Critical Care: Student/Resident Case Report Poster - Critical Care II |

An Unusual Cause of Atrial Fibrillation With Rapid Ventricular Response FREE TO VIEW

Kasra Sedarati, MD; Farnoosh Taghadosi, MD; Igor Aksenov, MD; James Ramage, MD
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Memorial Health University Medical Center, Savannah, GA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):404A. doi:10.1016/j.chest.2016.08.417
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION:Ehrlichia chaffeensis is the causative agent of human monocytic ehrlichiosis. Ehrlichiae are obligate intracellular bacteria that grow within membrane bound vacuoles in human and animal leukocytes. Clinical presentation is typical for headache, leukopenia, elevated liver enzymes and thrombocytopenia.

CASE PRESENTATION: A 71-year-old Caucasian female presented to the ED with altered mental status. On presentation, she was found to have atrial fibrillation with rapid ventricular response, with a heart rate of 227. History revealed 3 days of back pain, followed by subjective fevers and proximal muscle weakness. Labs showed pancytopenia with bandemia, acute kidney injury and elevated transaminases. Integumentary exam showed a maculopapular rash noted encompassing only the chest, and extremities. Neurological exam showed dysarthria with some word finding difficulties. Diagnosis of severe sepsis with multiorgan dysfunction was made and the patient was admitted to the critical care service. All etiologies were considered, including viral, parasitic, and bacterial. After talks with the family, it became apparent that the patient had recent exposure to wildlife and ticks 1 week prior while hiking on Sapelo Island, Georgia. The patient was placed on Doxycycline and Ceftriaxone for possible tick-bourne illness. Over the next few days, her status began to improve and her laboratory abnormalities all continued to trend to normalcy. Serologies returned, showing Ehrlichia Chaffeensis to be the causative agent with titers of >1:1024.

DISCUSSION: Our case is unique in that the patient's initial presentation was atrial fibrillation with rapid ventricular response (RVR). Although our patient did have many of the typical findings associated with human monocytic ehrlichiosis, our literature review failed to produce a case where atrial fibrillation with RVR was the presenting finding. Most likely, the patient’s recent use of Prednisone accentuated her underlying infection, which in turn accelerated the incubation period and resulted in her presentation of severe sepsis.

CONCLUSIONS:Ehrlichiosis generally presents with headache, leukopenia, elevated liver enzymes and thrombocytopenia. Symptoms may progress to fulminant multiorgan disease and even septic shock. The case-fatality rate is 2.7%. As mentioned above, initial presentation is extremely variable. Considering the increasing prevalence of ehrlichiosis, the variability in presentation and severity of disease it may cause, further awareness of this disease process must be attained.

Reference #1: Dahlgren FS, Mandel EJ, Krebs JW, Massung RF, McQuiston JH. Increasing incidence of Ehrlichia chaffeensis and Anaplasma phagocytophilum in the United States, 2000-2007. Am J Trop Med Hyg(85)2011,124

Reference #2: CDC. Anaplasmosis and ehrlichiosis - Maine, 2008. MMWR Morb Mort Wkly Rep(58)2009,1033

Reference #3: Nahed Ismail, Karen C. Bloch, Jere W. McBride. Human Ehrlichiosis and Anaplasmosis. Clin Lab Med. 2010 March; 30(1): 261-292.

DISCLOSURE: The following authors have nothing to disclose: Kasra Sedarati, Farnoosh Taghadosi, Igor Aksenov, James Ramage

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