Great Boar Hunter

   A forty-five-year-old Caucasian male presents to the Emergency Room, with a complaint of fever, headache, and swollen testicles. He is coherent, but weak and clearly in pain.

Question 1 - Single Best Answer

Your differential diagnosis for this set of symptoms might include:   

A) Relapsing fever, mumps (a virus), genital Herpes
B) Pneumonia, Lyme disease, syphilis
C) Chancroid, Gonorrhea, meningitis
D) Gonorrhea, Brucellosis, AIDS
E) Relapsing fever, Brucellosis, mumps, and Tularemia

You begin his history by asking him when his fever began. He says this is the fourth time in three weeks that he has had a fever, and this is by far the worst. The bouts with fever lasted from four to five days with a respite of one to two days in between. When he realized that the fever was a repeat of the earlier ones, he decided to get some help.

Question 2 - Single Best Answer

This pattern of fever is characteristic of:   

A) mumps and gonorrhea
B) brucellosis and relapsing fever
C) lyme disease and chancroid
D) anthrax and cholera
E) herpes and hepatitis

Just like the other times, he now has constipation, and is sweating profusely enough to soak the sheets on the exam table. He says he has taken no other medication besides ibuprofen for his fever, and the pain in his back and extremities. He does not eat because he does not feel hungry, and has lost several pounds since his illness began. He has consumed large amounts of Gatorade to maintain his energy and replace lost fluid. This has helped somewhat, but he still feels weak.

As far as his testicles go, he says that they began to swell up two days ago. He favors them somewhat while walking, and tries not to disturb them while urinating or dressing. He says that he has never had a venereal disease, and his wife is his sole sexual partner. He drinks socially, and smokes two packs of cigarettes per day. He denies the abuse of illegal drugs as well.

He remarks that the illness began roughly four days after a hunting trip with his cousin Vern. Vern is an experienced woodsman, and the patient explains that he just followed him around. They were hunting wild boar and other small game in the Ocala National Forest. They sustained no animal bites, and very few insect bites. He cannot remember finding any ticks on his body.

Question 3 - Single Best Answer

What diseases are transmitted by ticks?   

A) Lyme disease and mumps
B) Brucellosis and Lyme disease
C) Relapsing fever and Brucellosis
D) Relapsing fever and Rocky Mountain Spotted Fever
E) Tularemia and Anthrax

They carried most of their food and water with them, though they did consume some wild blackberries and two rabbits which they were able to capture.

Question 4 - Single Best Answer

Rabbits are a risk factor for which disease?   

A) Brucellosis
B) Tularemia
C) Lyme disease
D) Rocky Mountain Spotted Fever
E) Mumps

Vern allowed him to kill the first boar they happened upon. He vividly remembers this because Vern forced him to drink a bit of the boar's blood as an initiation for his first kill, as well as smearing some of the blood on his face.

Question 5 - Single Best Answer

Wild swine could possibly transmit:   

A) Brucellosis and salmonellosis
B) Brucellosis and relapsing fever
C) Mumps and brucellosis
D) Salmonellosis and tularemia
E) Syphilis and gonorrhea

Your physical exam reveals a temperature of 104 F. The patient shows evidence of diffuse joint tenderness during examination of his extremities. Many of the lymph nodes of his head, neck and axilla as well as in the inguinal region are swollen. There are no unusual rashes or sores on his skin. He reminds you that his back hurts as well. EENT exam reveals papilledema in both eyes, however all else seems normal. His lung sounds are clear. His heart is mildly tachycardic, but reveals no rubs or murmurs.

Upon percussion, his liver seems somewhat enlarged. His spleen also is enlarged, and projects well below the costal margin. It is palpable but neither the abdominal region of this organ or the liver is tender enough to produce pain. His testicles are enlarged roughly three times their normal size, and they display a reddish pink color as well. His penis appears normal with no visible sores or purulent discharge.

Question 6 - Single Best Answer

Based on the data from your physical exam, you might believe that the patient has:   

A) acute viral hepatitis
B) Plague
C) Relapsing fever
D) Syphilis
E) Brucellosis

Question 7 - Single Best Answer

He continues to sweat profusely as you draw samples for the lab. Samples that should be taken include:   

A) perspiration
B) CSF
C) testicular biopsy
D) blood
E) hair

Based on these data you continue the ibuprofen and prescribe tetracycline, and begin IV fluids to replace his blood volume.

Question 8 - Single Best Answer

Does the negative blood culture mean that he does not have Brucellosis?   

A) yes
B) no

Question 9 - Single Best Answer

What kind of sample should be taken to isolate the organism that leads to Brucellosis?   

A) CSF
B) Bone marrow
C) Sputum sample
D) Liver biopsy
E) blood

Question 10 - Single Best Answer

What organism is this consistent with?   

A) Borrelia
B) Brucella
C) Salmonella
D) Neisseria
E) Treponema

Question 11 - Single Best Answer

To confirm your diagnosis, what other test should you perform?   

A) An additional bone marrow culture
B) CT scan of the patient's liver
C) a blood culture after 1 week
D) Brucellergin DTH test
E) VDRL

With the confirmation of your diagnosis you must provide a more effective therapy for this disease. You prescribe a more powerful antibiotic, Doxycycline at 100mg twice a day for the next four weeks.

Question 12 - Single Best Answer

How did this individual contract Brucellosis?   

A) from the swine blood
B) from diseased rabbit meat
C) from insect or tick bites
D) from contaminated ground water
E) from contaminated fruit

Question 13 - Single Best Answer

What is the major virulence factor of Brucella abortus?   

A) toxin
B) adherence to genital mucosa
C) antigenic variation
D) intracellular growth
E) a polysaccharide capsule