A 49 year old female from Connecticut was in her usual
state of health until August when she presented with a 1
week history of fever, headache, chills, nausea and
malaise. She was seen by a local physician who suspected
sinusitis and treated her initially with an oral
cephalosporin. Other than scleral icterus, head, neck,
heart and lungs were normal. Her presenting symptoms
continued. She had been in the woods 2 weeks prior to the
onset of her symptoms but knew of no tickbite.
Medications on admission included pindolol, conjugated
estrogens, aspirin, hydrochlorothiazide.
Past medical history:
Splenectomy 17 years prior following trauma
Pancreatitis 30 years prior following cholecystectomy
Hypertension
Social history:
She did not use tobacco, alcohol, or illicit drugs. She
had vacationed in the Caribbean 10 months earlier. Review
of systems was otherwise negative.
Physical Exam:
The temperature was 99.4, pulse 95 min, respiratory rate
20minute and blood pressure 109/54. She appeared
jaundiced and diaphoretic. Other than scleral icterus,
head and neck were normal. She had two ecchymotic lesions
on her right upper arm but no other skin abnormalities
were noted. She had minimal right upper quadrant
tenderness but the liver was not enlarged. The spleen was
absent. She had no palpable lymphadenopathy.
Laboratory Results
The hematocrit was 32%; platelet count was 136,000 mm3;
and the white blood cell count 13,000 mm3 with a
differential of 5% band forms, 51% PMNs, 28% lymphocytes,
14% monocytes, 1% basophils. Serum electrolytes were
remarkable for a potassium of 2.9 meq Liter, blood urea
nitrogen of 41 and serum creatinine of 1.7. Serum
chemistries were notable for the following: Total
bilirubin of 15.3 mg/dL; direct bilirubin of 11.9mg/dL;
AST 55 IU/L; alkaline phosphatase 247 IU/L; lactose
dehydrogenase 900 IU/L. Urinanalysis showed the presence
of hemoglobin. Her chest radiograph was normal.