A 16‐year‐old previously healthy male was transferred to our hospital with a two day history of fever, headache, rash, lethargy, nausea, and diarrhea, and one week of fatigue and anorexia. He resides in the country, is exposed to ticks, and has two pet dogs. On exam the patient was sleepy but arousable, had nuchal rigidity, papilledema, conjunctival injection, splenomegaly, and a pink macular‐papular rash over his torso with some petechiae of lower extremities. Initial labs were notable for leukopenia (WBC 3.7k), bandemia (49%), thrombocytopenia (47k), hyponatremia (132mmol/L), and transaminitis (AST 187 U/L, ALT 190 U/L). Differential diagnosis included tick‐borne disease, leptospirosis, and viral etiologies like acute HIV, mononucleosis from EBV or CMV, enterovirus and arborviruses. Doxycycline was started as well as vancomycin and ceftriaxone given the potential for bacterial meningitis. Head CT was negative and platelet transfusion was completed prior to lumbar puncture. Cerebrospinal fluid (CSF) studies were notable for 155 nucleated cells (59% neutrophils, 16% lymphocytes, 7% monocytes), 114 RBC, glucose of 44 and elevated protein (101 mg/dL) with an opening pressure of 38 cm of H2O suggestive of secondary intracranial hypertension. Mono spot, parvovirus and EBV IgM antibody titers; CMV, enterovirus, and HSV PCR; acute hepatitis panel were all negative. The patient showed rapid clinical improvement. Vancomycin was stopped given low suspicion for staphylococcus meningitis. Pancytopenia and hyponatremia normalized prior to discharge, thought to be due to tick‐borne disease or viral suppression. He was discharged on doxycycline and ceftriaxone. The Ehrlichiosis profile resulted positive for Ehrlichia chaffeensis. Ceftriaxone was discontinued and the patient completed a 14 day course of doxycycline with resolution of all symptoms.
Ehrlichiosis is a relatively common tick‐borne illness, especially in southeast United States. It is diagnosed and presumptively treated based on classic clinical symptoms of headache, fever, fatigue, and myalgias. Head imaging and CSF studies are not routinely recommended for work up of suspected Ehrlichiosis, but many patients present with neurologic symptoms (including confusion, lethargy, hyperreflexia, photophobia, nuchal rigidity) with one study reporting neurologic symptoms in 20% of patients with E. chaffeensis infections. Of these, >70% had a lymphocytic pleocytosis and elevated protein on CSF evaluation. There is limited data on the frequency and clinical outcomes of Ehrlichia meningitis. The majority of patients recover with doxycycline treatment with fatality reported in 2.7% of cases.
Despite limited data on Ehrlichia meningitis, hospitalists must be aware that neurologic findings and meningitis and associated intracranial hypertension is not uncommon and may lead to hospitalization for further evaluation, as well as affect clinical course and outcomes.
To cite this abstract:Sawyer C, Balasubramanian S, Stephany A. Tick‐Borne Illness: Beyond Just a Headache. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 287. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/tickborne-illness-beyond-just-a-headache/. Accessed March 31, 2020.