Going Down the Rabbit Hole

This case chronicles the diagnostic journey of an 8-year-old girl with prolonged fever, pharyngitis, and cervical lymphadenopathy during a summer visit to Nantucket, Massachusetts. Initially treated for presumed streptococcal pharyngitis, she failed to respond to multiple antibiotic regimens, prompting evaluations for mononucleosis, tickborne illness, autoimmune conditions, and incomplete Kawasaki’s disease. After CT imaging suggested necrotizing lymphadenitis and exposure history revealed contact with dead rabbits, tick bites, and spring water ingestion, tularemia was suspected. Treatment with intravenous gentamicin followed by oral ciprofloxacin resulted in clinical recovery. Serology later confirmed Francisella tularensis infection. The case emphasizes the importance of thorough exposure history and diagnostic persistence in zoonotic disease.

This case chronicles the diagnostic journey of an 8-year-old girl with prolonged fever, pharyngitis, and cervical lymphadenopathy during a summer visit to Nantucket, Massachusetts. Initially treated for presumed streptococcal pharyngitis, she failed to respond to multiple antibiotic regimens, prompting evaluations for mononucleosis, tickborne illness, autoimmune conditions, and incomplete Kawasaki’s disease. After CT imaging suggested necrotizing lymphadenitis and exposure history revealed contact with dead rabbits, tick bites, and spring water ingestion, tularemia was suspected. Treatment with intravenous gentamicin followed by oral ciprofloxacin resulted in clinical recovery. Serology later confirmed Francisella tularensis infection. The case emphasizes the importance of thorough exposure history and diagnostic persistence in zoonotic disease.