Christopher Radcliffe1, Cynthia Tsay2, Kimberly Glerum2, Jane Liao2, George Goshua3, Gerard Kerins4,5. 1. Yale University School of Medicine, 333 Cedar St., CT, 06510, New Haven, USA. christophervradcliffe@gmail.com. 2. Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. 3. Section of Hematology and Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. 4. Yale University School of Medicine, 333 Cedar St., CT, 06510, New Haven, USA. 5. Section of Geriatric Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
Abstract
BACKGROUND: Pancytopenia, fever, and elevated D-dimer are significant clinical findings. The differential diagnosis includes hematological malignancies, severe coronavirus disease 2019 (COVID-19), tick-borne illnesses, and other etiologies. CASE PRESENTATION: We report the case of a 95-year-old woman who presented with high fever (103.6 °F), pancytopenia, and markedly elevated D-dimer (32.21 mg/L; reference range ≤ 0.95 mg/L) in late-autumn during the COVID-19 pandemic at a large academic institution. After remaining persistently febrile, a peripheral blood smear was ordered and revealed parasites consistent with Ehrlichia spp. Doxycycline monotherapy led to symptomatic improvement and resolution of her pancytopenia. During her hospital stay, a computed tomography angiogram of the chest revealed pulmonary emboli, and esophagogastroduodenoscopy uncovered arteriovenous malformations. After appropriate treatment, she was discharged on hospital day 7 and has since done well. CONCLUSIONS: Overall, our case offers a dramatic, unexpected presentation of ehrlichiosis in a nonagenarian. To our knowledge, this is the first report of concurrent ehrlichiosis and pulmonary embolus.
BACKGROUND:Pancytopenia, fever, and elevated D-dimer are significant clinical findings. The differential diagnosis includes hematological malignancies, severe coronavirus disease 2019 (COVID-19), tick-borne illnesses, and other etiologies. CASE PRESENTATION: We report the case of a 95-year-old woman who presented with high fever (103.6 °F), pancytopenia, and markedly elevated D-dimer (32.21 mg/L; reference range ≤ 0.95 mg/L) in late-autumn during the COVID-19 pandemic at a large academic institution. After remaining persistently febrile, a peripheral blood smear was ordered and revealed parasites consistent with Ehrlichia spp. Doxycycline monotherapy led to symptomatic improvement and resolution of her pancytopenia. During her hospital stay, a computed tomography angiogram of the chest revealed pulmonary emboli, and esophagogastroduodenoscopy uncovered arteriovenous malformations. After appropriate treatment, she was discharged on hospital day 7 and has since done well. CONCLUSIONS: Overall, our case offers a dramatic, unexpected presentation of ehrlichiosis in a nonagenarian. To our knowledge, this is the first report of concurrent ehrlichiosis and pulmonary embolus.
Entities:
Keywords:
Case report; Ehrlichiosis; Pancytopenia; Pulmonary embolus
Authors: David B Sykes; Eric W Zhang; Rebecca S Karp Leaf; Valentina Nardi; Sarah E Turbett Journal: N Engl J Med Date: 2020-03-26 Impact factor: 91.245