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Recurrent and prolonged fever in asplenic patients with human granulocytic ehrlichiosis.

Sir,

The ehrlichioses are emerging zoonotic infections transmitted by ticks and caused by obligate intracellular organisms of the genus Ehrlichia . Two forms of human infection have been distinguished: human monocytic ehrlichiosis (HME), caused by E. chaffeensis 1 and human granulocytic ehrlichiosis (HGE), caused by an organism shown to be phylogenetically similar to E. equi and E. phagocytophilia .2 The first report of human ehrlichiosis in the US was published in 1987.3 These increasingly recognized infections present a difficult diagnostic challenge as a result of their protean clinical manifestations and the absence of a reliable laboratory marker, especially in the acute stage of the disease.

Although HGE is most commonly considered in cases of brief, acute febrile illness, it can take an unusual clinical course, especially in cases of coinfection with other parasites, such as Babesia or Borrelia . The disease can also take a different course in asplenic patients. We describe two cases of HGE in asplenic patients who presented with unusual features including prolonged and/or recurrent fever, atypical neurological manifestations and leukocytosis. To our knowledge, this is the first report of HGE in asplenic individuals.

Patient 1, a 71‐year‐old White male was admitted for evaluation of fever of unknown origin associated with acute mental status changes. For 6 weeks prior to admission, he had been suffering from recurrent episodes of fever, anorexia, diarrhea, and mild diffuse abdominal pain. More recently, the patient had developed progressive unsteadiness of gait and confusion. Prior to admission he had undergone an extensive diagnostic evaluation including CT scans of the brain, abdomen, and pelvis, ultrasound of the abdomen, serial chest radiographs, cultures of blood and stool, and C. difficile toxin screening, all with negative results. Several courses of empiric treatment with ciprofloxacin, …