Arnold N. Weinberg

Case 22-1972

Presentation of Case A 32-year-old woman was admitted to the hospital because of a pulmonary infiltrate. She had been well until 20 months previously, when coryza, pharyngitis and a cough productiv...

Case records of the Massachusetts General Hospital. Case 31-2010. A 29-year-old woman with fever after a cat bite.

Dr. Allyson K. Bloom (Infectious Disease): A 29-year-old woman was admitted to the hospital because of fever after a cat bite. The patient had been well until 5 days before admission, when, while working as a veterinarian’s assistant at an animal hospital, she was bitten on the right thenar eminence by a domesticated cat, sustaining a single puncture wound. The cat, which had received rabies vaccinations in the past, had disappeared from its home for several days and had returned febrile, jaundiced, and anemic. After being bitten, the patient washed the wound and took one dose of amoxicillin, according to workplace protocol. She continued to work that day and handled cats, rabbits, guinea pigs, and dogs (including a dog with elevated results of liver-function tests and a history of leptospirosis). During the next 4 days, the patient cleaned cages, handled animals, and petted horses, sheep, and unvaccinated “barn cats” outside. She did not report that any animal licked her wound. The day before admission, swelling, erythema, and pain developed over the volar radial surface of the patient’s hand. The same day, the cat was euthanized because of progressive illness, and a specimen of the brain was sent for rabies testing. The next morning, throbbing pain developed in the patient’s hand. She went to another hospital, where she rated the pain at 8 on a scale of 0 to 10, with 10 indicating the most severe pain. On examination, the vital signs were normal. The thenar eminence was red, hot, and swollen, with evidence of a small puncture wound; the range of motion of the joints was full, without pain, and there was no fluctuance. Ampicillin–sulbactam was given intravenously, and immunizations for diphtheria, tetanus, and pertussis were administered intramuscularly. Amoxicillin–clavulanic acid and oxycodone were prescribed, and the patient was discharged 2 hours after presentation, with instructions to follow up the next day, or sooner if the condition worsened. Approximately 9 hours later, she returned to the other hospital because of increasing pain (rated at 10 of 10) and swelling of the hand, difficulty moving her wrist, malaise, chills, neck pain, swollen lymph nodes, and subjective fever. On examination, the temperature was 37.7°C; other vital signs were normal. There was 1+ nonpitting edema on the right arm; edema and erythema were present over the thenar eminence, with proximal streaking and increased warmth. Range of motion at the wrist was normal. Right axillary lymphCase 31-2010: A 29-Year-Old Woman with Fever after a Cat Bite

Case 30-1968

Presentation of Case A fifty-four-year-old man was admitted to the hospital because of weakness and diarrhea. He had been well until one year previously, when a radiologic examination revealed exte...

Case 25-1964

Presentation of Case A sixty-eight-year-old man entered the hospital because of muscle weakness. He had been well until four weeks previously, when a sore throat developed, accompanied by coryza, c...

Case 31-2010

Dr. Allyson K. Bloom (Infectious Disease): A 29-year-old woman was admitted to the hospital because of fever after a cat bite. The patient had been well until 5 days before admission, when, while working as a veterinarian’s assistant at an animal hospital, she was bitten on the right thenar eminence by a domesticated cat, sustaining a single puncture wound. The cat, which had received rabies vaccinations in the past, had disappeared from its home for several days and had returned febrile, jaundiced, and anemic. After being bitten, the patient washed the wound and took one dose of amoxicillin, according to workplace protocol. She continued to work that day and handled cats, rabbits, guinea pigs, and dogs (including a dog with elevated results of liver-function tests and a history of leptospirosis). During the next 4 days, the patient cleaned cages, handled animals, and petted horses, sheep, and unvaccinated “barn cats” outside. She did not report that any animal licked her wound. The day before admission, swelling, erythema, and pain developed over the volar radial surface of the patient’s hand. The same day, the cat was euthanized because of progressive illness, and a specimen of the brain was sent for rabies testing. The next morning, throbbing pain developed in the patient’s hand. She went to another hospital, where she rated the pain at 8 on a scale of 0 to 10, with 10 indicating the most severe pain. On examination, the vital signs were normal. The thenar eminence was red, hot, and swollen, with evidence of a small puncture wound; the range of motion of the joints was full, without pain, and there was no fluctuance. Ampicillin–sulbactam was given intravenously, and immunizations for diphtheria, tetanus, and pertussis were administered intramuscularly. Amoxicillin–clavulanic acid and oxycodone were prescribed, and the patient was discharged 2 hours after presentation, with instructions to follow up the next day, or sooner if the condition worsened. Approximately 9 hours later, she returned to the other hospital because of increasing pain (rated at 10 of 10) and swelling of the hand, difficulty moving her wrist, malaise, chills, neck pain, swollen lymph nodes, and subjective fever. On examination, the temperature was 37.7°C; other vital signs were normal. There was 1+ nonpitting edema on the right arm; edema and erythema were present over the thenar eminence, with proximal streaking and increased warmth. Range of motion at the wrist was normal. Right axillary lymphCase 31-2010: A 29-Year-Old Woman with Fever after a Cat Bite

Case 39-1967

Presentation of Case A forty-four-year-old man was admitted to the hospital because of hematemesis. He had been well until two years previously, when he began to experience episodes of burning mide...