45 y male with no known medical problems presents to the emergency department complaining of tender lump to left axillary region worsening over the last 2 days. Pt notes that over the last 3 days he had also been having subjective fevers, chills, and HA. Pt has never had similar issues in the past. States that he did recently come to the Northeast after moving from Colorado. On exam patient has stable vitals other than fever to 102.1. Pt’s left axilla has tender, non-fluctuant, mass with surrounding erythema. A picture of the axilla is shown below.
What’s the diagnosis?
Bubonic plague – this is a bubo(swelling of a a lymph node). I know you are thinking, we took care of this years ago, but it is still around! The disease still occurs in the U.S. (only 57 reported cases between 2000-2009), most commonly in the southwestern U.S., but has been migrating northeast. It is important to diagnose early, as it is treatable with Streptomycin (alternatively Gentamicin), because it can be deadly if it progresses – most recent death was in June of this year from bubonic plague. It is a zoonotic infection caused by the organism Yersinia Pestis and humans are incidental hosts. It is typically acquired by bites from fleas inhabiting rodents (rats, squirrels, etc.). Incubation period is from 2-8 days. Initial symptoms are typically, HA, fevers and chills followed by buboes. Buboes are typically non-fluctuant, tender and may be associated with erythema and edema. Most commonly they occur in the inguinal region, but may also occur in the axillary or cervical regions. You may notice flea bites to extremities, although often you will not unless they have associated drainage, eschars or pustules. In the absence of treatment, bubonic plague may be followed by sepsis in 50% of cases, which may lead to pneumonia, meningitis, and septic shock. Diagnosis is with culture or serologic testing.