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Blood film findings in anaplasmosis

A 62-year-old female with a past medical history of hypertension, presented with complaints of fever, headaches, muscle aches, abdominal pain and weakness. She quickly decompensated and developed ventilator-dependent respiratory failure. A further history from the family revealed that she lived in a heavily wooded area in Pennsylvania, USA, and had removed ticks from her body approximately 1 week before presentation. During hospitalization, the patient was persistently febrile. She developed acute kidney injury, requiring temporary haemodialysis. She also had moderately increased liver transaminases, thrombocytopenia and a slightly elevated white blood count. Peripheral blood films showed granulocytes with intracytoplasmic basophilic inclusions and intracytoplasmic morulae (images), suggestive of anaplasma or ehrlichia. A polymerase chain reaction (PCR) analysis was positive for Anaplasma phagocytophilum and negative for Ehrlichia chaffeensis. The patient was treated with a 21-day course of doxycycline. Her kidney function, thrombocytopenia and elevated liver enzymes had returned to normal by the time of discharge. Tick-borne anaplasmosis is caused by a small obligate intracellular bacterium, A. phagocytophilum. Morulae may be observed in white blood cells in peripheral blood films. Although these intracytoplasmic bodies are not frequently seen, and should not be required for diagnosis, their presence is highly specific if detected by an experienced microscopist.