Our case represents the first association of progressive hepatosplenomegaly with systemic monocytic ehrlichiosis. It is possible that our patient's previous exposure to Lyme disease may account for the delayed onset of symptoms, though the exposure also may have been at a date later than the reported tick bite, since tick exposure was a frequent occurrence on his farm. Other symptoms occurring in half or more of patients at some time during the illness included myalgia, rigor, arthralgia, nausea, diaphoresis, and anorexia. Pharyngitis, vomiting, cough, abdominal pain, diarrhea, rash, lymphadenopathy, and confusion were seen much less frequently, often later in the course of illness. It is well known that cholestasis, as well as transaminase elevations, can occur in the presence of endotoxemia, septicemia, severe infection, and toxic shock, due to an impairment of bile secretion, transport, and regulation.
Persistent jaundice is associated with a poor outcome, reflecting the underlying disease process.
Pancytopenia with ehrlichiosis is primarily due to sequestration, consumption, or destruction peripherally.17 Cases reviewed by Dumler et al17 showed marked monocyte phagocytic system proliferation and activation in the liver, spleen, lymph nodes, and bone marrow, which may help explain the unique clinical picture in our patient. Unfortunately, immunocompetence of the host may also result in detrimental responses associated with similar infective syndromes, such as death from thrombocytopenia or DIC-associated hemorrhage. Diagnosis of ehrlichiosis requires a high index of suspicion. History, physical examination, and laboratory findings should help in making a provisional diagnosis. A polymerase chain reaction test is under investigation and should allow rapid diagnosis in the future.26 Tetracyclines are the antibiotics of choice for treatment of ehrlichiosis.