Case records of the Massachusetts General Hospital. Case 10-2005. A 73-year-old man with weakness and pain in the legs

Severe rhabdomyolysis as a rare complication of human granulocytic anaplasmosis

Human granulocytic anaplasmosis (HGA) is a tick-borne illness caused by infection with Anaplasma phagocytophilum. Although rare, rhabdomyolysis and acute renal failure are potential complications of HGA. We present the case of an 86-year-old male who exhibited severe myopathy, rhabdomyolysis, and acute renal failure necessitating hemodialysis. Treatment with doxycycline resulted in partial renal function improvement, allowing discontinuation of dialysis after 8 weeks. This case underscores the importance of considering rhabdomyolysis as a manifestation of HGA, particularly in individuals residing in or traveling to endemic areas.

Altered Mental Status on Top of Anaplasmosis-Induced Severe Rhabdomyolysis: A Rare Clinical Presentation

Human granulocytic anaplasmosis (HGA) is a disease caused by tick-borne infection of Anaplasma phagocytophilum. The typical symptoms are fever, malaise, and body aches accompanied by abnormal blood tests such as leukopenia, thrombocytopenia, and transaminitis. Some rare complications may occur, especially in patients living in heavily wooded areas, with a mean age of 70 years. We present a case of a 67-year-old male who was admitted for lower abdominal pain, fever, and diarrhea with derangement of his blood tests. Despite treatment, his condition deteriorated and complicated rhabdomyolysis and acute kidney dysfunction. Empiric treatment including doxycycline was initiated while waiting for the infection blood work results. PCR came back positive for HGA. Empiric therapy was narrowed down to doxycycline for 14 days, and the patient's condition began to improve gradually and steadily. Aggressive hydration markedly improved rhabdomyolysis and, in turn, kidney function. Our case underscores the importance of considering HGA in ambiguous clinical scenarios and highlights the value of early diagnosis, empiric treatment, and intravenous hydration, especially in the presence of rhabdomyolysis.

Human Granulocytic Anaplasmosis-A Systematic Review of Published Cases

Anaplasma phagocytophilum is an emerging, Gram-negative, obligate intracellular pathogen that is transmitted by a tick vector. Human infection ranges from asymptomatic to severe disease that can present with pancytopenia, multiorgan failure, and death. The aim of this systematic review is to analyze case reports and case series reported over the last two decades in peer-reviewed journals indexed in the Medline/PubMed database according to the PRISMA guidelines. We found 110 unique patients from 88 case reports and series. The most common mode of transmission was tick bite (60.9%), followed by blood transfusion (8.2%). Infection was acquired by blood transfusion in nearly half (42%) of the immunocompromised patients. Most patients reported fever (90%), followed by constitutional (59%) and gastrointestinal symptoms (56%). Rash was present in 17% of patients, much higher than in previous studies. Thrombocytopenia was the most common laboratory abnormality (76%) followed by elevated aspartate aminotransferase (AST) (46%). The diagnosis was most commonly established using whole-blood polymerase chain reaction (PCR) in 76% of patients. Coinfection rate was 9.1% and Borrelia burgdorferi was most commonly isolated in seven patients (6.4%). Doxycycline was used to treat 70% of patients but was only used as an empiric treatment in one-third of patients (33.6%). The overall mortality rate was 5.7%, and one patient died from trauma unrelated to HGA. The mortality rates among immunocompetent and immunocompromised patients were 4.2% (n = 4/95) and 18.2% (n = 2/11), respectively. Four of the six patients who died (66.6%) received appropriate antibiotic therapy. Among these, doxycycline was delayed by more than 48 h in two patients.

Human granulocytic anaplasmosis combined with rhabdomyolysis: a case report

BACKGROUND

Human granulocytic anaplasmosis (HGA) is a systemic inflammatory response caused by the rickettsial bacterium Anaplasma phagocytophilum. Rhabdomyolysis and acute kidney injury (AKI) are rare complications of HGA. Here, we report a case of HGA concurrent with rhabdomyolysis and AKI in an elderly patient.

CASE PRESENTATION

An 84-year old woman with a medical history of hypertension was hospitalised after two days of fever, dizziness, whole body pain, and general weakness. Laboratory investigations showed severe thrombocytopenia, leukopenia, impaired renal function, and elevated cardiac enzyme and myoglobin levels. On the day after admission, peripheral blood smear revealed morula inclusions in neutrophils, a suggestive finding of HGA. Real-time polymerase chain reaction (PCR) results indicated the presence of A. phagocytophilum. Antibiotics were de-escalated to doxycycline monotherapy. After 10 days of antibiotic treatment, laboratory tests showed complete recovery from HGA complicated with rhabdomyolysis and AKI.

CONCLUSIONS

HGA can lead to serious complications in patients with associated risk factors. Therefore, in patients with HGA accompanied by rhabdomyolysis, management with antibiotics and hydration should be initiated immediately, and not delayed until diagnostic confirmation.

Rhabdomyolysis: An Unusual Presentation of Mycoplasma pneumoniae Infection in an Adult-A Case Report and Literature Review

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia, and many extrapulmonary manifestations have been described, but rhabdomyolysis is infrequently reported in adults. Of the few cases that have been reported in adults, it was almost exclusively seen when pneumonia was present. We report a case of a 30-year-old male who came in with complaints of fever and myalgia for three days. Immunoglobulin M antibodies for Mycoplasma pneumoniae were positive and trending up, despite having no radiographic evidence of pneumonia on chest X-ray or CT scan. He was treated successfully with levofloxacin and intravenous hydration. Later, his condition was clinically and biochemically improved, and he was discharged. Our patient did not present with typical respiratory tract symptoms of a mycoplasma infection. In addition, there was an absence of pneumonia on imaging, suggesting that rhabdomyolysis secondary to mycoplasma might be underdiagnosed and go untreated in the setting of low clinical suspicion. Upon review of the literature, there is only one other case of mycoplasma infection where rhabdomyolysis occurred in the absence of pneumonia. However, the degree of rhabdomyolysis in our case was much more severe. Although rare, when faced with rhabdomyolysis, Mycoplasma pneumoniae should be kept as a differential diagnosis even in the absence of pneumonia on radiological imaging.

Severe Fever with Thrombocytopenia Syndrome Presenting with Rhabdomyolysis

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging febrile illness. While many kinds of severe complications including acute renal failure have been reported, rhabdomyolysis is rarely reported in association with SFTS. A 54-year-old female farmer was admitted with fever and diffuse myalgia. Laboratory finding showed thrombocytopenia, leukopenia, azotemia, extremely elevated muscle enzyme levels and myoglobinuria. We describe a fatal case of rhabdomyolysis with acute renal failure complicated by SFTS.

Ehrlichia chaffeensis presenting with bilateral anterior thigh pain (Louria's sign)

Bilateral anterior thigh pain may indicate bacteremia (Louria's Sign). We present a case of Ehrlichiosis due to Ehrlichia chaffeensis whose predominant presenting symptom was localized bilateral anterior thigh pain.