Case Presentation:

A 72‐year‐old man was admitted with a 2‐day history ot lever, chills, headache, myalgias, diarrhea, and confusion. On admission, he developed respiratoryfailure and rapid atrial fibrillalion requiring intubation, and he was admitted to the intensive care unit (ICU). Laboratory data were consistent with acute kidney injury (creatinine 5.9), abnormal liver function tests, anemia and thrombocytopenia. The patient was started on broad‐spectrum antibiotics — cefepime and vancomycin as well as doxycycline (starting day 1). Lumbar puncture, serologies for influenza A and B, R. typhi IgM, RMSF Land Lyme PCR, Babesia smear, and anaplasmosis PCR were negative. Ehrlichia PCR came back positive and confirmed the diagnosis of HME. His blood smear showed the typical dispersed intracytoplasmicindusionsof HME seen in monocytes (Fig. 1). His acute kidney injury was attributed to acute tubular necrosis which required dialysis. The fever abated after 3 days of admission. He improved gradually, and he was extubated 5 days after his presentation. His kidney function remained compromised and he was continued on hemodialysis. He was discharged home after 10 days of his admission


Human monocytic ehrlichiosis (HME) is a tick‐borne disease caused by the infection by E. chaffeensis. It mainly presents as a clinically mild to moderate acute illness. A delay in therapy initiation has been proven to increase the morbidity of the disease. Only in rare cases, the disease can be severe and may progress to death. The diagnosis of ehrlichiosis is often delayed because of its nonspecific clinical and laboratory manifestations. Early therapy is very important in the course of the disease, and appropriate antibiotic treatment with doxycycline in the first 24 hours of admission has proved To have a major impact on the morbidity of the disease (ICU admission, mechanical ventilation, length of stay). In our case, doxycycline was started since day 1 of presentation given the unexplained fever presentation and the triad of anemia, thrombocytopenia and elevated transaminase. Even though the patient ended up with a renal failure requiring continuous hemodialysis, his general course was favorable.


Our case emphasizes that in elderly hosts, clinical manifestations related to HME can be severe and can include neurological deterioration and multiorgan failure. It also emphasizes the importance of starting empirical therapy for HME in any suspected patient living in an endemic area.

Author Disclosure:

R. Yachoui, none: M. Sabbah, none; A. Subhi, none.