68 yr old presented with fevers for 2- 3 weeks and increasing pre-auricular, and submandibular painful lymphadenopathy. He had two cats, one recently passed away. He remembered that the cat had a febrile illness and the patient sustained several scratches prior to his illness.
Francisella turarensis antibody returned positive 1:1280
1. The incidence of tularemia is mostly centered in midwest US with highest numbers reported in Missouri (19%), Arkansas (13%), and Oklahoma (9%). Subspecies tularensis (Jellison Type A) is the most virulent subspecies of Francisella tularensis and is the primary subspecies found in North America. There are six clinical tularemia syndromes defined by site of inoculation and presentation. The ulceroglandular and glandular forms are the two most common types in North America . Oropharyngeal,oculoglandular and typhoidal forms are less common. Of 106 Francisella tularensis isolates, mostly from Nebraska, collected during 1998–2012: 48% of cases were feline-associated.
2. The most common confirmatory study for tularemia is the microagglutanin test using antibody titers which develop about two weeks after incident infection. A one-time titer of 1:160 or a four-fold increase in titers from serums taken two weeks apart are considered diagnostic.
3.The WHO recommends using the bactericidal antibiotics gentamicin for 10 days or bacteriostatic antibiotic doxycycline for 14 days
The patient above had a good response to oral doxycycline.
Case 2: Varicella Zoster meningoencephalitis
65 yr old with myasthenia gravis presented with right ear pain and headaches and subjective fevers. She was on 40 mg of prednisone two days a week. She was febrile to 38.2C and had small vesicular lesions on her right external ear and one vesicular lesion on her right knee and L1 dermatome.
1. Involvement of the CNS with cutaneous herpes zoster is probably more common than recognized clinically. A rare manifestation of CNS involvement by herpes zoster is granulomatous cerebral angiitis, which usually follows zoster ophthalmicus. Rash is usually present but not always before the CNS disease.
2. Zostavax developed specifically for protection against herpes zoster contains higher plaque-forming units (PFU) per dose, compared to chickenpox vaccines . Although contraindicated in patients with immunecompromise as it is live vaccine - it could be considered in patients ≥50 years old who are receiving therapies that induce low levels of immunosuppression ( prednisone < 20 mg / day).
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