Images in Clinical Medicine
Borreliosis
N Engl J Med 1998; 338:231January 22, 1998
- Article
Figure 1 A throbbing headache, diffuse abdominal pain, fever (temperature, 40°C [104°F]), hepatosplenomegaly, and pancytopenia (white-cell count, 3800 per cubic millimeter; hematocrit, 31 percent; and platelet count, 78,000 per cubic millimeter) developed in a 34-year-old woman several days after she had cleared rats' nests from underneath her country home. Wright's staining of her peripheral-blood smear under blue-filter microscopy showed multiple spirochetes (Panel A, ×40). Staining with acridine orange (which stains bacterial and fungal RNA and single-stranded DNA bright orange and human tissue apple green) highlighted the spirochete in the blood smear (Panel B). Because of the patient's history, it was assumed that she was infected by a tick-borne vector (most commonly Ornithodoros turicatae in San Antonio, Tex.). She was treated with intravenous doxycycline and, after receiving the first dose, had worsening rigors and an acute drop in blood pressure. The infusion of more than 7 liters of crystalloid was required during the next 24 hours to maintain adequate blood pressure. By the second hospital day the patient was afebrile. Pancytopenia and hepatosplenomegaly improved several days later, and she was discharged on the sixth hospital day while taking oral doxycycline. Her response to the initiation of antimicrobial therapy was considered to be a typical Jarisch–Herxheimer reaction.
Randy I. Cooper, M.D., Capt., M.C., U.S.A.F.
Thomas Neuhauser, M.D., Capt., M.C., U.S.A.F.
Wilford Hall Medical Center, San Antonio, TX 72836
