42 year old woman who was complaining of shaking chills and fever went to the Salt Lake City Homeless clinic. She had enlarged lymph nodes in the right axilla. Upstream from the enlarged nodes was an ulcer on the top of the patient’s right hand. When carefully questioned the patient said she remembered being bitten there by an insect resembling a horsefly but with yellow stripes on its abdomen; Its what we used to call a deerfly she added laconically. The patient denied any contact with rats or fleas. The patient’s disease was most likely to be: A. Brucellosis B. Ulcero-glandular tularemia C. Pneumonic plague D. Relapsing fever
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