Hindawi Publishing Corporation Infectious Diseases in Obstetrics and Gynecology Volume 2008, Article ID 359172, 3 pages doi:10.1155/2008/359172 Case Report Human Granulocytic Ehrlichiosis Complicating Early Pregnancy Tyler Mufﬂy, T. Chad McCormick, Christopher Cook, and Jeffrey Wall Department of Obstetrics and Gynecology, University of Missouri at Kansas City, Kansas City, MO 64108, USA Correspondence should be addressed to Tyler Muﬄy, tylermuﬄy@hotmail.com Received 17 December 2007; Accepted 11 March 2008 Recommended by Sibai Baha Background. The goal of this case is to review the zoonotic infection, human granulocytic ehrlichiosis, presenting with pyrexia. Case. A 22-year-old multigravid female presented to the emergency department with a painful skin rash, high fever, and severe myalgias. The patient underwent a diagnostic evaluation for zoonotic infections due to her geographical and seasonal risk factors. Treatment of human granulocytic ehrlichiosis was successful though the patient spontaneously aborted presumably due to the severity of the acute illness. Conclusion. Treatment of human granulocytic ehrlichiosis in pregnancy presents unique challenges. Management of pyrexia during pregnancy is limited to external cooling in the setting of thrombocytopenia and elevated aminotransferases. Extensive counseling regarding teratogenic potential of medications allows the patient to weigh the pros and cons of treatment. Copyright © 2008 Tyler Muﬄy et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. INTRODUCTION The tick-borne illness, human granulocytic ehrlichiosis (HGE), is rare during pregnancy. A MEDLINE search from January 1966 through November 2007 using the key words “ehrlichiosis” and “pregnancy” found 21 English language articles. We comment on the therapeutic dilemmas of this unusual combination of hyperthermia and pregnancy that has not been previously described. 2. CASE A 22-year-old multigravid female at seven weeks gestational age presented to the emergency department at a rural referring hospital with symptoms of a rash for three days, vomiting, nonproductive cough, and complaining of “sore throat and burning skin.” The severe burning pain was constant and localized to the areas of the rash. Her prenatal care started at ﬁve weeks and was complicated by tobacco use and one episode of suspected streptococcal pharyngitis treated with penicillin six days prior. After evaluation at the referring emergency department, she was transferred to our facility via air medical service. On examination, the patient was found to be diaphoretic, febrile to 102.1 degrees Fahrenheit, and normotensive. Physical examination showed a diﬀuse maculopapular rash sparing the palms and soles. A bedside abdominal ultrasound study conﬁrmed fetal movement and a fetal heart rate of 160 beats per minute. Of note, she was leukopenic, throm- bocytopenic, and had elevated plasma aminotransferases to ten times normal values. Our suspicion was high for human granulocytic ehrlichiosis due to her presentation from rural Missouri, symptomatology, and classic laboratory ﬁndings of leukopenia, thrombocytopenia, and elevated amino- transferases. Thus, with her informed consent, empiric doxycycline treatment was administered. Over the next 24 hours, the patient became progressively more febrile spiking temperatures to 103.9 degrees Fahrenheit. Over hospital days two and three, her aminotransferases decreased, however she continued to have fevers and the patient remained ill-appearing. The patient’s symptoms of burning skin pain, myalgias, and malaise decreased slowly. On the third day of the hospitalization, she began having vaginal bleeding and passed tissue consistent with a seven- week gestation. Clinical examination and falling beta-HCG levels conﬁrmed a complete abortion. The painful skin rash improved but limited her range of movement. After nine days