A 32-year-old male is brought to the emergency room complaining of a severe headache, fever, aching muscles and joints. He says that he has not been able to get the energy to go into work for the last two days. He is somewhat impatient with the physician collecting information from him and threatens to leave without further evaluation or treatment. At one point he attempts to leave the examination room but collapses on his way out and had to be placed on a stretcher for further evaluation.
His physical examination was as follows. He had an elevated body temperature of 38℃. His respiratory rate was 21/minute; chest examination was normal/clear, and he did not have or report a cough. Blood pressure was 122/60 mm/Hg. Other than his presenting symptoms he appeared to be a healthy 32-year-old male with no significant past medical history.
His occupation was not one that would alert you to any predisposing factors. However, his occupation as a salesman for a deep sonar software company did expose him to various scenarios where infectious diseases could be contracted since his sales territory was worldwide. He had recently arrived from a two-week sales trip to Kampala/Uganda in Africa, and Manaus/Brazil, in South America to present the software and provide a short demonstration of its utility to prospective customers.
He participated in activities in both geographic areas that placed him in suspicion for possibly contracting any of a variety of tropical diseases. Both in Africa and South America he had taken part in excursions that took him in rural areas where he may have been exposed to vectors of various diseases and he did recollect having been bitten a number of times in both locations.
Shortly upon arriving at Manaus/Brazil he claims to have noticed several tender areas a around the neck that he described as swollen lymph nodes. Prior to arriving in Brazil he had also noticed that at the swolen lymph nodes area he had previously noticed two areas in which an insect had bitten him which resulted in in an itchy somewhat inflammatory reaction at the site. The swollen posterior lymph nodes (according to the patient) had shown a decrease in size but were still palpable and tender according to him. An examination of the posterior cervical area on the patient did indeed reveal two swollen lymph nodes that were distinctly palpable and tender to the touch.
Considering his clinical presentation and travel history, the patient was suspected of acquiring an infectious process during his travels. No one else in his family had his clincal symptoms and no one in the family had accompanied him during is travel.
Considering his agitated state, headache, and a positive Kernigs Sign, the patient had a lumbar puncture performed. He also had blood cultures drawn; a UA and Urine culture performed; a complete blood cells count; serum electrolytes; SGOT, C-reactive protein, and CPK. The CSF had a multiplex PCR test performed on it, and cell count, protein, glucose, and culture/gram stain. The patient was admitted for supportive care and observation to rule out meningitis or an acquired infectious tropical disease.
The results are as follows for the laboratory testing performed:
| Test Performed | Patient Result |
| CSF protein | 77mg/dL |
| CSF glucose | 46 mg/dL |
| CSF WBC | 590 (80% lymphocyte) |
| CSF Gram stain | NOS |
| Peripheral CBC White blood cell count Red blood cell count Hematocrit/hemoglobin Differential | WBC = 6.8 K/UL RBC = 28.4%/9.8 g/dL platelet count was slightly decreased at 120 K/UL |
| Serum electroytes | normal |
| C-reactive protein | < 0.3 mg/dL |
| SGOT / CPK | 30 U/L / 110 U/L |
| CSF Culture/Gram stain | No Growth after 3 days |
| Urine Culture/Gram stain | No Growth |
| Blood cultures | No Growth after 5 days |
| Urinalysis | Normal |
The complete blood cell count performed by the laboratory reported a significant finding in the analysis of the Wright’s stained peripheral smear. An Infectious Disease Physician was called for a consult. The image is shown below.
With the clinical presentation, history, test results, and image of the Wright’s stain can you identify the infection that this patient has?
Can you be specific of the probable organism considering the patient’s travel history and why? Genus – species – subspecies?
What is the prognosis of this patient with or without treatment?
What is the primary vector of transmission for this organism and what is the primary reservoir for it?