Internal Medicine Case Challenge: A Highly Active 80-Year-Old Woman With Sudden Illness

Zafar Jamkhana, MD, MPH; Nirav Patel, MD


April 03, 2023


The patient was admitted to the intensive care unit and was managed using a septic shock treatment protocol. She developed progressive multiorgan failure, requiring mechanical ventilation, multiple vasopressor support, and renal replacement therapy. Broad-spectrum antibiotics, including intravenous vancomycin and meropenem, were started. On day 2 of hospitalization, intravenous doxycycline was also administered. The patient was transferred to a tertiary center for a higher level of care. A whole-blood polymerase chain reaction test identified Ehrlichia chaffeensis; however, the patient expired before the result of the test.

In this case, the differential diagnosis was broad but was narrowed based on the clinical history and presentation. Lyme disease is a prototypic tick-borne illness; however, an erythema migrans lesion is frequently seen in early disease, and frank sepsis/septic shock is not clinically seen.

Given the abdominal symptoms, gastroenteritis was also considered. Furthermore, acute kidney injury, anemia, and thrombocytopenia are concerning for hemolytic-uremic syndrome, which is associated with infection with enterohemorrhagic Escherichia coli. However, nausea and vomiting are less frequent presenting symptoms, and the need for vasopressor and mechanical ventilatory support are less commonly associated with this infection or hemolytic-uremic syndrome. More specifically, the associated diarrhea is typically described as bloody, especially later in the illness. Furthermore, the peripheral smear was negative for schistocytes, which are frequently seen with the microangiopathic hemolytic anemia seen in hemolytic-uremic syndrome.

Rocky Mountain spotted fever can present with nonspecific symptoms that progress to multiorgan failure. The geographic distribution of cases also includes southern Illinois, so it must be considered in the differential diagnosis of tick-borne illness. However, the fever was a minimal symptom in her presentation, and she had no evidence of rash. Neither is specific to Rocky Mountain spotted fever infection; however, without either of the symptoms, and in the setting of leukopenia, this disease is less likely.

Southern tick-associated rash illness can also be considered, given the appropriate geographic distribution as well as tick exposure; however, the disease is frequently mild and does not progress to such a severe presentation. Furthermore, similar to Lyme disease, it typically presents with an erythema migrans-like skin lesion. Again, no rash was noted in this case.

Intra-abdominal abscess is also a frequent complication seen in patients with inflammatory bowel disease. In this case, the patient has quiescent disease and is controlled with minimal immunosuppression. The patient also underwent CT scan without direct evidence of intra-abdominal infection.


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