Case 1. 60 year old man with acute onset fever, confusion, renal failure, progressive pancytopenia, respiratory distress, and septic shock secondary to Heartland virus infection.
(Picture taken from: http://upload.wikimedia.org/wikipedia/commons/2/29/Amblyomma_americanum_tick.jpg)
1. Heartland virus is a newly discovered phlebovirus (family Bunyaviridae) first described in 2009 in a farmer from northwestern Missouri who presented with fever, thrombocytopenia, and leucopenia. It is also transmitted by the Lone Star tick (Amblyomma americanum), the main vector of ehrlichiosis, tularemia, and Southern Tick Associated Rash Illness (STARI).
2. A patient who presents with fever, leucopenia, thrombocytopenia, and transaminitis but has repeatedly negative tests for Ehrlichia should be tested for Heartland virus infection (contact Dr. George Turabelidze at george.turabelidze@health.mo.gov of the Missouri Health Department). Heartland virus is diagnosed by a positive Heartland virus RNA or a fourfold rise of antibody titers between acute and convalescent samples.
3. The Heartland virus will not respond to doxycycline. No therapy is available.
4. Heartland virus infection can be lethal. Our case represents the 3rd mortality in the US (first mortality was from Tennessee, second mortality was from Oklahoma).
5. Heartland virus closely resembles the severe fever with thrombocytopenia syndrome virus recently described from China in 2007.
Case 2: A 15 year old male with acute abdominal pain, fever, and hypotension secondary to Campylobacter jejuni infection
1.This patient eventually developed diarrhea during his hospital stay. Patients with fever and diarrhea should always have a stool culture to rule out invasive bacterial infection secondary to Salmonella, Shigella, and Campylobacter. Other causes of fever and diarrhea include rotavirus, norovirus and Clostridium difficile infection.
2. Campylobacter infection can be associated with reactive arthritis (3% of cases), Guillain-Barre syndrome (<1% of cases), and bacteremia (<1% of cases). Reactive arthritis and Guillain-Barre syndrome usually manifest 1-2 weeks (occasionally several weeks) after onset of diarrhea.
Case 3. This is a management case.
Patient with acute myelogenous leukemia who presents with multi-drug resistant Enterococcus infection (vancomycin resistant, susceptible only to linezolid and daptomycin), Candida glabrata (susceptible only to fluctosine, no susceptibility break point for amphotericin), and Stenotrophomonas maltophilia (susceptible only to minocycline).
1. Patient was treated with minocyline, amphotericin, and linezolid. Amphotericin-resistant Candida is exceedingly rare (except for Candida lusitaniae).
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