The NEW ENGLAND JOURNAL of MEDICIN E CASE RECORDS of the MASSACHUSET GENERAL HOSPITAL Founded by Richard C.Cabot EricS.Rosenberg,M.D.,Editor Nancy Lee Harris, M.D.,Editor Jo-Anne O. Shepard, M.D., Associate Editor Alice M. Cort, M.D., Associate Editor Sally H. Ebeling, Assistant Editor Emily K. McDonald, Assistant Editor Case 24-2015: A 28-Year-Old Pregnant Woman with Fever, Chills, Headache, and Fatigue
Basic informantion of the case admission 5 day 3 day 2 day ay felt warm malaise and Braxton hicks came to the headaches contractions and outpatient 28 weeks of frequent fetal obstetrics clinic of gestation movement this hospital she took because of a diphenhydramine temperature of for sleep at night 37.4°C
5 day felt warm 3 day malaise and headaches 2 day Braxton Hicks contrac9ons and frequent fetal movement she took diphenhydramine for sleep at night 1 day came to the outpa9ent obstetrics clinic of this hospital because of a temperature of 37.4°C admission Basic informan-on of the case 28 weeks of gesta-on
Temperature variation The day before admission, she came to the hospital because of a 42 temperature of374℃ 9 On examination in hospital: T 367C, BP 103/ 66, P 72, the average 40 fetal heart rate was 125 beats pet 386388 minute On ultrasonography, the 38 fetus was normal and active 37.4 That evening, increased fatig 37.4 diffuse body aches, low back pain 36 363 and an earache occurred and the temperature rose to 38. C. the 34 patient go to a local emergency department for evaluation except platelet count of 125,000 per cubic millimeter the examination was eportedly negative included admission peripheral-blood smear. OVernight, the temperature rose to ◆ Later that day, the temperature rose to394℃388℃ and nausea developed. That evening, she On the morning of admission, the presented to the labor and delivery unit of this patient reported fever, with a current ospItal temperature of 37. 4
uLater that day, the temperature rose to 39.4 ℃ and nausea developed. That evening, she presented to the labor and delivery unit of this hospital. uThe day before admission, she came to the hospital because of a temperature of 37.4 ℃. u On examina9on in hospital:T 36.7℃, BP 103/66 , P 72, the average fetal heart rate was 125 beats per minute. On ultrasonography, the fetus was normal and ac9ve . uThat evening, increased fa9gue, diffuse body aches, low back pain, and an earache occurred, and the temperature rose to 38.6 ℃. the pa9ent go to a local emergency department for evalua9on, except platelet count of 125,000 per cubic millimeter, the examina9on was reportedly nega9ve included peripheral-blood smear. uOvernight, the temperature rose to 38.8 ℃. uOn the morning of admission, the pa9ent reported fever, with a current temperature of 37.4 ℃. A -1 (1 ) A -1 (2 ) A -1 (3 ) A (1 ) A (2 ) A (3 ) A (4 ) A (5 ) 3 4 3 6 3 8 4 0 4 2 Te mpr at u r e （ ℃ ） admission 37.4 36.7 38.6 38.8 37.4 39.4 38.9 36.3 Temperature varia-on
findings on admission Tablel. Laboratory Data. Reference rat On ade 4th Day QOn presentation, the patient variable Adults This Hospital This Hospital reported mild headache neck Hematocrit(%) 36.0-460(women) 304 stiffness, a left earache globin(g/dl) .2.0-16.0(women) intermittent contractions and a possible erythematous rash on her White-cell count (per mm 450110 right shin Differential count(%) ◆ On examination,T363°C,BP Neutrophils 40-70 900 620 110/ 64 mm Hg, p 98 beats per Lymphocytes 22-44 61 29 minute, and r 18 breaths per Monocytes 70 minute the fetal heart rate was Eosinophils 30 beats per minute, with Basophils 02 accelerations there was a faint area of lacy blanching erythema (4 Platelet count (per mmr) 150.0040000 8100 cm in diameteron the right shin Sodium(mmol liter) 135-145 Blood tests were almost normal 3.448 thick and thin giemsa-stained Chloride(mmol/liter) l00108 99 smears of peripheral blood were 230-319 negative for babesia asma anion 12
uOn presenta9on, the pa9ent reported mild headache, neck s9ffness, a leS earache, intermiTent contrac9ons, and a possible erythematous rash on her right shin uOn examina9on, T36.3°C, BP 110/64 mm Hg, P 98 beats per minute, and R 18 breaths per minute. the fetal heart rate was 130 beats per minute, with accelera9ons. There was a faint area of lacy, blanching erythema (4 cm in diameter)on the right shin. uBlood tests were almost normal, thick and thin Giemsa-stained smears of peripheral blood were nega9ve for babesia findings on admission
Other informantion She was gravida 3 had had two previous spontaneous miscarriages She reported contact with an indoor cat at home and with outdoor cats and dogs at the home of relatives she knew of bats in the vicinity of her home and mice in the basement of her coastal vacation residence She traveled to a coastal area in massachusetts weekly She was allergic to cephalexin and TMP SMZ, which caused a rash and to multiple fruits and vegetables, which caused anaphylaxis
