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Tick bites and fever. HPI: 64 wf was outside, later had up to 35" ticks on her skin. Developed daily fevers to 101 F, chills, sweats for 5 days, mild confusion, headache. Seen in MBS ER.ROS: petechiae and bruises diffusely, mainly on upper extremities. No other rashes. Generalized body aches. PH
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1. Disclosures for J. Evan Sadler
2. Tick bites and fever HPI: 64 wf was outside, later had up to 35 ticks on her skin. Developed daily fevers to 101 °F, chills, sweats for 5 days, mild confusion, headache. Seen in MBS ER.
ROS: petechiae and bruises diffusely, mainly on upper extremities. No other rashes. Generalized body aches.
PH: RA, right forearm rheumatoid nodule resected 2005, on methotrexate until a few wks ago, inactive. DM type 2. DJD. Hypothyroid on replacement. H/o morbid obesity, lost 150# over 1 year on phentermine by hx.
SH: Married, lives at home with husband. 90 pack year cigarettes
PE: 100.2 °F, 90, 114/70, 18. Chest tender diffusely. Decreased breath sounds. Abd no masses. Skin ecchymoses both forearms, petechiae on abdomen.
3. Tick bites and fever Lab: Admission Hgb 11.5, normal indices, WBC 2.7 (98% neuts), plt 40K, PT 12.8, PTT 42.7, AST 877, ALT 416, Na+ 129, Blood C&S NG, ANA <1:40, C diff negative.
Course: For presumed tick-borne infection and sepsis, received doxycycline 100 mg iv q12h, Zosyn 4.5 g q8h, Vanc 1 g q12h, Diflucan 100 mg qd. Dopamine transiently for hypotension. Persistent fever to 102 °F. Head CT old lacunar infarct.
Hgb 10.3, WBC 1.1, plt 28K, LDH 3648, AST 1911, ALT 808, TP 4.1, Alb 1.7, anti-SM 1:40, Ferritin 32500, Lyme antibody negative, E. chaffeensis & A. phagocytophila titers <1:64, Hep A/B/C negative, anti-mitochondrial antibody negative. Abd sono no hepatosplenomegaly, trace ascites
Transferred to BJH Medicine service after 3 days
4. Tick bites and fever PE: 38.4 °C, 64, 128/70, 16, 100% RA. 76.1 kg (108 kg 11/07, 120 kg 4/03). Comfortable. ENT petechiae in oropharynx. Chest clear. Abd no hepatomegaly, possible spleen tip. Skin UE and LE ecchymoses and petechiae, sparing soles and palms. Lymph no adenopathy. Neuro alert, pleasant, oriented x 3. Nonfocal. No Babinski.
Lab: None yet.
Problems: Fever, pancytopenia, purpura, transaminitis, hypoalbuminemia, hypoproteinemia, hyperferritinemia, hyponatremia. (Hypothyroidism, type 2 DM, DJD, h/o RA, h/o obesity)
Differential Diagnosis?
5. BJH Day 1 Infection Blood and urine cultures, CXR, titers for EBV, CMV, parvovirus
Pancytopenia Retic count, haptoglobin, Coombs, Heme consult for BM exam
Transaminitis RUQ sono with dopplers
Possible HLH Lipid panel, fibrinogen, soluble CD25, soluble CD163
Rx: Doxycycline, Cefepime, Vanc
6. Ehrlichiosis? Ehrlichia chaffeensis human monocytic ehrlichiosis (HME)
Anaplasma phagocytophilum human granulocytic anaplasmosis (HGA)
Epi: May through August, when various ticks are out. Same vectors also transmit Borrelia burgdorferi (Lyme disease) and tick-borne encephalitis viruses.
7. Ehrlichioses in Humans
8. Symptoms, Signs, Laboratory Findings
9. Complications of Ehrlichiosis
10. Diagnosis
11. Diagnosis
12. Treatment
13. Hemophagocytic Lymphohistiocytosis?
14. Hemophagocytic Lymphohistiocytosis?
15. Extremely Elevated Ferritin
16. Extremely Elevated Ferritin
17. Extremely Elevated Ferritin
18. Extremely Elevated Ferritin
19. Day 1
20. Day 2
21. Day 3
22. Day 4
23. Day 5
24. Day 6
25. Day 7
26. Hospital Course
27. Hospital Course
28. Hospital Course
29. Summary