Case Presentation: A 77-year-old male with a PMH of atrial fibrillation, coronary artery disease, type 2 diabetes, hypertension and hyperlipidemia presented for a mechanical fall. He endorsed generalized malaise, subjective fevers, chills and fatigue days prior to the event. He denied any headache, cough or shortness of breath. On physical exam, he was febrile and tachypneic with no focal neurological findings. Labs on admission revealed hyponatremia (Na 125), pancytopenia, transaminitis (AST 1223, ALT 221), AKI (Cr 1.8), elevated CPK (3718) and COVID NAAT positive. CXR, CT brain without IV contrast and trauma work up were negative for acute pathology. He was admitted for sepsis secondary to COVID, however patient’s respiratory status was deemed stable and was not started on remdesivir and was given normal saline. While inpatient, he had persistent fevers, for which CT abdomen-pelvis without IV contrast showed mild enterocolitis and he was started on vancomycin and meropenem. On day 3, the patient became hypotensive requiring pressor support and was upgraded to the medical ICU. On day 4, patient had drop in hemoglobin from 8 to 5.5, he received 5 units of red blood cells. CT brain without IV contrast had visualized bilateral subdural hematoma. CTA abdomen-pelvis with IV contrast visualized a left large retroperitoneal and iliopsoas hematoma. On day 5, IR was consulted for possible angiogram and embolization. Patient went into DIC, continued to have drop in hemoglobin with worsening renal function, elevated liver enzymes and mental status. After discussion with the patient’s family, it was determined the patient had possible tick exposure and a tick-born panel was sent and resulted positive on day 6 for Ehrlichia Chaffeensis. After goal of care discussion, the family decided to place the patient on comfort care and the patient expired on day 7.
Discussion: Ehrlichiosis is a tick-born disease cause by the bacteria Ehrlichia chaffeensis, E. ewingii and E. muris eauclairensis. Most cases of Ehrlichiosis in the United State are due to E. chaffeensis. Cases of Ehrlichiosis have steadily increased over the years; only 200 cases were reported in the year 2000 and 2093 cases in 2019. Ehrlichiosis occurs in the spring and summer months. It is more prevalent in southeastern, south-central and mid-Atlantic regions of the United States. Ehrlichiosis can be mild to severe. Most patients present with nonspecific symptoms such as fever, malaise, myalgia, headache, arthralgia and vomiting, less commonly pancytopenia, transaminitis and hyponatremia. However, some patients can present with symptoms mimicking COVID infection such as confusion and respiratory symptoms. Risk factors for severe illness include immunocompromised status and having comorbid conditions such diabetes or connective tissue disorders. The gold standard for diagnosis is diagnosed via PCR. The first-line treatment for Ehrlichiosis is doxycycline for 7-10 days. The mortality rate for Ehrlichiosis is 1.0-2.7 %.
Conclusions: The overlapping symptoms of Ehrlichiosis and COVID infection can lead to anchoring bias and a delay in the diagnosis of Ehrlichiosis. Clinicians should keep Ehrlichiosis coinfection in their differential diagnosis when diagnosing patients with risk factors to prevent significant morbidity and mortality.