Associates' Presentations
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Human granulocytic ehrlichiosis-Unsuspected cause of sepsis.
Hariot Sidhu, M.D. (Associate), Marshfield Clinic/St. Joseph's Hospital, Marshfield, WI
This is the case of a 79 year old man with a history of coronary artery disease, status post coronary artery bypass grafting and mitral valve replacement, who presented with a 1-2 week history of generalized weakness and fatigue, so much so that the patient was unable to get out of bed. It was associated with profound anorexia and low grade fevers. The patient was recently treated with a course of amoxicillin/clavulanic acid for upper respiratory tract infection. The patient gave no history of tick bite, though the patient lived in rural Wisconsin. Exam revealed an ill appearing patient with blood pressure - 74/40 mmHg, temperature - 97.7, heart rate - 74. Lungs - bilateral basilar rales, Heart - irregularly irregular, prosthetic valve click auscultated. Extremities - no edema, cool and clammy to touch. Labs: WBC - 11,000, Hb 10.6 grams, Platelets 210,000, B-18, N74, L-5, M-1, E-1. LFT's - Low albumin otherwise normal. Babeosis Ab<I:6, Babeosis smear negative, Lyme titre 1:32, ESR-80. CXR - Changes consistent with mild CHF. 2-D echocardiogram showed no evidence of endocarditis. CT scan of the abdomen/pelvis did not reveal any focus of infection. Serial blood cultures - negative. Patient was admitted with provisional diagnosis of sepsis of unknown etiology and was treated empirically with IV ceftriaxone. Patient required dopamine for blood pressure support. In spite of several days of IV antibiotics the patient continued to be febrile and hypotensive, and was unable to be weaned from the dopamine. On day 4 of hospitalization peripheral smears revealed inclusion bodies consistent with human granulocytic ehrlichiosis.
The diagnosis was subsequently confirmed by serology and by polymerase chain reaction (PCR) technology. Patient was treated with IV doxycycline and became afebrile within 24 hours and had an immediate response in his blood pressure.
This case demonstrates HGE as a cause of sepsis in a clinical setting where a tick-borne illness seemed unlikely. HGE can cause symptoms ranging from non-specific illness to potentially fatal condition if undiagnosed and untreated.
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