nausea, vomiting, fever, and a fall

67F with T2DM (well-controlled w/o insulin), hypoTh, asthma, presented after 3d n/v, with lightheadedness, weakness, low-grade fever, and a fall.

Denies hitting head.

At baseline previously.

100.3F at home. No sick contacts. Non-productive cough, also x3d.

No new meds. No known inciting events.

Woke up and called a friend (not found down).

OSH - hypotensive, given zosyn and 2L LR

SHx

• 2-4 beers/day

PMHx

• T2DM
• asthma
• depression
• osteoporosis

Meds

• metformin
• synthroid
• lexapro
• inhalers
• fosamax

VS

Hypotensive, tachypnea On pressors

PE

tachycardic, tachypneic, fairly warm, AOxSelf, still following commands

Data

• WBC 2.4, Hgb 10.7, Plt 28
• COVID -ve
• Bicarb 12, Cr 1.7
• Bili 2.8, D bili 2.3
• ALK/AST/ALT elevated
• 7.3/33
• LA 4.5

… went to huddle, missed a bunch…

Dx

Ehrlichiosis! Tx w doxy.

Time to diagnosis is delayed in pts who require ICU admission (Kuriakose 2020, JAMA Network Open, e202577)

Pearls

For RMSF, no need to send w/u unless clear geographic exposure.

Send Ehrlichia/anaplasmosis PCR, smear, consider babesia.

Lyme: should have travelled north of the Mason-Dixon line, not endemic to TN.