Case 59
A 56-year-old man was admitted to a hospital in Arizona.  He, his wife, and his sister-in-law had visited Tanzania and Kenya in recent weeks.  He claimed that he had been bitten by insects (possibly biting flies), under the jaw, on the shoulder blades, and possibly on the lips.  Approximately ten days after some of the bites, he became ill, complaining of fever, chills, headaches, back pain and malaise.  He also had occasional bouts of nausea and vomiting and occasional right scotomata (dimness or dark spots in field of vision).  His sister-in-law also received bites, but was asymptomatic.  He visited a physician while overseas who prescribed Ciprofloxicin and doxycycline.  At follow-up in Arizona, he had right submandibular swelling with superficial ulcerations with some serous drainage.  There was also a quarter-sized induration/ulcer on his left scapula.  The organisms shown in the following images were seen in his blood smears.  What is your diagnosis?  Based on what criteria?

A	B

C	D

E

Acknowledgement: This case was kindly provided by the Arizona State Laboratory, Infectious Disease Microbiology Section.

Click here for the answer to Case 59.

Case 60
A man in his early 50's had recently camped in the North Georgia mountains.  A few days after the trip, he noticed that a small area of his lower back had an itchy sensation.  With the aid of a mirror, he observed a small bug attached to his skin.  He removed the bug using a pair of tweezers.  Figure D shows the area from where the bug was removed.  Figures A, B, and C are pictures of the bug.  What is your diagnosis?  Based on what criteria?

A	B

C	D

Click here for the answer to Case 60.