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.  

Pathology:

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.

3 Year-Old with Fever and Rash

Presented by Sylvia Moscone, M.D.
Block Island, New York

The patient is a 3-year-old girl who was seen for evaluation of a solitary lesion on the midback that has been present for about four days.  At the onset, she had a high fever, 105-106 F.  She was seen in the ER and referred to her pediatrician.  A diagnosis of Lyme disease was made and the patient was started on amoxicillin.  Blood studies were drawn.  Over the next two days, the fever persisted and then disappeared two days ago.  The child has a good appetite, sleeping well, playing normally.  Her parents feel she is "grumpy." She says the area on her back hurts. 

O/E:  The examination shows a 3 cm in diameter somewhat circular, erythematous scaly area.  A portion of this is flesh-colored.  There are no other similar lesions and there is no lymphadenopathy.   A baseline photo, taken by her mother, shows the initial lesion to be larger.

Clinical Photos:

At onset with fever

 

Four days later

Lab:  Lyme titers are negative.  Titers for Ehrlichiosis and Bartonellosis may have been drawn, but are not available now.

IMPRESSION:   A lesion less than 5 cm in diameter that is not enlarging is unlikely to be Lyme disease.  I do not have a specific diagnosis here. However, the lesion in the initial photo, taken by the child's mother may well have been > 5 cm in diamedter.  I woulld appreciate some guidance from VGRD members.  For the time being, the child is doing very well and she will be observed.  

Comment:  In the initial photo taken by the patient's mother, the lesion looks to be ~ 5 cm or larger.  This would suggest Lyme disease.  High fever is unusual with Lyme disease so the question of co-infection with Ehrlichiosis or Babesiosis needs to be considered.  Amoxicillin is not effective for those disorders, but many cases resolve spontaneously.    For the time being, it might be best to observe this child.  Serologies for the latter two diagnoses could be drawn if they were not looked for initially.