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A 65-year-old female with a history of multiple tick bites presented with fever and pancytopenia. Intracytoplasmic rickettsial morulae were detected on peripheral smear and bone marrow biopsy specimens, and PCR amplified Ehrlichia ewingii DNA from both specimens. To our knowledge, this is the first report of E. ewingii infection of human bone marrow. CASE REPORTA 65-year-old female from rural north-central Arkansas presented in July to an emergency department with weakness and fatigue. She had a 5-day history of subjective fever, productive cough, generalized myalgia, and progressive fatigue. She denied nausea, diarrhea, bleeding, and rash but stated that she had had a urinary tract infection (UTI) 1 month prior that had been treated with sulfamethoxazole-trimethoprim without resolution. She reported multiple recent tick bites while working in her yard and was in close contact with several pet dogs.Past medical history was significant for type 2 diabetes mellitus, hypertension, hypothyroidism, and laryngeal squamous carcinoma that had been in remission since treatment with chemotherapy and radiation 2 years prior to presentation. The physical examination was significant for fever of 101.3°F and bilateral upper extremity petechiae and bruising.Initial laboratory studies revealed a white blood count (WBC) of 2,000/l (reference range, 3,000 to 12,000/l), a hemoglobin level of 8.9 g/dl (reference range, 11.5 to 16 g/dl), and a platelet count of 32,000/l (reference range, 150,000 to 500,000/l). Each of these values had been within normal limits during an evaluation for her UTI that had been performed 3 weeks earlier. The total bilirubin level was 1.3 mg/dl (reference range, 0.2 to 1.2 mg/dl), and the lactate dehydrogenase level was 314 IU/liter (reference range, 100 to 248 IU/liter). Iron studies showed a decreased total iron binding capacity of 234 g/dl (reference range, 250 to 425 g/dl) and an increased peripheral blood ferritin level of 732 g/dl (reference range, 11 to 306 g/dl) with normal iron and folate levels. The antinuclear antibody (ANA) titer was increased at 1:160. Random-inpatient blood glucose levels ranged from 102 to 111 mg/dl, and her diabetes was adequately controlled with metformin and glipizide by her treatment as an outpatient. HIV serology results were negative.The patient was admitted to the hospital and was started on vancomycin and cefepime because of fever and neutropenia and was started on doxycycline to address the potential for tick-borne illness. Since recurrent malignancy, myelodysplastic syndrome following chemotherapy, and other marrow processes were in the differential diagnosis for her pancytopenia, peripheral smear and bone marrow aspirate and core biopsy procedures were performed. Review of the peripheral blood smear revealed leukopenia with neutrophilic bands containing intracytoplasmic morulae (Fig. 1), pancytopenia with leftshifted granulopoiesis, reactive lymphocytes, a relative monocytosis, thrombocytopenia, and mild erythrocyte anisopoikilocytosis. The marrow aspirate showed...

Persons coinfected with tuberculosis (TB) and HIV are at high risk of death, in part due to suboptimal utilization of HIV-specific health care. We sought to better understand HIV-associated health care utilization and mortality in a retrospective cohort of TB=HIV coinfected cases reported in North Carolina 1993. In this cohort, HIV was newly diagnosed during TB presentation for 34.2% of coinfected patients. Patients had advanced HIV (median CD4 104 cells=mm 3 ) at TB diagnosis. Of 260 patients previously known to be HIV positive, 32.3% had seen a physician for HIV care in the previous 6 months and only 18.5% were taking antiretrovirals when TB was diagnosed; 34.8% of patients started antiretrovirals during TB treatment. Twenty-seven (5%) patients died prior to starting TB treatment; of those who survived, 13.6% (70=515) died prior to completing TB treatment, and 42.7% (220=515) died during a median 1408 days of follow-up. CD4 count (relative risk [RR] 0.53 per 100 cell increase, 95% confidence interval [CI] 0.34, 1.02) and highly active antiretroviral therapy (HAART) use during TB therapy (RR 0.37, 95% CI 0.13, 1.02) were independently associated with decreased mortality, while age greater than 45 (RR 2.18, 95% CI 1.11, 4.29) was independently associated with increased mortality during TB treatment. We conclude that TB=HIV coinfected patients had low utilization rates of HIV-specific care prior to TB diagnosis. Many did not receive potentially lifesaving HIV treatment while on TB therapy, and mortality was high as a result. Interventions to enhance utilization of HIV-related health care and integration of TB and HIV services should be studied to improve outcomes.

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