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Disclosures for J. Evan Sadler

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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Disclosures for J. Evan Sadler

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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

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