View Abstract

A5195 - Atypical Presentation of a Wartime Illness
Author Block: C. McCormick1, H. Mehta2, S. Shahzad3; 1Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States, 2PCCM, NewYork-Presbysterian Brooklyn Methodist Hospital, Brooklyn, NY, United States, 3PCCM, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States.
Introduction
Bartonella quintana, historically known as trench fever, is a facultative intracellular gram-negative rod bacterium transmitted by the human body louse Pediculus humanus. The first recognized clinical manifestation was during the epidemic of trench fever in World War I. It was characterized by an acute fever, often quintian, headache, and leg pain. The reemergence of the illness appeared in HIV and homeless populations as bacillary angiomatosis, chronic bacteremia, and endocarditis. In the following case, we are presented with an atypical presentation of Bartonella quintana with severe sepsis, thrombocytopenia, and transaminitis.
Case Report
A 37-year-old male with no significant past medical history presented with high-grade fever, weakness, and lethargy for five days. Two weeks prior he was in Berkshire county engaging in outdoor activities. On exam, he appeared toxic and diaphoretic with tachycardia. The patient was admitted to the intensive care unit for severe sepsis with the involvement of multiple organs. Initial workup demonstrated severe thrombocytopenia, leukopenia, acute renal failure, hyponatremia, and transaminitis. Imaging and peripheral blood smears were unremarkable. The patient was started on doxycycline for presumed tick-borne illness. Further studies were negative for tick-borne diseases, sexually transmitted diseases, and viral diseases. Bartonella quintana IgM was the only titer which returned positive. Patient’s clinical status and labs improved over six days with resolution of thrombocytopenia and improvement in transaminitis. The patient was discharged on doxycycline to complete a course of ten days.
Discussion
The clinical presentation of Bartonella quintana varies from classical trench fever to the lesser known modern infections which appeared with a reemergence of the disease in HIV and homeless populations. To this date, there have been no case reports of Bartonella quintana causing severe sepsis with multiorgan failure. Our patient is immunocompetent without risk factors and presented with active Bartonella quintana as proven by serology with thrombocytopenia and transaminitis. Transaminitis has never been reported in this infection or to occur with thrombocytopenia. The history was suspicious for tick-borne disease such as Anaplasmosis, but serology was negative for it and other suspected infections. This case demonstrates the emergence of another variable presentation of the disease as it continues to be studied. Our patient showed improvement with doxycycline and supportive care although definitive therapy is unknown due to limited data on disease treatment.