2 of doxycycline the patient improved and was discharged to home in good condition. The rash cleared and the patient had no residual symptoms of disease. 3. COMMENT Human granulocytic ehrlichiosis is an underreported tick- borne illness. Ehrlichiosis should be included in the diﬀeren- tial diagnosis of any patient presenting with thrombocytope- nia, elevation of aminotransferases, painful skin rash, and high fevers. Our patient had no recollection of a tick or insect bite, but she lives in rural Missouri which is mostly wooded containing multiple forms of wildlife. Human granulocytic ehrlichiosis is endemic to Missouri with 0.01–11.9 cases per million persons yearly. Other disease processes with similar pyrogenic presentations include viral exanthems, Epstein-Barr virus, leptospirosis, Rocky Mountain spotted fever, cytomegalovirus, Lyme disease, and Q fever [1]. These illnesses that cause hyperthermia during pregnancy are of particular concern because immunosuppression may cause a more severe disease presentation. Zoonotic infections of pregnant women have been documented in the literature. Pregnant women outdoors during the spring and fall tend to wear less clothing which may increase their risk for zoonosis. Fever and rash in a pregnant patient are symptoms that should initiate a diﬀerential diagnosis including zoonotic infections. Rocky Mountain spotted fever presents in a speciﬁc geographic area with a fall and spring temporal distribution. The maculopapular rash in Rocky Mountain spotted fever is similar to that of other tick-borne illnesses. The main clinical factor that discriminates Rocky Mountain spotted fever from HGE is the lack of temperature above 102 degrees Fahrenheit. Leptospirosis has also been reported in pregnant women and is the most common zoonosis worldwide [2]. Conjunctival suﬀusion is pathognomonic for leptospirosis in a patient with nonspeciﬁc febrile illness and myalgias. Exposure to lake, river, and stream water contaminated with animal waste increases the risk of acquiring Leptospira interrogans [3]. Q fever is caused by inhalation of infected particles of animal feces. The disease can present with fever, rash, and ﬂu-like illness. Also, Q fever presentation tends to be age-speciﬁc, with younger patients developing hepatitis and the older population acquiring pneumonia. Coxiella burnetti infection should be considered in patients who have ﬁrst trimester obstetric complications and fever [4]. Lyme disease manifests with intermittent fevers and chills. The classic Lyme disease rash is an asymptomatic erythema migrans which presents as central clearing within an erythematous base. The list of potential parasitic zoonoses is quite large, however careful history and physical examination can lead to early detection [2]. In the pregnant patient, maternal hyperthermia greater than 103 degrees Fahrenheit denatures proteins causing cell death, membrane disruption, vascular disruption, and placental infarction during organogenesis. Treatment of infectious febrile illnesses during pregnancy can be accom- plished with pharmacologic and external cooling methods [5]. However, nonsteroidal anti-inﬂammatory agents, and Infectious Diseases in Obstetrics and Gynecology acetaminophen are relatively contraindicated antipyretics in a patient with thrombocytopenia and elevated aminotrans- ferases. Antipyretic agents work by lowering the hypothala- mic setpoint, which is increased during pyrexia [6]. Endoge- nous pyrogens, such as interleukin-1 and interleukin-6, cause febrile response by stimulating cerebral prostaglandin- E synthesis [7]. Antipyretic agents block this process by inhibiting the arachidonic acid cycle in the brain [8]. The result is a lowering of the hypothalamic setpoint, which activates the body’s two principle mechanisms for heat dissipation: vasodilation and sweating. External cooling methods attempt to maximize the amount of heat diﬀused by convection, conduction, and radiation. External cooling methods used to maintain normothermia include water-ﬂow blankets, ice packs to the axillae and groin, intravenous and oral hydration with cool ﬂuids, or immersion in a tepid bath. Shivering causes increased heat production and is a sign to halt cooling eﬀorts. Some diseases have a limited array of pharmacologic treatments and may potentially cause harm to the fetus. The view that doxycycline, to treat HGE, is relatively contraindicated in pregnancy due to its eﬀects on fetal teeth and bones is no longer accepted as a valid point of medical dogma. Doxycycline is no longer absolutely contraindicated in pregnancy [9]. Alternative treatment for ehrlichiosis during pregnancy includes rifampin in a limited number of patients. Microscopy of buﬀy coat smear, PCR, and cell culture are ideal methods to conﬁrm the diagnosis of HGE [10]. Wright’s stained buﬀy coat of peripheral blood will show morulae characteristics on histopathology. Elevated serum antibody titers to HGE can also eliminate rickettsial disease. We suspect that there is much more to be known about the eﬀects of ehrlichiosis on pregnancy. The case here, with abortion, hyperpyrexia, consumptive coagulopathy, and hepatic involvement, contradicts the recent observation that ehrlichosis was not particularly fulminant in pregnancy. The literature describes human granulocytic ehrlichiosis as a mild illness because of the immunosuppression during pregnancy [11]. The severity of the laboratory ﬁndings, clinical presentation, and gestational age make this case unique. ACKNOWLEDGMENTS We would like to thank Roger P. Smith, M.D. at the University of Missouri at Kansas City for his continued support. There was no ﬁnancial support given for this study. The authors received no writing assistance. This paper has not been presented in any meetings. REFERENCES [1] L. J. Demma, R. C. Holman, J. H. McQuiston, J. W. Krebs, and D. L. Swerdlow, “Epidemiology of human ehrlichiosis and anaplasmosis in the United States, 2001-2002,” American Journal of Tropical Medicine and Hygiene, vol. 73, no. 2, pp. 400–409, 2005. [2] A. C. Steere, A. Dhar, J. Hernandez, et al., “Systemic symptoms without erythema migrans as the presenting picture of early