Gyrus Daily Questions; Internal Medicine #31

[cingulate.gyrus]

I-27. A 24-year-old healthy man who has just returned from a 1-week summer camping trip to the Ozarks presents to the emergency room with fever, a severe headache, mild abdom-inal pain, and severe myalgias. He is discharged home but 1 day later feels even worse and therefore returns. Temperature is 38.4°C; heart rate is 113 beats/min; blood pressure is 120/ 70. Physical examination is notable for a well-developed, well-nourished, but diaphoretic and distressed man. He is alert and oriented to time and place. His lungs are clear to auscultation. He has no heart murmur. His abdomen is mildly tender with normal bowel sounds. Neurologic exam-ination is nonfocal. There is no evidence of a rash. Labora-tory evaluation is notable for a platelet count of 84,000/µL. A lumbar puncture is notable for 5 monocytes, no red blood cells, normal protein levels, and normal glucose levels. What should be the next step in this patient’s management?

A. Atovaquone
B. Blood cultures and observation
C. Doxycycline
D. Rimantadine
E. Vancomycin, ceftriaxon

[heartbeat]

C. Doxycycline

[step_enhancer]

Answer C Doxycycline

Seems like Q fever to me ,since no rash .Blood culture is of no use for intracellular bugs .

[cingulate.gyrus]

The answer is C. Doxycycline.

This patient likely has Rocky Mountain spotted fever. The headache and thrombocytopenia after a recent camping trip in a rickettsial en-demic region are typical findings. As this is usually a serologic diagnosis requiring signif-icant laboratory processing time, and can be fatal, empirical therapy with doxycycline is warranted. The lack of a rash does not preclude this diagnosis because the characteristic macular rash spreading from the wrists and ankles centripetally appears 2–5 days after the first fever. Atovaquone is used for babesiosis, a disease that is defined by hemolysis and is not prevalent in the Ozarks. The patient has no evidence of bacterial meningitis to warrant empirical coverage. While fever and myalgias are typical of influenza, it is most common in winter and does not typically cause thrombocytopenia.

[heartbeat]

OMG RMSF(triad of fever + headache + rash). It seems to be like Q fever ( fever, a severe headache, mild abdominal pain, and severe myalgias, abdomen is mildly tender, platelet count of 84,000/µL)
Ok both are treated with Doxy