A previously - pacemaker

[ArchivalUser]

A previously healthy 63-year-old man is brought to the emergency department because of a 3-day history of fever, nonproductive cough, rhinorrhea, pain in his thighs and calves, and progressive weakness of his legs. He and his wife recently returned from a 1-week vacation in Virginia, where they had hiked and fished in rural areas. His wife is well.

On physical examination, temperature is 39.2 °C (102.6 °F), pulse rate is 94/min, respiration rate is 18/min, and blood pressure is 166/94 mm Hg. There are no rashes. Cardiopulmonary examination is normal. Examination of the abdomen is normal except for mild diffuse tenderness. There is trace pedal edema of the lower extremities and moderate muscle tenderness on palpation of the thighs and calves. On neurologic examination, the gait is unsteady because of weakness. Cranial nerves are intact. Muscle strength is diminished in the lower extremities symmetrically and normal elsewhere. Sensation is normal. Reflexes are decreased in the lower extremities and normal in the upper extremities. The plantar reflexes are flexor bilaterally.

Laboratory Studies
Hemoglobin

13.2 g/dL (132 g/L)
Hematocrit

40%
Leukocyte count

3700/μL (3.7 × 109/L) with 69% neutrophils, 21% lymphocytes, 8% monocytes, 1% eosinophils, and 1% basophils
Platelet count

34,000/μL (34 × 109/L)
Blood urea nitrogen

15 mg/dL (5.36 mmol/L)
Serum creatinine

1.1 mg/dL (97.26 μmol/L)
Serum electrolytes

Normal
Serum aspartate aminotransferase

310 U/L
Serum alanine aminotransferase

390 U/L
Serum alkaline phosphatase

189 U/L
Serum amylase

41 U/L
Serum lipase

33 U/L

A peripheral blood smear shows several leukocytes with deep-blue“straining intracytoplasmic inclusions (morulae).

Which of the following is the most likely diagnosis?

A Lyme disease
B Anaplasmosis (formerly human granulocytic ehrlichiosis)
C Salmonellosis
D Parvovirus B19 infection

[ArchivalUser]

B..

[ArchivalUser]

b morulae

[ArchivalUser]

bb

[ArchivalUser]

B..

[ArchivalUser]

yup b!!!

bust still pace can u pls give us explanation!!!

[ArchivalUser]

bb

[ArchivalUser]

yesB

[ArchivalUser]

Correct Answer = B)
Key Points

* Anaplasmosis (formerly human granulocytic ehrlichiosis) is characterized by fever, flu-like symptoms, leukopenia, thrombocytopenia, liver chemistry abnormalities, and a peripheral blood smear showing morulae.
* Doxycycline is the treatment of choice for anaplasmosis.

This is a typical presentation of anaplasmosis (formerly human granulocytic ehrlichiosis). The onset with fever, flu-like symptoms, leukopenia, thrombocytopenia, and elevated liver chemistry test results in a patient who had been in an endemic area are all characteristic of this disease. The diagnosis is confirmed by finding morulae in granulocytes, and the treatment of choice is doxycycline. Any patient with newly diagnosed anaplasmosis should also be evaluated for Lyme disease and babesiosis because these infections are also endemic in many of the same geographic areas.

This patient has no findings consistent with Lyme disease. However, concomitant infections with anaplasmosis and Lyme disease occasionally occur, and the patient should be monitored for the development of erythema migrans. Doxycycline is effective for both infections. Although salmonellosis should be included in the differential diagnosis, the morulae on the peripheral blood smear rule out this infection as the cause of the patient's findings. Parvovirus B19 infection can also cause the fever and other nonspecific symptoms but would not be expected to cause the changes in the leukocyte and platelet counts, liver chemistry studies, and peripheral blood smear.