A Deer HUNTER’S DEADLY GAME—CASE PRESENTATION

1. A Deer HUNTER’S DEADLY GAME—CASE PRESENTATION By ShabnamZarrabi D.O. EM PGY-4 Rowan-SOM/Kennedy University Hospital

2. History of Present Illness • The patient is a 27-year-old Caucasian male presenting to the emergency department from home accompanied by his wife complaining of a sore throat, rash, and myalgias over the last several days • He was seen by his PCP 2 days ago, tested positive for Streptococcus pharyngitis and was subsequently prescribed amoxicillin/clavulanic acid • Reports worsening symptoms despite taking several doses of his antibiotics

3. Review of Systems Pertinent Positives Pertinent Negatives • Headache • Photophobia • Phonophobia • Cough • Nausea • Vomiting • Diarrhea • Dysuria • Subjective fevers • Neck stiffness • Symmetrical polyarthralgiasinvolving his hips, knees, and fingers • Progression of a non-pruritic rash starting in his wrists and ankles which has now spread centripetally to his abdomen

4. Past Medical History • Medical History: Significant for his recent diagnosis of Streptococcal Pharyngitis • Surgical History: Septorhinoplasty • Family History: Non-contributory • Allergies: No known drug allergies • Home Medications: • Amoxicillin/clavulanicacid 875 mg by mouth twice a day • Ibuprofen 600 mg by mouth three times a day

5. Past Medical History Cont. • Social History: • The patient works for the Army Corps of Engineers and frequently travels to disaster-stricken sites such as Missouri and Alabama • He currently resides with his wife in a wooded area in NJ known as the Pine Barrens • He is an avid hunter, particularly deer and birds • In fact, the patient comments that he hunted and skinned a deer ten days prior to the onset of his illness

6. Physical Exam • Vital signs: T 101.2 degrees Fahrenheit, BP 135/67, HR 111, RR 20, Pain 10/10, Pox 98% on room air • HEAD: Normocephalic and atraumatic • EYES: Anicteric with normal conjunctiva and sclera • ENT: Notable for numerous dental caries, mild gingival inflammation, and a geographic tongue with minimal erythema. His pharynx and both tonsils are injected with exudates present • NECK: Supple with bilateral tender adenopathy. The cervical spine is non-tender; however, meningismus is present, along with limited range of motion and pain

7. Physical Exam Cont. • LUNGS: Clear and equal breath sounds to auscultation bilaterally • CARDIAC: Normal S1,S2, tachycardia with a regular rhythm, no murmur • ABDOMEN: Soft and nontender, with no distention or organomegaly • SKIN: There is a blanching, non-petechial, maculopapular rash on his face, abdomen, and bilateral upper and lower extremities, without involvement of the palms and soles. There is relative sparing of his oral mucosa and trunk • NEURO: GCS 15, no focal motor, sensory, or speech deficits

8. Labs • Neutrophils99.1% Lymphocytes 3.6% Eosinophiles 0.1%

9. Labs Cont. • Liver Function Tests • Bilirubin, Total: 1.6 mg/dl • Bilirubin, Direct: 0.5 mg/dl • ALT: 33 U/L • AST: 21 U/L • Coags • PT: 16.3 sec • PTT: 43.3 sec • INR: 1.4 sec • Lactate: 0.8 mmol/L • CRP: 26.2

10. Additional Studies • Urinalysis: • Protein 30 mg/dL • Ketones 40 mg/dL • Bacteria Moderate/HPF • WBCs 5-10/HPF • Epithelial cells Few/HPF • Leukocyte esterase Negative • Nitrite Negative • Urine cultures • Blood cultures x 2 • Please note that the patient refused a lumbar puncture, as such, CSF could not be analyzed

11. Portable Chest Xray

12. Portable

14. CT head Without Contrast

16. CT Soft Tissue Neck With IV Contrast

18. ED Course of Stay • Upon arrival, the patient received acetaminophen 650 mg by mouth for his fever. In addition, he was treated with the following: • Vancomycin 1 gm IV • Ceftriaxone 2 gm IV • Dexamethasone 10 mg IV • Ketorolac 30 mg IV • Morphine 4 mg IV • Hydromorphone 1 mg IV • 0.9% sodium chloride 1 Liter IV

19. Disposition • The patient was admitted to the hospital for further evaluation and treatment

20. Diagnosis