A 22-year-old man presented with 1 day of fever (101.0°F) and a papular rash all over his body.

In early August, a 22-year-old man from Kentucky presented with 1 day of fever (101.0°F) and a papular rash all over his body (see figures below). He was diagnosed with an unspecified viral syndrome and treated with nonsteroidal anti-inflammatory drugs.

During the next 2 days, the patient continued to have fevers (up to 103.0°F) and variable rash. The patient was further examined, and then discharged after being diagnosed with a viral infection.

Four days following the initial treatment, the patient was again evaluated because of lethargy. Laboratory test results revealed thrombocytopenia (42 × 109 platelets/L), a white blood cell count of 3.3 × 109 cells/L, hemoglobin of 10.4 g/dL, and sodium of 134 mmol/L. The following day the patient was admitted and treated with intravenous ceftriaxone and methylprednisolone. Two days later, the patient was transferred to a tertiary care hospital. Physical examination on admission revealed a fine petechial rash on the trunk, groin, hands, and ankles (see figures).

The patient was further treated with intravenous vancomycin, doxycycline, and cefotaxime, but his condition still continued to deteriorate. Eight days after initial treatment, he died from multiple system failure. A serum specimen collected 2 days earlier tested positive by enzyme immunoassay for immunoglobulin M antibodies reactive with Rickettsia rickettsii at 9.4 index value units.

Question:

Which of the following should have triggered an early administration of doxycycline?

a) history and physical examination
b) leukopenia
c) thrombocytopenia
d) skin biopsy
e) It is more common in adults than adolescents

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A 17-year-old male presents with a worsening headache, fever, chills, and vomiting.

A 17-year-old male presents complaining of a worsening headache, fever, chills, and vomiting over the past week. He states he has also had nasal congestion for 2 weeks, and remembers bumping his head approximately 10 days ago. On exam, he is ill appearing, holding his head, and asking for pain medicine. He has swelling and tenderness of his forehead, but is otherwise alert, appropriate with a normal physical exam. His MRI is shown below.

Image courtesy of Trevor Tredway, MD

Question:

Which of the following statements is true about his condition?

a) It is associated with foreign travel
b) A urine drug screen is indicated
c) The incidence is increasing
d) It is not associated with trauma
e) It is more common in adults than adolescents

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