their back yard. There was even a nest in the shed near their house where one of the rabbits had a litter.
The patient was horrified to hear that these cute creatures were likely the source of her weekslong illness. She started on the antibiotic right away. It was only a two-week course of medicine, but the recovery took a lot longer.
How the Patient Fared
The patient's fevers resolved first. Then the nausea. But the pain in her chest, probably caused by her tender, swollen spleen, and the fatigue held on. Her husband wasn't able to go back to work for almost three months.
While at home, her husband set himself the task of ridding their yard of all those rabbits. He destroyed the nests and put up fences. They became, he told me, "bunny-phobic."
And their brush with illness made the couple aware of how difficult it can be to raise a child so far from the help that grandparents can offer. This spring the little family moved back to her home state, across the street from the patient's parents, where they are hoping to keep their yard rabbit-free.
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