uShe was gravida 3, had had two previous spontaneous miscarriages uShe reported contact with an indoor cat at home and with outdoor cats and dogs at the home of rela9ves; she knew of bats in the vicinity of her home and mice in the basement of her coastal vaca9on residence uShe traveled to a coastal area in MassachuseTs weekly uShe was allergic to cephalexin and TMP SMZ, which caused a rash and to mul9ple fruits and vegetables, which caused anaphylaxis Other informan-on
Inpatient Period first day > During the next 4.5 hours the temperature rose to 38.9%C Ceftriaxone and rifampin were administered >results of testing for hepatitis a and b viruses were Next suggestive of protective immunity and results of testing three for Epstein-Barr virus were suggestive of past infection ay testing was negative for cytomegalovirus nucleic acids Hiv, heterophile antibodies and IgM and lgG antibodies to borrelia burgdorferi, Coxiella burneti ehrlichia, and anaplasma >The patient became afebrile within 48 hours and her headache resolved on the fourth hospital day Fifth day >a diagnostic test result was received Anaplasmosis or Borrelia miyamoto infection(伯氏疏螺旋体
ØDuring the next 4.5 hours, the temperature rose to 38.9°C. CeSriaxone and rifampin were administered. First day Next three day FiSh day ØThe pa9ent became afebrile within 48 hours and her headache resolved on the fourth hospital day. Øresults of tes9ng for hepa99s A and B viruses were sugges9ve of protec9ve immunity, and results of tes9ng for Epstein–Barr virus were sugges9ve of past infec9on; tes9ng was nega9ve for cytomegalovirus nucleic acids, HIV, heterophile an9bodies, and IgM and IgG an9bodies to Borrelia burgdorferi, Coxiella burne-i, ehrlichia, and anaplasma. Øa diagnos9c test result was received. Anaplasmosis or Borrelia miyamotoi infec/on（伯氏疏螺旋体） Inpa-ent Period
Conclusion Borrelia miyamoto, a spirochete that is discovered in Japan in 1995, belongs to the relapsing fever group of borrelia It was first identified as a human pathogen in 2011, which is now recognized as the fifth agent of human disease to be transmitted by the ixodes scapularis(肩突硬蜱) tick in the northeastern United states Diagnoses: Exposure: outdoor activities or contact with pets and mice cErtain features: including headache rash, thrombocytopenia, and hepatitis ◆ Laboratory data Blood RT: the platelet decreased earlier and neutrophils Lymphocytes changed Real-time PCr testing: targeting the 23S ribosomal rna gene of borrelia species was positiv ELISA: initially negative for igM and lgg antibodies to the glpQ antigen of B. miyamoto. 1 week later, ELISA was positive for the igM antibodies but negative for the IgG antibodies findings that are consistent with recent b. miyamoto infection
Borrelia miyamotoi, a spirochete that is discovered in Japan in 1995, belongs to the relapsing fever group of Borrelia .It was first iden9fied as a human pathogen in 2011, which is now recognized as the fiSh agent of human disease to be transmiTed by the Ixodes scapularis （肩突硬蜱）9ck in the northeastern United States. Diagnoses: uExposure: outdoor ac9vi9es or contact with pets and mice uCertain features: including headache, rash, thrombocytopenia, and hepa99s uLaboratory Data Blood RT: the platelet decreased earlier and neutrophils 、Lymphocytes changed Real-9me PCR tes9ng: targe9ng the 23S ribosomal RNA gene of borrelia species was posi9ve ELISA: ini9ally nega9ve for IgM and IgG an9bodies to the glpQ an9gen of B.miyamotoi. 1 week later, ELISA was posi9ve for the IgM an9bodies but nega9ve for the IgG an9bodies, findings that are consistent with recent B. miyamotoi infec9on. Conclusion
Therapeutic schedule The patient had marked improvement during the first 24 hours of receiving antibiotic therapy The high probability of anaplasmosis led us to recommend an empirical 7 day course of oral rifampin The ideal treatment for B. miyamoto infection and the risk of transplacental fetal infection are unknown We elected to treat the patient with intravenous ceftriaxone for 4 weeks Prognosis of the case C Labor was induced at 37 weeks of gestation and the patient had a vaginal delivery of a boy with normal Apgar scores C At his 1-month and 4-month checkups the infant and his mother were noted to be doing well
Therapeu-c schedule uThe pa9ent had marked improvement during the first 24 hours of receiving an-bio-c therapy uThe high probability of anaplasmosis led us to recommend an empirical 7- day course of oral rifampin uThe ideal treatment for B. miyamotoi infec-on and the risk of transplacental fetal infec9on are unknown. We elected to treat the pa9ent with intravenous ceKriaxone for 4 weeks. Prognosis of the case uLabor was induced at 37 weeks of gesta9on, and the pa9ent had a vaginal delivery of a boy with normal Apgar scores. uAt his 1-month and 4-month checkups, the infant and his mother were noted to be doing well
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