33-year old woman
> SIGNS & SYMPTOMS
--6-day history of fever
--Groin pain and swelling
--Recent hiking trip in Colorado
> THE CASE
A 33-year-old Caucasian woman presented to the emergency department with a 6-day history of fever (103[degrees]-104[degrees]F) and right groin pain and swelling. Associated symptoms included headache, diarrhea, malaise, weakness, nausea, cough, and anorexia. Upon presentation, she admitted to a recent hike on a bubonic plague-endemic trail in Colorado.
Her vital signs were unremarkable, and the physical examination demonstrated normal findings except for tender, erythematous, nonfluctuant right inguinal lymphadenopathy. The patient was admitted for intractable pain and fever and started on intravenous cefoxitin 2 g IV every 8 hours and oral doxycycline 100 mg every 12 hours for pelvic inflammatory disease vs tick- or flea-borne illness. Due to the patient's recent trip to a plague-infested area, our suspicion for Yersinia pestis infection was high.
The patient's work-up included a negative pregnancy test and urinalysis. A complete blood count demonstrated a white blood cell count of 8.6 (4.3-10.5) x [10.sup.3]/UL with a 3+ left shift and a platelet count of 112 (180-500) x 103/UL. A complete metabolic panel showed hypokalemia and hyponatremia (potassium 2.8 [3.5-5.1] mmol/L and sodium 134 [137-145] mmol/L). Blood cultures were negative for any bacterial or fungal growth after 48 hours; stool cultures were negative for Salmonella, Shigella, Campylobacter, Giardia, generalized Yersinia, and Escherichia coli 0157:H7. Swabs for Gardnerella vaginalis, Trichomonas vaginalis, Candida, Chlamydia trachomatis, and Neisseria gonorrhea also were negative. Lyme, Bartonella henselae, and heterophile antibodies were also negative. Francisella tularensis was not cultured due to low suspicion.
* Imaging included a normal chest x-ray and a computed tomography scan of the abdomen and pelvis that showed enlarged right inguinal lymph nodes with fatty stranding, a thicker distal right iliopsoas, hepatosplenomegaly, and an enlarged right adnexa (FIGURE 1). Initial ultrasound of the bubo showed 2 enlarged suprapubic lymph nodes, the largest measuring 3.5 x 1.4 x 2.4 cm3 (FIGURE 2), and 8 enlarged inguinal nodes.
The patient continued to have a low-grade fever, diarrhea, and inguinal lymphadenopathy throughout her first 2 hospitalized days. The cefoxitin was discontinued by Day 3, and the consulting infectious disease physician started oral metronidazole 500 mg every 12 hours due to the patient's failure to improve. Later that night, the patient experienced increasing erythema and pain in her right inguinal region. A repeat ultrasound showed increased inguinal lymphadenopathy with the largest nodes measuring 2.9 x 1.5 x 2.5 [cm.sup.3] and 2.7 x 1.3 x 2 [cm.sup.3] (FIGURE 3).
Although doxycycline is considered an acceptable regimen for Y pestis infection, the infectious disease physician added oral ciprofloxacin 750 mg every 12 hours the following morning, as the patient had not improved.
Although the initial gram stain was negative for Yersinia, clinical suspicion pointed to a diagnosis of bubonic plague. Serology was considered; however, it was not available through the hospital. A definitive diagnosis required bubo aspiration and culture, which was performed but required 48 hours before results would be available.
By Day 5, the patient was clinically improved and deemed safe for discharge on empiric treatment with ciprofloxacin 750 mg twice daily and doxycycline 100 mg twice daily to complete a 14-day course of antibiotic therapy for bubonic plague. The bubo culture subsequently grew Ypestis, confirming the diagnosis. The patient made a full recovery and was greatly improved when seen in the outpatient setting by the treating infectious disease physician. Outpatient ultrasound repeated 3 weeks after discharge showed borderline lymphadenopathy, no greater than 1 cm.
