Rhabdomyolysis and Acute Renal Failure Associated With Human Granulocytic Anaplasmosis

Abstract

To the Editor: Rhabdomyolysis and renal failure have rarely been reported in patients with human granulocytic anaplasmosis (HGA) (formerly called ehrlichiosis). We report an unusual case in which a patient with HGA presented with severe myositis, rhabdomyolysis, and acute renal failure. Report of a Case. A 69-year-old woman was admitted to the hospital with a 3-day history of high fever with chills, general fatigue, and diarrhea followed by generalized arthralgia, profound thigh pain, and dark-colored urine. She lived alone in a wooded suburb in the northeastern United States and recalled removing numerous ticks from her body in the preceding month. The patient's temperature was 39.5°C, pulse rate was 110/min, and initial blood pressure was 100/60 mm Hg. She was exquisitely tender on both thighs and was unable to bear weight or transfer from the lying to the sitting position without assistance. The conjunctivas were clear, and no rash or petechiae was noted. Results from examination of all her other systems were within normal limits. Initial blood studies showed mild anemia, severe thrombocytopenia, leukopenia, elevated hepatic transaminase levels, and an elevated creatinine value (Table 1). A peripheral blood smear showed the presence of typical morulae in the neutrophils. Negative serologic titers were obtained for Lyme disease, West Nile virus, and Babesia microti. Blood and urine cultures yielded no growth. Renal ultrasound revealed normal-sized kidneys with normal renal cortical echogenicity and no hydronephrosis. Imaging studies excluded any pelvic, hip, or femur fractures.TABLE 1Selected Laboratory Data From a Patient With HGA*ALT = alanine aminotransferase; AST = aspartate aminotransferase; HGA = human granulocytic anaplasmosis; ND = not done.VariableDay 1Day 2Day 5White blood cell count (× 109/L)4.63.39.1Hematocrit (%)1.026.230.8Platelet count (× 109/L)382992Serum urea nitrogen (mg/dL)708566Creatinine (mg/dL)4.05.23.0Creatine kinase (U/L)15,03913,276733Creatine kinase-MB fraction (U/L)11871NDAST (U/L)520457149ALT (U/L)153137126* ALT = alanine aminotransferase; AST = aspartate aminotransferase; HGA = human granulocytic anaplasmosis; ND = not done. Open table in a new tab The patient was hydrated with normal saline, and intravenous doxycycline was administered. Defervescence occurred within 24 hours. Her laboratory abnormalities slowly improved (Table 1), and she was discharged to a rehabilitation facility on the 5th day of hospitalization. Three months later, her primary care physician reported complete normalization of her renal function and resumption of her active life. Discussion. This case is unusual because of the prominence of the myositis, the presence of rhabdomyolysis, and the severity of the renal dysfunction. Rhabdomyolysis and acute renal failure have rarely been reported in patients with HGA.1Heller HM Telford III, SR Branda JA Case records of the Massachusetts General Hospital: a 73-year old man with weakness and pain in the legs.N Engl J Med. 2005; 352 (Case 10-2005.): 1358-1364Crossref PubMed Scopus (10) Google Scholar, 2Javed MZ Srivastava M Zhang S Kandathil M Concurrent babesiosis and ehrlichiosis in an elderly host.Mayo Clin Proc. 2001; 76: 563-565Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar No cases of renal failure were noted in a review of 546 confirmed cases of anaplasmosis from the Connecticut surveillance data from 1995 through 2005.3Ertel S Esponda B Nelson R Human granulocytic anaplasmosis (HGA) — Connecticut, 2005.Conn Epidemiologist. September 2006; 26: 15-16Google Scholar Given the potential for severe and fatal disease, a therapeutic trial is indicated once the disease is suspected. As our case illustrates, early institution of appropriate therapy can lead to rapid resolution of symptoms. Tetracycline remains the drug of choice. Currently, no clear therapeutic alternatives are available. On the basis of in vitro studies, levofloxacin activity is only marginal.