[Photos omitted on LymeInfo - go to URL at top of page to view photo captioned below.]
Illustration by Jan Schwochow
Fever Drenching sweats alternated with chills at night. Body aches Not just in the neck, but hotness and soreness all over. Liver abnormalities Revealed by blood tests.
It was the woman's husband who noticed the first symptom. The couple were walking along a street of town houses on the Upper West Side of Manhattan. Her husband had pointed to some architectural detail and looked to see her reaction. The young woman tipped her whole body back in order to look up.
"What's wrong with your neck?" her husband asked. "Are you O.K.?" As soon as he asked, she realized that her neck felt stiff and that she wasn't O.K.
She was well into her fifth month of pregnancy and was used to the minor aches and pains of her new shape, but this, this was different. She felt hot, achy, sore --not just in her neck but all over. They walked to a pharmacy and bought a thermometer. Her temperature was 101.
They had looked forward to this Friday-evening visit to the city, but now the woman felt too ill to enjoy it. They decided to go back home to Connecticut.
She phoned her OB-GYN's office and spoke with the doctor on call. After listening to her symptoms, he said he wasn't worried. It was probably a virus. He recommended Tylenol and rest. That night, the woman alternated between teeth-rattling chills and a fever that left her drenched in sweat.
The next morning she still had the fever and aches. She thought it over. She was a physician, an internist -- she should be able to figure this out. Lying in bed, she tried to think about herself the way she might any other patient.
She was 30 and she was healthy. She didn't smoke and hadn't touched a drop of alcohol since she found out she was pregnant. Her pregnancy had been problem-free until three weeks earlier, when blood tests showed that her liver was a little abnormal.
Her OB had screened her for the most common forms of hepatitis, but the tests were all fine. The doctor was going to follow up at her next appointment. Could those liver abnormalities be linked to this fever? About a week after the liver results, she found a tick on her thigh, which she recognized as the type that could carry Lyme disease.
Could this illness be Lyme? She had been on the lookout for the telltale rash but hadn't seen anything.
2. Investigation
Being a doctor, she was surrounded by doctors. "Sandy thinks you have ehrlichiosis," her husband, also an internist, announced after speaking with a friend who had gone through residency with the couple. Ehrlichiosis, too, can be transmitted by a tick and can cause both fever and transient liver abnormalities.
A good diagnosis, but the timing was wrong. The liver tests were abnormal the week before she found the tick.
She called the OB-GYN again. He thought ehrlichiosis was pretty unlikely. Even a healthy pregnant woman could get a viral illness,he reasoned. Bed rest and Tylenol for the weekend, and they would see how she was doing on Monday.
The patient hung up the phone completely unsatisfied. She couldn't wait another day. What if this illness was hurting her baby? She wanted a second opinion.
She called a favorite professor of hers, Vincent Andriole -- an infectious-disease specialist. Right away he wanted to look for the ehrlichia in her blood. One interesting thing about these bacteria is that if you use the right stains, you can sometimes see the organisms under the microscope.
The tiny bugs look like little clusters of round black dots trapped inside white blood cells. "Morulae" are what these little clusters are called, Latin for mulberries.
He invited her to come immediately to the lab. She sat miserably with her head in her arms as Andriole and her husband scanned the blood smear under the microscope. No little clusters. Too bad, Andriole said. That would have been a great diagnosis.
Normally, she might have just soldiered on, but there was her baby to think about. The next day, she called another former teacher, Michele Barry, who told her to come by the following morning.
Barry is a tiny tornado of a woman who exudes a restless energy that leaves an impression of movement even when she's sitting still.
The patient looked tired but not severely ill, Barry noted as she listened to her story. She didn't have a fever, and her blood was getting enough oxygen. She had no rash. Her throat was a little red,but her lymph nodes weren't swollen, and the rest of her exam was normal.
But she was pregnant, a time of reduced immunity. The body is less able to fight off infections on its own. Also, whatever this problem was, the treatment had to be one that would cure the mom without injuring the fetus.
So what were the possibilities? Mononucleosis usually presents with these very symptoms: fever, a reddened throat and abnormal liver- function tests. The organism that causes mono, Epstein Barr, has been implicated in a few reports of fetal abnormalities, though this is a very rare complication.
And in any case, there is no treatment for mono. H.I.V., the virus that causes AIDS, was also possible. It can cause this kind of fever and body aches. The patient's job as a physician put her at higher risk for this disease, though she couldn't recall any recent exposures. Still, if she had H.I.V. and it wasn't diagnosed, the fetus could be infected at birth.
Toxoplasmosis was also a worry. This disease, which is found in undercooked meat and is carried by cats, can cause terrible injury to the unborn child. The woman did have a cat, and like most pregnant women, she had been tested early on. That test showed that she had never been exposed to the disease. Could she have it now?
3. Resolution
Barry would need to send blood for tests to look for each of these infections. Finally, there was still the possibility of ehrlichiosis. Morulae are seen in only one-third of ehrlichiosis cases, and if you aren't able to see them under the microscope, it's not easy to confirm the diagnosis. There are other tests, but they won't be positive until the worst of the disease is over.
Because of this, diagnosis is usually based on the clinical picture, and treatment, a strong antibiotic called doxycycline, tends to be started before infection is confirmed.
The patient's pregnancy made this difficult, however. Physicians are loath to start any medication during pregnancy, and doxycycline is particularly dangerous for a fetus. Fortunately, Barry knew of a researcher who was developing a diagnostic blood test for ehrlichiosis that could quickly detect the DNA of the bacterium itself. The researcher agreed to test the woman's blood that day.
Late that afternoon, Barry's pager chirped: the researcher had news.He had found the bacteria's DNA in the patient's blood; she had ehrlichiosis. Barry immediately called the patient with the news.
She had read of at least one case in which a pregnant patient had been successfully treated with another antibiotic, rifampin, and put the mother to be on it that day. "I started to feel better almost immediately," she told me recently.
When her liver was tested two weeks later, the abnormalities had disappeared. Still, the sequence of events troubled her. How could her liver have been abnormal before she was even bitten by the tick? Could she have missed the tick for all that time? That seemed unlikely.
Was it possible that the abnormal liver tests were just a coincidence? That seemed unlikely, too. She favored another explanation, the two-tick theory --that she'd been bitten by not one but two ticks and simply missed the first.
"If I hadn't been so persistent," the patient told me recently, "I don't know how long it would have taken me to get a definitive diagnosis. Maybe never."
Barry agrees: "There was a rush to get this diagnosis, and there should have been." Barry has seen reports of cases in which ehrlichiosis is passed from mother to fetus. Early intervention can prevent that, she said. And it seems to have worked. Four months later, the patient gave birth to a healthy baby girl.
If you have a solved case to share with Dr. Sanders, you can e-mail her at [email protected]. She is unable to respond to all e-mail messages.
***** Letters to the Editor: [email protected] Posted by minimonkey (Member # 8693) on :
Nan --
You beat me to the punch, here -- I was going to post this, too.
Uh, yeah.... generally erlichia isn't seen without Lyme, now is it???? I'd be pretty worried about that baby, myself.... it may appear healthy now, but what about later???
Still, glad that this was run, as it does bring awareness to TBDs in general.
Posted by csperanza (Member # 9613) on :
I saw that article and as soon as she described the symptoms, I thought "Lyme!" I was a little disappointed that magically the woman took one or two doses of abx and felt so much better. It just feeds into that mentality that tick-borne illnesses are easy to treat and quick to recover from. After several months of abx and a resurgence of symptoms, I've learned all too well that this isn't the case! Carol
![[Frown]](frown.gif)