A Bicyclist’s Tale

(See pages xx for the Answer to the Photo Quiz.) In August, a 55-year-old man presented with fever, progressive lethargy, body aches, joint pains, and intermittent confusion that lasted for 10 days. Past medical history included alcohol use and splenectomy. The patient was a resident of western Pennsylvania, lived in the countryside, and enjoyed bicycling. He did not recall being bitten by a tick or receiving a blood transfusion. He had not traveled out of the state or abroad prior to symptom onset. On examination, the patient was febrile and hypotensive. He had jaundice, hepatomegaly, and asterixis. Initial laboratory results included a white blood cell count of 15 700 cells/mm3, hemoglobin of 14.3 g/dL, and platelet count of 70 000 cells/mm3. Hemoglobin dropped to 8.4 g/dL over the course of a day, with low serum haptoglobin and high serum lactate dehydrogenase levels. Hyperferritinemia (80 709 ng/mL) and hypertriglyceridemia (533 mg/dL) were noted. Elevation of serum creatinine (5.39 mg/dL), aspartate aminotransferase (400 U/L), alanine aminotransferase (88 U/L), total bilirubin (16.5 mg/dL), direct bilirubin (10.8 mg/dL), and international normalized ratio (6.4) was noted. Giemsa-stained peripheral blood smears are shown in Figures 1 and 2. Commercial blood Babesia microti polymerase chain reaction (PCR) and serology for B. microti immunoglobulin (Ig) M and IgG were negative.