Title

A Shocking Discovery: Ehrlichia chaffeensis as a Cause of Septic Shock in a Renal Transplant Patient

Authors

Bradley Bakst DO, Raven Boone DO, Internal Medicine, ChristianaCare, Newark DE

Introduction

Ehrlichia chaffeensis is a zoonotic tick-borne pathogen that is transmitted by infected Amblyomma americanum (lone star ticks). ?E. chaffeensis is known to have a mortality rate upwards of 3% due to its severity of disease.¹ The disease course has been infrequently reported in immunosuppressed patients, such as those receiving solid organ transplants.

Case Presentation

A 73-year-old male with a past medical history significant for two renal transplants presented to the emergency department with acute onset fever and chills. The patient’s immunosuppression therapy is being managed with mycophenolate mofetil and tacrolimus. In the emergency department, he was noted to have borderline hypoxemia, but otherwise had stable vital signs. He was admitted to the medical floor for further evaluation of fever and acute kidney injury. His hospital course was complicated by worsening encephalopathy, respiratory failure, renal failure, transaminitis, and pancytopenia. He was treated for septic shock that was initially felt to be from a urinary source as imaging was notable for a stone in the renal pelvis. Despite antibiotic management and percutaneous nephrostomy tube placement, the patient continued to deteriorate and required transfer to the medical intensive care unit. Seven days into his hospitalization, he was empirically started on doxycycline for concern of tick-borne-illness. His social history revealed his occupation as a farmer and that he resided in a marsh land in which the family reports as being heavily tick infested. Laboratory testing for acid fast bacilli, legionella urine antigen, fungal culture and smear, galactomannan, fungitell, histoplasma antigen, BK virus PCR, CMV PCR, EBV PCR, lyme titer, and rickettsial titers. Further testing ultimately showed a positive PCR for Ehrlichia chaffeensis. The patient’s pancytopenia and transaminitis improved with initiation of doxycycline however, the encephalopathy and renal failure did not improve despite treatment efforts. On day fourteen of his hospitalization, the patient was transitioned to comfort measures and ultimately expired.

Discussion

This case illustrates the importance of identifying occupational and environmental exposures that can predispose patients to tick-borne illnesses. The diagnosis of ehrlichiosis can be challenging in solid organ transplants patients since ehrlichiosis is not a classic opportunistic infection in solid organ transplants. In patients who live in endemic areas for Ehrlichiosis, it is important for clinicians to have a high-index of suspicion, especially in patients for acute febrile illness that are solid organ transplant recipients and immunosuppression given the risk for an increased severity of disease.²

References

1. Madison-Antenucci S, Kramer LD, Gebhardt LL, Kauffman E. Emerging Tick-Borne Diseases. Clin Microbiol Rev. 2020 Jan 2;33(2):e00083-18. doi: 10.1128/CMR.00083-18. PMID: 31896541; PMCID: PMC6941843. 2. Masterson EM, Gupta S, Jakharia N, Peacock JE Jr. Ehrlichiosis in a recent kidney transplant recipient: The repellent that did not repel! A case report and literature review of ehrlichiosis in solid organ transplant patients. Transpl Infect Dis. 2020;22(4):e13299. doi:10.1111/tid.13299