In this case report, a 79-year-old male sought care through the ER at a New York City hospital after experiencing acute illness and his wife noticed blood in his urine. The patient had several medical comorbidities including: “hypertension, benign prostate hypertrophy status post transurethral prostatectomy, cerebrovascular accident, and pulmonary hypertension.” He presented additional symptoms with fever, shortness of breath, severe thrombocytopenia, hematuria, elevated liver enzymes, and acute renal failure.
The patient’s condition progressed quickly to acute hypoxic respiratory failure, and he required mechanical ventilation. He was then started on intravenous (IV) ceftriaxone and azithromycin for suspected pneumonia, then switched to broader cover antibiotics, IV vancomycin and piperacillin/tazobactam. However, even with change to antibiotics, the patient remained febrile and experienced worsening anemia and heart failure. The primary care team “was anchored in the diagnosis of pneumonia and stayed locked in the initial diagnosis without considering further differential.” It was not until day 6 of hospitalization that infectious disease was consulted that the patient’s wife was asked about possible tick exposure. She stated that “the patient regularly walked in a park in New Jersey, and had had a recent tick bite.” With the tick exposure knowledge it was recommended that the patient’s treatment be upgraded to meropenem and doxycycline. Direct detection tests for anaplasmosis were conducted, however this method is only successful in detection in about 20% of patients, and were negative for this patient.
Due to the delay in diagnosis, this patient suffered from severe illness and complications from anaplasmosis and required an extended hospital stay. Tick-borne disease treatment was delayed for six days since these illnesses were not considered in the differential. The primary care team lacked the knowledge of tick-borne diseases that are not often seen in a city hospital. Authors note that empirical treatment of tick-borne illnesses should be considered in the proper clinical setting, and travel history should be relevant in any patient presenting with “fever, thrombocytopenia, leukopenia, and elevated liver enzymes, especially between spring and early fall,” even in city hospitals. They further suggest that the delay of early and appropriate treatment may result in the onset of severe illness.
Read the full text case report here
Read more LDA articles on anaplasmosis here