What is the diagnosis for an 18-year-old man presenting with fever, cough, eye pain, and a history of recent hunting exposure, with clinical findings of erythematous left eye, purulent drainage, corneal ulceration, diffuse coarse lung sounds, tender cervical lymph nodes, and radiographic evidence of peribronchial infiltrates and pleural effusions?

Differential Diagnosis

• Single most likely diagnosis
  • Tularemia: The patient's symptoms, including fever, cough, eye pain, and lymphadenopathy, along with his recent hunting trip and exposure to small game, are highly suggestive of tularemia. The presence of a corneal ulceration and purulent drainage, as well as the spontaneous drainage of malodorous fluid from a preauricular lymph node, are also consistent with this diagnosis.
• Other Likely diagnoses
  • Cat-scratch disease: Although the patient's symptoms are more severe than typical cat-scratch disease, the presence of lymphadenopathy and a history of exposure to small animals could suggest this diagnosis.
  • Q fever: The patient's symptoms, including fever, cough, and pleural effusions, could be consistent with Q fever, especially given his exposure to small game.
  • Leptospirosis: The patient's symptoms, including fever, cough, and eye pain, along with his recent hunting trip and potential exposure to contaminated water, could suggest leptospirosis.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Anthrax: Although less likely, anthrax is a potentially deadly diagnosis that must be considered, especially given the patient's exposure to small game and the presence of a severe respiratory illness.
  • Plague: The patient's symptoms, including fever, cough, and lymphadenopathy, could be consistent with plague, especially given his exposure to small game.
  • Tuberculosis: Although less likely, tuberculosis is a potentially deadly diagnosis that must be considered, especially given the patient's symptoms and the presence of pleural effusions.
• Rare diagnoses
  • Brucellosis: The patient's symptoms, including fever, cough, and lymphadenopathy, could be consistent with brucellosis, although this diagnosis is less likely given the patient's exposure history.
  • Hantavirus pulmonary syndrome: The patient's symptoms, including fever, cough, and pleural effusions, could be consistent with hantavirus pulmonary syndrome, although this diagnosis is less likely given the patient's exposure history and the lack of other typical symptoms, such as renal failure.