A previously healthy 20-year-old man is brought to the emergency department for fever, dysphagia, drooling, and poor coordination. The symptoms started last week with mild fever, throat pain, and malaise. He was able to eat some food but is afraid to drink any fluids as he feels his "throat closing up." The patient, an anthropology student, went on a school trip 2 months ago during which he explored several caves. He took several over-the-counter analgesic medications without relief. He does not recall any bites, scratches, or animal exposures. The patient has received all standard immunizations and takes no medications. He is febrile and tachycardic. Examination shows dehydration, lethargy, and ataxia. Drool is pooling in his mouth. No pharyngeal erythema or exudates are seen.
Which of the following is the most likely diagnosis in this patient?

Question

A previously healthy 20-year-old man is brought to the emergency department for fever, dysphagia, drooling, and poor coordination.  The symptoms started last week with mild fever, throat pain, and malaise.  He was able to eat some food but is afraid to drink any fluids as he feels his "throat closing up."  The patient, an anthropology student, went on a school trip 2 months ago during which he explored several caves.  He took several over-the-counter analgesic medications without relief.  He does not recall any bites, scratches, or animal exposures.  The patient has received all standard immunizations and takes no medications.  He is febrile and tachycardic.  Examination shows dehydration, lethargy, and ataxia.  Drool is pooling in his mouth.  No pharyngeal erythema or exudates are seen.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfbb_823b_8f63_b17471166f7d_MD0005_00 This patient's dysphagia, drool, and history of cave exposure are concerning for rabies transmitted by bats. Hydrophobia is pathognomonic for rabies; water triggers pharyngeal spasms that cause the patient to be frightened of drinking. The illness usually starts with a few days of nonspecific prodromal symptoms, including fever and malaise. Neurologic symptoms (eg, confusion, lethargy, paralysis, aphasia) develop later in the course of the disease. In developing countries, domestic animals (eg, dogs) are common sources of infection. In the United States, bats and wild animals (eg, raccoons) are the most common reservoirs of infection. The acquisition of rabies from bats can occur from an unrecognized bite or a scratch, and possibly by inhalation of aerosolized viral particles. Bats are found in all states, and spelunking (cave exploration) is a risk factor for rabies acquisition from bats. (Choice A) Epiglottitis can cause dysphagia, odynophagia, and drooling, but affected patients typically have stridor and rapid upper airway obstruction with illness onset. (Choice B) Histoplasmosis can occur after spelunking from exposure to bird or bat droppings. However, respiratory symptoms (eg, cough, chest pain, hemoptysis) are usually prominent, and hydrophobia is not seen in histoplasmosis. (Choice C) Pertussis typically manifests as paroxysmal episodes of cough. This patient has no cough or rhinorrhea, as is typically seen in pertussis. (Choice E) Tetanus is characterized by involuntary muscle contractions but is unlikely to occur in a fully vaccinated patient. Educational objective: Acquisition of rabies from bats can occur from an unrecognized bite or scratch. Hydrophobia is the hallmark sign of rabies. References: Rabies surveillance in the United States during 2012. (http://www.ncbi.nlm.nih.gov/pubmed/24004227) Diagnosis, management and post-mortem findings of a human case of rabies imported into the United Kingdom from India: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/24708671)

A Previously Healthy 20-Year-Old Man Is Brought to the Emergency