Between 2000 and 2009, there were 57 cases of Ypestis in the United States; in early 2015, 11 cases were found in 6 Western states. (1) The plague presents in the bubonic form 80% to 95% of the time, and it has never been reported in Michigan (where we treated this patient); however, there was a laboratory case in Illinois. Although rats were traditionally the host for Ypestis, the prairie dog, Cynomys gunnisoni, is a host in the United States. (2) Rodents are the most important hosts, but more than 200 mammalian species, including domestic pets, have had reported infections. Transmission is primarily via flea bites, but Ypestis also may be transmitted via respiratory secretion, inhalation, or direct handling of contaminated animal tissues. Due to the risk of respiratory spread, the Centers for Disease Control and Prevention must be notified of a diagnosis. (3,4)
Y pestis travels from the site of the flea bite to regional lymph nodes, where it reproduces, and the resultant inflammatory reaction creates buboes. The bacteria then circulate in the blood to other organs, although Y pestis bacteria are primarily removed by the liver and spleen. Patients
often develop symptoms such as headache, fevers, chills, and gastrointestinal distress. Diagnosis is reached by bubo culture or rapid testing for the F1 antigen. Early intervention with antibiotics is crucial as untreated bubonic plague has a mortality rate of 50% to 90%. (3,4)
* The differential diagnosis for unilateral inguinal lymphadenopathy with associated constitutional symptoms was broad, in this case, and included pelvic inflammatory disease, bubonic plague, iliopsoas abscess, lymphogranuloma venereum, bartonellosis, infectious mononucleosis, and tick-borne diseases, such as ehrlichiosis, tularemia, Lyme disease, Rocky Mountain spotted fever, and Colorado tick fever.
* Treatment. Food and Drug Administration-approved treatments include streptomycin (gentamicin 5 mg/kg/day IM or IV for 14 days is more widely utilized), doxycycline 200 mg PO once daily for 10 to 14 days, and fluoroquinolones (ciprofloxacin 500750 mg every 12 hours for 10-14 days).
* Trimethoprim-sulfamethoxazole may be used as an alternative, but limitations include potentially incomplete or slowed responses.
This case points to the importance of a complete, systematic approach to each patient. While bubonic plague is not a diagnosis that would immediately come to mind in a patient visiting an emergency department in Michigan, a thorough history revealed a recent trip to a bubonic plague-endemic area. A thorough physical exam demonstrated unilateral painful inguinal adenopathy--which, when paired with the patient's history--was consistent with the uncommon diagnosis of bubonic plague.
The authors thank Brian Waite, MD, and James Addison, MD, for critically revising this report for important intellectual content.
Katherine Lazet, DO; Stephanie Rutterbush, MD
St. Vincent Ascension Health, Evansville, Ind (Dr. Lazet); Munson Healthcare Ostego Memorial Hospital, Lewiston, Mich (Dr. Rutterbush)
The authors reported no potential conflict of interest relevant to this article.
Katherine Lazet, DO, 3838 N First Avenue, Evansville, IN 47710; email@example.com
(1.) Kwit N, Nelson C, Kugeler K, et al. Human Plague - United States, 2015. MMWRMorb Mortal WktyRep. 2015,64:918-919.
(2.) Friggens MM, Parmenter HR, Boyden M, et al. Flea abundance, diversity, and plague in Gunnison's prairie dog (Cynomys gunnisoni) and their burrows in Montane grasslands in northern New Mexico. J Wildl Dis. 2010;46:356-367.
(3.) Mandell G, Bennett J, Dolin R. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2010:2943-2953.
(4.) Perry RD, Featherston ID. Yersinia pestis - etiologic agent of plague. Clin Microbiol Rev. 1997;10:35-66.
Caption: FIGURE 1 CT scan from admission was revealing
Caption: FIGURE 2 An ultrasound look at the lymph nodes
Caption: FIGURE 3 Repeat ultrasound showed an increasing number of enlarged inguinal lymph nodes
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|Title Annotation:||bubonic plague|
|Publication:||Journal of Family Practice|
|Article Type:||Clinical report|
|Date:||Dec 1, 2018|
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