33: Low Platelets

A 62-year-old female with a history of sarcoidosis and hypertension presents to the ED for 4 days of fever, vomiting, malaise and generalized abdominal pain that is worst in the right upper quadrant.  Her vitals are normal except for a temperature of 102.1 F.  Her exam is otherwise normal except for generalized abdominal tenderness with guarding in the right upper quadrant, an enlarged spleen and a few petechiae on both shins.

An abdominal ultrasound shows a dilated gallbladder with a thickened wall and pericholecystic fluid, but no stones or sludge.  The spleen is also noted to be enlarged.  Her lab tests are notable for a sodium of 127, an AST of 441, an ALT of 288 and a platelet count of 14,000.  A blood smear is done due to the low platelets.

What diagnostic finding is shown in the smear below? What is the diagnosis? What is the treatment?

HINT: Patient was recently hiking in the Sierra Mountains of California

SCROLL DOWN FOR CASE ANSWER AND AREA TO MAKE COMMENTS

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Get Side-Kick: Emergency Medicine or Quick Essentials: Emergency Medicine

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Answer: Relapsing Fever

The smear shows normochromic RBC’s & decreased platelets. There is a spirochete in the right lower corner of the field with 12 loose coils consistent with Borrelia (5-12 loose coils).

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EXCERPT ON RELAPSING FEVER

from

QUICK ESSENTIALS EMERGENCY MEDICINE

General:  Western US mountains.  Borrelia recurrentis from rodent ticks.

Clinical: F/C, HA, Abdominal pain, V, arthralgias.  (Hepatosplenomegally, rash, CNS).
Sx last 3-10 days then resolve and 1-2 wks later recur (up to 3-10 times).

Lab: Spirochetes seen on CBC, LFT’s up, low Platelets, anemia.  RPR may be positive

Rx: TCN or erythro for 10d.  Aspirin or TNF-Ab may ameliorate Jarixch-Herxheimer reaction

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