A case worthy of Dr. House

Here is the first case presentation. Please post your differential diagnosis, and your best guess!
Good luck!

CASE 1: Patient (Pt) is a 28 y/o male who presents to ER accompanied by roommate approx 28 days status post bite of unknown origin. Pt’s friend states pt was intoxicated at a party and woke up with a large bite on his upper right extremity just above elbow, positive for skin breakage. Pt cleaned wound out in shower and covered with bandage. Wound now red, edges still raw, edema around site, swabbed for infection. Pt’s roommate states he brought pt in for eval due to altered mental status (AMS) with flat affect and lethargy, and brief periods of aggressive behavior. Pt’s roommate noticed decreased appetite, insomnia. Roommate states pt not into drugs, social alcohol use only, non-smoker. Pt formerly active runner, healthy eater up until 1 month ago. No recent international travel.
Physical exam found: fixed and dilated pupils; skin pale, cool, moist with greyish hue; stiffness in joints; dulled responses to pain. Labs showed anemia and possible immune response, basic tox screen negative. Low temperature indicated probable viral infection. Oxygen sats normal..

Plan:wound irrigation, stitiches, more blood work, culture sample from wound, overnight observation, contact family for PMH (past medical history), and family history.

So what’s up with this guy? What could cause such a rapid change in a young, healthy guy? Any guesses?

2 thoughts on “A case worthy of Dr. House

  1. An occlusive bite resulting in an avulsion. Pt presents with chills, and greying of skin. All test results negative (hep B & C, rabies, HSV, tetanus, syphilis, TB, actinomycosis). No evidence of staph infection. Abnormal blood work. HR and BP in dangerously low ranges. Observed decreased mobility, stiffening of joints. Speech has become slowed.

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