Abstract 18602: A Rare Case of Ehrlichiosis Induced Myocarditis

Abstract

Description of Case: A 64-year-old female presented with progressively worsening shortness of breath, headaches, weakness, intermittent confusion, and persistent fevers. Laboratory work-up revealed leukopenia, thrombocytopenia, elevated transaminases, negative viral panel, and elevated CRP. Chest CT revealed ground glass opacities and bilateral interlobular thickening. TTE obtained was normal. She was started on empiric meningitis treatment. She was transferred to the ICU after becoming more hypoxic and hypotensive. Further history revealed recent tick exposure while visiting the eastern North Carolina woods. Doxycycline was started for suspected tick-borne disease on day 2 of her ICU stay. LP was non-revealing. Her course was complicated by development of inferolateral ST segment elevation on EKG. Initial troponin I level was 155.66 ng/mL peaking at 209.24 ng/mL (reference range <= 0.03 ng/mL). Cardiac catheterization revealed no epicardial coronary disease. Repeat TTE showed a decreased LVEF at 25-30% and global hypokinesis. Cardiac MRI revealed evidence of an inflammatory myocardial process, myocardial edema and epicardial fibrosis. The patient had a positive Erhlichia chaffensis IgG antibody titer and Ehrlichia chaffensis DNA polymerase chain reaction was positive. She demonstrated improvement with continuation of doxycycline. Heart failure guideline directed medical therapy was initiated prior to her discharge. Discussion: Ehrlichia infections occur primarily in areas of south and central United States. Transient flu-like symptoms are the most typical manifestations, but more severe complications can occur such as meningoencephalitis, respiratory failure, coagulopathy, myocarditis and death. There are only a few documented cases of myocarditis due to Ehrlichia infections. If not recognized early, myocarditis can be a serious and fatal complication of ehrlichiosis, even in immunocompetent patients. A high level of suspicion for this should be kept in the differential for patients with cardiac manifestations presenting from endemic areas, especially during warmer seasons. Doxycycline therapy should be started promptly for clinical suspicion of Ehrlichia infection.