Borreliosis And Human Granulocytic Anaplasmosis Coinfection With Positive Rheumatoid Factor And Monospot Test: Case-Report
M Sami Walid, M Ajjan, N Patel
anaplasma, borrelia, hepatomegaly, lymphocytes, monospot, rhematoid
M Sami Walid, M Ajjan, N Patel. Borreliosis And Human Granulocytic Anaplasmosis Coinfection With Positive Rheumatoid Factor And Monospot Test: Case-Report. The Internet Journal of Infectious Diseases. 2006 Volume 6 Number 1.
We are reporting a case of co-infection with
A 36-year-old Caucasian man from Warner Robins, GA, an engineer, presented with a two-week history of febrile illness up to 103 F, severe headaches, fear of light, body aches, irritability, weakness and night sweats. This started two weeks after a 5-days trip to Panama City, Florida, where he had to work outdoors. Physical exam yielded no specific signs. Ultrasound showed hepatomegaly. Laboratory studies revealed elevated liver enzymes,
Patients who have been diagnosed with one tick-borne infection are at an increased risk and should be tested for other related infections. Rheumatoid factor and monospot test may be falsely positive in such cases.
Anaplasmosis (ehrlichiosis) is the general name used to describe noncontagious infectious diseases of animals and humans transmitted by ticks caused by the organisms in the family
The family Anaplasmataceae (Ehrlichiaceae) consist of gram-negative minute cocci that are obligate intracellular parasites classified in the order
The identification of
Recently, Dumler et al.  unified
Cases of coinfection with tick-born microorganisms
We are reporting a case of Lyme Disease-human granulocytic anaplasmosis combination with unusual lab results.
A 36-year-old Caucasian man from Warner Robins, GA, an engineer, presented with a two-week history of febrile illness up to 103 F, severe headaches, fear of light, body aches, irritability, weakness and night sweats. This started two weeks after a 5-days trip to Panama City, Florida, where he had to work outdoors and recollected being bitten by some insects. No other family members got ill.
The patient, non-smoker and a social drinker, had no significant past medical or surgical history. Family history was significant for multiple myeloma (mother) and aneurysm (father).
On physical examination, the patient was in no acute distress, intoxication or sepsis. On palpation, there was no marked lymphadenopathy or organomegaly.
Laboratory studies revealed white blood count with normal limits (from 7.7 to 9.8 × 109 per liter over six days since admission) developing anemia (hemoglobin fell from 14.3 g/dl to 12.9 g/dl), decreasing neutrophils (from 46.2% to 24.0%), increasing lymphocytes (from 41.0% to 60.4%) and monocytes (from 10.3% to 12.8%), atypical lymphocytes (from 18% to 10%), normal platelets count, elevated sedimentation rate (from 40 mm/hr to 30 mm/hr) and C-reactive protein (from 2.75 mg/dl to 1.59 mg/dl), elevated liver enzymes (GOT/AST from 61 iu/l to 139iu/l, GPT/ALT from 95 iu/l to 177iu/l, alkaline phosphatase from 107 to 173 iu/l), worsening hypoalbuminemia (from 3.3 g/dl to 2.9 g/dl), hyponatremia (131 mmol/l, corrected later), hypokalemia (3 mmol/l, corrected later), low osmolality (265 mos/kg), hypocalcemia (8.3 mg/dl), decreased BUN (4 mg/dl) and BUN/creatinine ratio (3.6), normal creatinine, normal glomerular filtration rate, hyperglycemia (161 mg/dl), elevated glucose point-of-care testing, positive rheumatoid factor, hepatitis A, B and C serum tests nonreactive or negative,
Human Monocytic Ehrlichiosis (HME) was first described in 1987 and occurs primarily in the southeastern and south central regions of the country [5, 6]. Human granulocytic anaplasmosis (HGA), is an emerging tick-borne infection of humans in the United States, was first described in 1994 in Minnesota then has been found in the upper midwestem states, northeastern states, and northern California . During 1986 to 1997, health departments and other diagnostic laboratories reported over 1200 cases of human ehrlichiosis to CDC. Approximately two-thirds of them were cases of HME .
The same ticks that transmit these diseases are also responsible for the transmission of
The prevalence of tick bites is particularly high during the warmer months between April and September, the season for adult
The symptoms of ehrlichiosis may resemble symptoms of various other infectious and non-infectious diseases. These clinical features generally include fever, headache, fatigue, and muscle aches. Other signs and symptoms may include nausea, vomiting, diarrhea, cough, joint pains, confusion, and occasionally rash. The lack of a rash distinguishes them from Rocky Mountain spotted fever and Lyme disease; lack of upper respiratory and gastrointestinal symptoms distinguishes them from influenza. Symptoms typically appear after an incubation period of 5-10 days following the tick bite. Laboratory findings indicative of ehrlichiosis include low white blood cell count (WBC), low platelet count, and elevated liver enzymes.
Case definitions used by state health departments for surveillance for these diseases were first adopted by the Council of State and Territorial Epidemiologists (CSTE) in 1996 and were revised in 2000 to incorporate the use of newer laboratory methods for case confirmation . A confirmed case of HA is a clinically compatible illness with either:
a four-fold change in antibody titer by indirect immunofluorescence assay (IFA) in acute and convalescent phase serum samples,
PCR amplification of HA DNA from a clinical sample, or
a smear that is positive for morulae in the granulocytes and a single IFA titer of >1:64.
A probable case is defined as a clinically compatible illness with a single IFA titer of
In our case, there was no decreased WBC or platelet count but
The clinical picture, including symptoms (fever, body aches and hepatomegaly) and lab results (elevated lymphocytes and monocytes, elevated liver enzymes, elevated atypical white blood cells and positive monospot test) also speaks for the possibility of a superimposed infectious mononucleosis later at the time of admission. However, infectious mononucleosis is a disease of adolescents and young adults, with a peak incidence at ages 15-17. By the time most people reach adulthood, antibodies against EBV can be detected in their blood. In the U.S., up to 95% of adults aged 35-40 have antibodies directed against EBV . Also, positive monospot tests are sometimes encountered in patients with liver complications . And in any case, infectious mononucleosis is a self-limited disease with no specific treatment.
Rheumatoid factor was positive in our case. This is not strange since it has been reported to temporarily correlate with Lyme disease activity [17,18].
Co-infection with tick-transmitted diseases is common. Patients who have been diagnosed with one tick-associated illness should have more extensive laboratory testing if the clinical picture is untypical or multiple tick-associated illnesses are suspected. Rheumatoid factor, atypical lymphocytes and monospot test may be falsely positive in such cases.
Mohammad Sami Walid, MD, PhD 840 Pine Street, Suite 840 Macon, GA 31201 Phone: 478-743-7092 ex. 266 Fax: 478-738-3834 email@example.com