Case#5:

Clinical Presentation:
A 74 year old woman with a two week history of fever, chills, myalgias, and confusion. She lives in Westchester county, NY and earlier in the summer she noticed two ticks on her body prior to symptom onset. Blood counts are significant for pancytopenia.

Clinical Diagnoses:
Babesiosis
Acute Lyme Disease
Bacterial Meningitis

Case 5 Image 1: peripheral blood smear demonstrating round intracytoplasmic inclusions within polymorphonuclear leukocytes. On higher power, the inclusions contained bacillary forms.

Discussion:
Microbiologic Diagnosis:
Human Granulocytic Ehrlichiosis
In the northeast US, this rickettsial pathogen may be transmitted by the bite of an infected deer tick Ixodes scapularis (Case 5 Image 2). Diagnosis can be made by expert examination of peripheral blood smears for the characteristic round morulae in the cytoplasm. This ehrilichial pathogen can coinfect humans along with the agents of Lyme Disease and Babesiosis.