Case Presentation: A 68 year-old male transferred from an outside hospital to this tertiary care academic medical center. He presented at the outside hospital with syncope, nausea, diarrhea, rash, profound weakness and fever. Because he was a rancher and frequently had tick bites, with one recently found to be deeply embedded and engorged with blood, he was started on IV doxycyline. He transferred due to persistent fevers, leukopenia, thrombocytopenia and mild transaminitis. Differential diagnosis included Heartland virus versus Severe Fever with Thrombocytopenia Syndrome (SFTS). Multiple serologies were obtained and were negative, including Rocky Mountain spotted fever, tularemia, brucella, babesiosis, and Q fever; molecular testing for Ehrlichia spp. and Anaplasma phagocytophilum; and blood thin smears for Babesia were negative. Results of evaluations for fungal pathogens (Aspergillus spp. galactomannan, antibodies against Histoplasma and Histoplasma antigen in serum and urine) were negative. Evaluations for cytomegalovirus, Epstein-Barr virus, and parvovirus showed past infection. Test results for hepatitis B and C viruses, West Nile virus, and HIV were also negative. Blood, sputum, and urine bacterial cultures were negative. Some tests resulted after the time of death. On the 9th day of illness he developed rapidly progressing respiratory failure and was transferred to the ICU, quickly developing ARDS requiring intubation, multiple pressor shock and worsening lactic acidosis. An echocardiogram revealed a reduced EF and global hypokinesis consistent with myocarditis. He developed renal failure and CRRT was initiated. Despite broadening of antibiotic treatment the patient’s condition rapidly deteriorated. He ultimately developed PEA cardiac arrest resulting in his demise.  

Discussion: Serologies were sent to the CDC, with a high suspicion for Heartland virus infection, however testing on blood collected on day 9 of illness suggested the presence of an unrecognized virus. Electron microscopy demonstrated viral particles consistent with viruses in the Orthomyxovirus family, most closely related to the Thogotovirus genus. This novel virus, not seen before, was named the Bourbon virus, after the patient’s county of residence. High levels of viremia in blood taken 2 days before the patient died suggest the virus may have contributed to his death. The lone star tick (A. americanum) is suspected to be a vector of Bourbon virus to humans. As of June 2018, a limited number of Bourbon virus disease cases have been identified in the Midwest and southern United States, per the CDC, with three cases resulting in death. Supportive care is recommended, as no definitive treatment has been identified. To prevent infection, recommendations include wearing long sleeves and pants, using an insect repellent that is effective against ticks, avoiding wooded or bushy areas, and checking for ticks after being outdoors.

Conclusions: The purpose of reporting this case of Bourbon Virus infection is to increase awareness of this recently identified virus, the signs and symptoms of infection, recommendations to avoid infection, and the possibility of developing fatal, rapidly progressive multi-system organ failure associated with this novel virus.