A 57‐year‐old healthy woman with no medical history was transferred to our institution for evaluation of fever, abdominal pain, and neutropenia. Patient reported that she developed abdominal pain 5 days prior to presentation and described the pain as being periumbilical initially and then moving to the right lower quadrant, achy in character and constant in nature, with no aggravating or relieving factors. She then developed fever on the subsequent day, and review of systems was positive for fatigue, nausea, and headache. Her history was negative for any tick bites or outdoor activities. Physical exam showed no rashes, petechial hemorrhages, or neck stiffness. Initial blood work showed leukopenia with absolute neutrophil count of 100, thrombocytopenia, elevated transaminases, lymphocytosis (52%) and monocytosis (44%), with atypical lymphocytes on the peripheral smear. Imaging of the abdomen revealed an inflammatory process involving the cecum (typhilitis), appendix, and terminal ileum and mesenteric adenopathy. She then underwent a bone marrow biopsy for a suspected lymphoproliferative process, which was negative for leukemia or lymphoma. Subsequently indirect fluorescent antibody (IFA) came back positive for Ehrlichia chaffeensis IgG (titer 1:64) and Anaplasma phagocytophilum IgG (titer 1:256). Intracytoplasmic inclusions (morulae) on the blood smear were negative. A repeat CT of the abdomen 4 days later showed interval improvement in the patient's cecal thickening and fluid surrounding the cecum and appendix. The patient was started on oral doxycycline and discharged home. A convalescent blood sample drawn 2 months later showed a drop in antibody titers of both Ehrlichia and Anaplasma, suggesting previous infection. We suspect the course of events in the patient started with ehrlichiosis, leading to neutropenia with subsequent development of typhilitis.
Ehrlichiosis is an infection of white blood cells that affects various mammals, including mice, cattle, dogs, deer, horses, sheep, goats, and humans.
Human granulocytic anaplasmosis (HGA) and human monocytic ehrlichiosis (HME) cause the same clinical manifestations; therefore, the term ehrlichiosis is used to encompass both types of infections. Amblyomma americanum (Lone Star tick) is the principle tick vector of E. chaffeensis and is the primary vector of human monocytic ehrlichiosis. Species that cause human granulocytic anaplasmosis may be transmitted by Ixodes persulcatus ticks and possibly Dermacentor variabilis (dog tick/wood tick).
This case is an example of a rare cause of neutropenic enterocolitis that hospitalists should be aware of.
A. Singh ‐ none; K. H. Kim ‐ none; R. Reilly ‐ none; N. Saraiya ‐ none
To cite this abstract:Singh A, Kim K, Reilly R, Saraiya N. A Case of Ehrlichiosis Presenting As Neutropenic Fever with Typhilitis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 397. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-ehrlichiosis-presenting-as-neutropenic-fever-with-typhilitis/. Accessed May 26, 2019.