Rare Case Of Hepatitis Due To Ehrlichiosis

INTRODUCTION: Ehrlichiosis has emerged as an increasingly recognized tick-borne rickettsial disease. The principal vector of Ehrlichia chaffeensis is the lone star tick. It presents with nonspecific symptoms, such as fever, malaise, myalgia, headache, and chills in majority of cases, nausea, vomiting, and arthralgias to lesser extent, and finally rash and neurologic symptoms in minority of patients. The most common laboratory abnormalities are leukopenia, thrombocytopenia, and mild to moderatetransaminitis (up to 10 times upper normal limit of liver enzymes). However, it was rarely reported to cause high raise in liver aminotransferases levels. Hence, we present a case of 69-year-old female with Ehrlichiosis that resulted in severe elevation of liver enzymes. To the best of our knowledge, this is the highest reported levels of liver enzymes due to Ehrlichiosis. CASE DESCRIPTION/METHODS: A previously healthy 69-year-old female presented to the hospital with 5 days of high fevers. Patient reported taking Tylenol and ibuprofen as anti-pyretic therapy. Physical examination was unremarkable. Basic laboratory tests showed white blood cell count 0.9 × 103/uL with neutropenia and lymphopenia, platelet count of 35 × 103/uL, aspartate aminotransferase 1599 units/liter, alanine aminotransferase of 1575 units/liter. Abdominal ultrasound and computed tomography of chest, abdomen and pelvis were unremarkable. Extensive infectious, autoimmune, genetic, toxic and malignancy workup was done to identify the cause, and the patient was empirically started on broad spectrum antibiotics including vancomycin and piperacillin-tazobactam as well as doxycycline to cover for tick borne illnesses. Polymerase chain reaction test was positive for Ehrlichia chaffeensis. Broad spectrum antibiotics were stopped, and the patient was discharged on oral doxycycline to complete a total of 10 days treatment. DISCUSSION: Although Ehrlichiosis commonly results in mild to moderate elevation in liver enzymes, high levels should not eliminate the possibility of Ehrlichiosis. Healthcare providers should be aware of this as serious morbidity and even death can be prevented with early recognition and proper treatment.