On March 3, 2017, a 35-year-old man who was homeless (resident in Mexico City for 4 years) was admitted to the Emergency Department in the General Hospital of Xoco of the Ministry of Health of Mexico City because of trauma after a fall of 6 m from a bridge as a result of a suicide attempt. At admission, no lesions were detected in internal organs; a transtrochanteric fracture of the left femoral head was surgically repaired without complications. However, the patient had profuse bleeding during the surgical procedure, for which it was necessary to provide multiple blood transfusions. The blood units came from resident donors of Mexico City and the neighboring state of Mexico. In the postoperative period, the patient remained hospitalized for 65 days, during which behavioral alterations with several psychotic periods developed. He also had febrile episodes that evolved to a torpid state.

Routine laboratory analyses (blood count, blood chemistry, and serologic studies for infectious diseases) were performed. Because the patient was homeless and had persistent febrile episodes and dysfunction of the coagulation system, a possible infection by a rickettsial agent or Bartonella spp. was suspected because Bartonella quintana has been detected previously in human lice from persons who were homeless in Mexico City (6). For this reason 5 mL of whole blood was obtained, stored in EDTA, and processed for DNA extraction by using the QIAamp DNA Mini Kit (QIAGEN, https://www.qiagen.com) according to the manufacturer’s instructions. Blood was then examined for Bartonella, Ehrlichia/Anaplasma, and Rickettsia spp. by amplifying fragments of the gltA, rrs, and sca5, genes and using primers and PCR conditions specified (7–9). Positive controls (E. canis [GenBank accession no. MG917715], B. vinsonii [KT326174], and Rickettsia amblyommatis [KX363842) DNA]) were also included.

On April 27, 2017, antibodies against Proteus OX-19 at a titer of 1:320, leukocytosis, thrombocytosis, lymphopenia, anemia, hypoalbuminemia, and coagulation and liver enzyme alterations were reported (Table). The patient was given a diagnosis of septic shock and urosepsis and died on day 63 of hospitalization.

During hospitalization, leukocytosis developed, which might have been associated with the multiple traumas. The patient initially had a platelet count within the reference range, but thrombocytosis developed, and the platelet count increased to 850,000/μL. However, with persistent leukocytosis, the platelet count dropped, and thrombocytopenia (108,000/μL) developed shortly before death.

Total serum protein and albumin concentrations at admission were within reference ranges, but during hospitalization they decreased, as would be expected for a diagnosis of ehrlichiosis. Alterations in liver enzyme levels and coagulation times also developed. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase also increased after admission; ALT showed the largest increase. The level of γ-glutamyl transpeptidase increased by >10 times over its reference value (Table). The increase in the level of ALT could be related to hepatic alterations linked to ehrlichiosis.

Necropsy showed hepatosplenomegaly and pleural effusions. Molecular assays did not detect Bartonella or Rickettsia spp., but they did detect Ehrlichia/Anaplasma spp. when primers Ehr1/Ehr2 were used. We isolated a 400-bp fragment of the 16S rRNA gene, which showed 99% identity with that of the E. chaffensis strain Arkansas. In addition, a 500-bp fragment of the dsb gene (present only in the members of the genus Ehrlichia) was amplified (10) and showed 100% identity with the sequence of E. chaffensis strain Arkansas.

Figure

Figure. Maximum-likelihood phylogenetic tree for Ehrlichia chaffensisfrom a patient with human monocytic ehrlichiosis, Mexico City, Mexico (blue diamond), and reference sequences. The tree was generated by using concatenated fragments...

Phylogenetic analysis of the isolated sequences grouped them with sequences of 2 strains of E. chaffensis (strain Arkansas and West Paces) detected in the United States; these sequences had a bootstrap value of 99. The sequences we obtained were deposited in GenBank under accession numbers MK351589 and MK370999 (Figure).

Ehrlichioses represent systemic infections that can cause damage to different organs and systems, affecting the liver, meninges, brain, heart, and lungs. Because the pathophysiology of this disease is not well established, the findings obtained by necropsy are useful. During his hospitalization, the patient acquired some bacterial infections, which could explain the paradox that he initially had thrombocytosis and leukocytosis instead of thrombocytopenia and leukopenia, as would be expected for ehrlichiosis. Leukopenia and thrombocytopenia are present in >50% of patients given a diagnosis of E. chaffeensis infection (5).

The patient might have been infected by blood transfusion because the long period between hospital admission and detection of thrombocytopenia is compatible with the incubation period for infection with E. chaffeensis. The patient received multiple blood transfusions from donors in Mexico City and the state of Mexico; in this state, a fatal case of ehrlichiosis caused by blood transfusion has been reported (5). A study in Costa Rica reported a large number of E. canis–infected healthy blood donors (11), and a study in the United States reported a patient who was infected by blood transfusion containing E. ewingii (12). More recently, a potential case of transfusion-transmitted human monocytic ehrlichiosis was reported in a 59-year-old woman in the United States after she received a blood stem cell transplant (13).

Although this possibility is less likely, it cannot be ruled out that ehrlichiosis could be acquired by tick bite. E. chaffeensis was previously detected in 3 hard tick species (Amblyomma americanum, A. mixtum, and Rhipicephalus sanguineus sensu 1ato) (14) in Mexico. Only the lone star tick (A. americanum) has been implicated as a primary vector of this pathogen in the United States; however, its presence in Mexico has only been recorded restricted to the Nearctic region (15). Conversely, no studies demonstrate the role of the other 2 tick species as potential vectors of this pathogen or whether DNA of this pathogen came from an infected host from which these ticks fed.

For this reason, it is essential to perform systematic surveillance of this and other tick-borne pathogens in blood donors in Mexico. Studies should also be conducted with questing ticks to identify the risk to which the population is exposed and establish the actual distribution of the pathogen.