A 44-year-old male farmer from rural southern Utah presented for evaluation of fever, lymphadenopathy, and a cutaneous lesion on his scalp. Three weeks earlier, he had awakened with a painful ulceration on the posterior aspect of his scalp. Within several days, the ulcer had healed, but the patient had tender lymphadenopathy and fever. He had no other significant medical history and denied exposure to ticks, deer flies, rabbits, or fleas. He was living temporarily in a building that had a dirt floor and that was frequented by field mice. After 1 week, he was seen by his primary care physician, who prescribed a course of amoxicillin, but there was no improvement in his condition. He then presented to the emergency department.
Hanson N, Hull C, Meyer L. Fever and Lymphadenopathy in a Farmer—Quiz Case. Arch Dermatol. 2004;140(12):1531-1536. doi:10.1001/archderm.140.12.1531-c