CASE 78
One summer evening, a 63-year-old white man came to the emergency department of a nearby hospital presenting with a 6-day history of fever, moderate headache, generalized myalgia, arthralgias, and fatigue. He had noticed a rash under the armpit that day that had spread rapidly, prompting him to seek medical attention.
PHYSICAL EXAMINATION
LABORATORY STUDIES
Diagnostic Work-Up
Table 78-1 lists the likely causes of illness (differential diagnosis). A clinical diagnosis was considered based on protracted fever, characteristic rash, and history of exposure, in an area where this disease is known to occur. Investigational approach for confirmation of microbiologic diagnosis may include
TABLE 78-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: Symptoms and signs are nonspecific and can be associated with several diseases, listed above. The fever, muscle aches, and fatigue can easily suggest viral infections, such as influenza or infectious mononucleosis, or aseptic meningitis if headache is a prominent symptom. Joint pain can be mistaken for other types of arthritis, such as rheumatoid arthritis or septic arthritis with the history of fevers. Tick bites are associated with several infections, including ehrlichiosis, RMSF, and Lyme disease. The first two infections usually manifest with generalized rashes. Characteristic expanding rash and history of tick bite in a geographic area are supportive of a diagnosis of Lyme disease.
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