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An Unsuspected Zoonotic Infection Presenting as Sepsis

  • Rachel Epstein
    Correspondence
    Requests for reprints should be addressed to Rachel Epstein, MD, MA, Pediatric Infectious Diseases, 670 Albany St., 6th Floor, Boston, MA 02118.
    Affiliations
    Department of Pediatric Infectious Diseases, Department of Infectious Diseases, Boston University School of Medicine, Boston Medical Center, Boston, Mass
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  • Author Footnotes
    1 Present Address for Dr Ristau: Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Room M-987, San Francisco, CA 94143-0119. E-mail address: [email protected].
    Jessica Ristau
    Footnotes
    1 Present Address for Dr Ristau: Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Room M-987, San Francisco, CA 94143-0119. E-mail address: [email protected].
    Affiliations
    Boston University School of Medicine, Boston Medical Center, Boston, Mass
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  • Jerrold J. Ellner
    Affiliations
    Department of Infectious Diseases, Boston University School of Medicine, Boston Medical Center, Boston, Mass
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  • Author Footnotes
    1 Present Address for Dr Ristau: Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Room M-987, San Francisco, CA 94143-0119. E-mail address: [email protected].
      We describe 2 patients from an urban center in New England with undifferentiated sepsis. Patient 1, a 65-year-old man with hypertension and diabetes, presented with 3 days of fevers and malaise. He denied tick bites, exposure to forested areas or animals, and blood transfusion, but he had returned from Bangladesh 3 weeks previously. Physical examination revealed a temperature of 38.8°C, heart rate of 93 beats/min, and tenderness to palpation of the large muscle groups; blood lactate was 5 mmol/L. Despite antibiotic coverage with ceftriaxone, azithromycin, and vancomycin, the patient's condition deteriorated over the next 3 days with “hectic” fevers (Figure 1A), profuse sweats, rigors, and confusion. Bacterial cultures, viral serologies, and computed tomography of the chest, abdomen, and pelvis were negative. He developed pancytopenia (Figure 1B). A blood smear to rule out malaria revealed intracytoplasmic inclusions in the neutrophils (morulae). Human granulocytic anaplasmosis was suspected, and doxycycline therapy was initiated. Dramatic clinical improvement followed (defervescence within 2 hours), and he recovered without sequelae. Serum polymerase chain reaction for Anaplasma phagocytophilum was positive.
      Figure
      FigureFever curve and laboratory values. A, Demonstrates the fever curve for patient 1, with star indicating the initiation of doxycycline. B, Displays laboratory values during acute illness and after treatment for both patients. ALT = alanine transaminase; AST = aspartate aminotransferase.
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