Spotted Palms

A ten-year-old African-American female is brought to the rural North Carolina clinic where you are volunteering your time for the summer. She presents with a severe headache and a high fever. On initial viewing, you observe that she appears to be in pain, and is squinting at the exam room's bright illumination. Otherwise she appears to be normally developed for her age.

Her father explains to you that she has been this way for the past eight hours starting at noon today. He had believed she was coming down with the flu due to the symptoms, but became worried when pain relievers gave her no relief. Since she is on summer vacation, his daughter often follows him into the nearby foothills with the family dog to collect blackberries for pastries. Her mother ensured she has had all of her shots required for school attendance, and she has never had rheumatic fever, mononucleosis nor any other serious illness. She is also prepubescent.

Physical exam reveals that she has a temperature of 103.2 F, and she is perspiring. When she is asked where the pain is, she points to her forehead and her legs. There is evidence of myalgia as you palpate the rear of her leg. The legs also show evidence of non-pitting edema.

As your exam continues, you notice her inguinal lymph nodes are swollen, as well as her axillary nodes. EENT exam reveals that her eyes are photophobic with the conjunctiva being injected and suffused. Her ears are normal, however her nasal passages show evidence of coryza. Her throat is not inflamed and her tonsils appear normal. The lymph nodes of her head and neck appear to be swollen also. Further examination reveals a barely noticeable rash on her arms and legs, as well as her torso. The rash is most obvious upon her palms due to the lighter skin color.

Question 1 - Single Best Answer

Some bacteria that can cause generalized lymphadenopathy include:   

A) Rickettsia, Francisella, Streptococcus pneumonia
B) Brucella, Borrelia, Clostridia
C) Afipia, Rickettsia, Yersinia
D) Mycoplasma, Mycobacteria, Helicobacter
E) Haemophilus ducreyi, Neisseria gonorrhea, Treponema pallidum

Question 2 - Single Best Answer

What are two of the diseases in which there is a rash on the palms and soles?   

A) syphilis and gonorrhea
B) meningococcal meningitis and toxic shock syndrome
C) cat scratch fever and Rocky mountain spotted fever
D) Rocky mountain spotted fever and syphilis
E) toxic shock syndrome and scarlet fever

You also notice what appear to be several insect bites behind her left ear, with one that appears to be inflamed. Upon closer examination you see that the head of a wood tick is imbedded in the area of the bite. This you quickly remove and store as a sample for the laboratory.

Question 3 - Single Best Answer

What diseases can ticks carry?   

A) brucellosis, sleeping sickness, Lyme borreliosis (Lyme disease)
B) malaria, Rocky mountain spotted fever, tularemia
C) tularemia, brucellosis, relapsing fever
D) Rocky mountain spotted fever, relapsing fever, Lyme disease
E) Rocky mountain spotted fever, anthrax, plague.

There is also evidence of splenomegaly, but no evidence of abdominal pain. Her liver is not swollen and appears normal. Her heart is normal with no rubs or murmurs, but she does display mild dyspnea.

You have a suspicion of the pathogen involved and prescribe an intravenous bolus of tetracycline and oral doses of 50 mg for the next four days.

Question 4 - Single Best Answer

What is your suspicion as to the disease involved?   

A) syphilis
B) Rocky mountain spotted fever
C) Lyme disease
D) Strep throat
E) relapsing fever

Question 5 - Single Best Answer

How could you rule out syphilis?   

A) VDRL
B) that">a
C) that are found in individuals with syphilis. If it were negative it would rule out syphilis. If it were positive it could mean syphilis or a number of other diseases that also cause a rise in the anti-cardiolipin antibodies that the test detects.
D) Weil-Feliz rx
E) history
F) blood culture
G) cold hemagglutinins

You obtain further samples of blood, urine, and throat swabs. You instruct the father to allow her to rest and observe her breathing for the next twelve hours. If she becomes worse, then he is to take her to the hospital. Otherwise give her plenty of fluids, rest and her medicine as prescribed. You warn him to have her use insect repellant while playing in the woods. She is to return in one week for further testing.

Question 6 - Single Best Answer

Oh, oh. The Weil- Felix reaction is negative. Does this mean she doesn't have RMSF?   

A) yes
B) no

She returns in one week and is no longer in pain, nor is she photophobic. Physical exam reveals that her rash is starting to disappear and she is alert and energetic. You draw another blood sample and take a urine sample for follow up testing.

Question 7 - Single Best Answer

What is the Weil-Felix reaction?   

A) a delayed type hypersensitivity skin test
B) a Rickettsial antigen agglutination test
C) part of the VDRL test
D) a Proteus antigen agglutination test
E) a test for syphilis

Question 8 - Single Best Answer

What diagnosis does a positive Weil-Felix reaction confirm?   

A) Treponema
B) Borrelia
C) Rickettsia
D) Erlichia
E) Brucella

Question 9 - Single Best Answer

Why did the blood culture of the patient's blood fail to produce any colonies of Rickettsia?   

A) the lab used the incorrect agar for growing Rickettsia
B) Rickettsia are obligate anaerobes
C) Rickettsia are obligate intracellular parasites
D) Rickettsia are obligate extracellular parasites
E) Rickettsia are evolved pox viruses

Question 10 - Single Best Answer

What other diseases can Rickettsia cause?   

A) typhus fever
B) typhoid fever
C) syphilis
D) tularemia
E) Lyme borreliosis