Sunday, March 22, 2015

72 yo man with malaise, rash and leucopenia

Presented by Hamish Dunwoodie
Moncton, New Brunswick

Abstract:  72 yo man with two weeks of malaise, 5 days of rash and low wbc

HPI:  The patient lives in rural New Brunswick and is an avid outdoors man who hikes weekly year-round. He noted the onset of malaise and decreased exercise tolerance ~ two weeks ago.  He'd been seen by his G.P., E.R. doctors, and a urologist.  A blood count was done ~ two weeks ago at the E.R. and he was told it his white cells were low, but that he probably had a viral infection.  He developed a rash ~ 5 days ago and sent photos to our New Brunswick teledermatoloy service. 

O/E:  The rash is mostly on his torso. There are 1 - 3 cm erythematous plaques on his torso, some with central clearing.

Clinical Photos:

Lab:  20.3.15  White count: 1600, other parameters normal, save for slight shift to the left. Lyme and anaplasmosis titers have been drawn. Repeat CBC 22.3.15 WBC 1300 (PMN 53, Bands 1, Lym 34, Mono 10, EO 2), PLT 233.
Lyme and Ehrlichiosis titers were negative.  


Diagnosis:  Leucopnia.  In spite of negative Lyme and Ehrlichia serologies a co-infection with Lyme and Ehrlichia still needs to be considered.

Course:  Over the past week, the patient has felt a bit better and his rash has subsided. 

Comments:  The patient lives distant from dermatological and infectious disease specialists.  He was started on doxycycline pending traveling to Moncton, NB to be seen at our hospital centre.  The differential diagnosis is large, but in an outdoors man with leucopenia, malaise and a peculiar rash tick born infection or co-infection needs to be considered.  The rash looks more like secondary Lyme, but thelow wbc goes along with anaplasmosis. Co-infections have been reported.  He has been started on doxycycline 100 mg b.i.d. until he is seen.

What are your thoughts?  We will update this post as more information is collected.

Update:  The patient's wbc bottomed out at 610 before rising to normal levels over a two week period.  His Lyme and Ehrlichia titers were negative x 2.  His rash gradually cleared and he felt better.  We assume he had Ehrlichiosis with negative titers and possibly co-infection with Lyme, but he may have had another infectious process.


  1. with marked leucopenia, Viral infection need to be considered high on the list.

    the distribution is rather unique. V of neck distribution. SLE is also a likely differential.

    drug related skin eruption. was she on any drugs recently?

  2. from Prof. K. Sharquie, Baghdad: In Lyme ds,we usually see typical primary target ringed lesion which is absent in this patient but the secondary rash is suggestive of Lyme ds.Still lupus erythematosis can give similar picture even with malaise and leukopenia.
    Here therapeutic test by giving antibiotics will cause rapid resolution of Lyme rash but not that of lupus rash.In addition to other differential lab tests that will distinguish between the two disorders


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