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Received: 30 January 2016    Revised: 11 May 2016    Revised: 29 June 2016    Accepted: 18 September 2016

DOI: 10.1111/tid.12652

S H O R T C O M M U N I C AT I O N

Early diagnosis of Ehrlichia ewingii infection in a lung transplant

recipient by peripheral blood smear

Hariharan Regunath1,2 | Christian Rojas-Moreno2 | Juan P. Olano3 | 

Richard D. Hammer4 | William Salzer2

1
Division of Pulmonary and Critical Care,
Department of Medicine, University of Abstract
Missouri, Columbia, MO, USA Ehrlichiosis in lung transplant (LT) recipients is associated with severe outcomes.
2
Division of Infectious Diseases, Department
Ehrlichia ewingii is a less frequent cause of symptomatic ehrlichiosis, characterized by
of Medicine, University of Missouri, Columbia,
MO, USA cytoplasmic inclusions (morulae) within circulating neutrophils. We report a case of
3
Department of Pathology, Member, Center E. ewingii infection in an LT recipient diagnosed promptly by blood smear exam and
for Biodefense and Emerging Infectious
confirmed with molecular studies.
Diseases, University of Texas Medical Branch,
Galveston, TX, USA
4 KEYWORDS
Department of Pathology and Anatomical
Sciences, University of Missouri, Columbia, blood smear, doxycycline, Ehrlichia ewingii, fever, lung transplant
MO, USA

Correspondence
Hariharan Regunath, MD, Divisions of
Hospital Medicine, Critical Care and Infectious
Diseases, Department of Medicine, University
of Missouri, Columbia, MO, USA.
Email: regunathh@health.missouri.edu

1 |  INTRODUCTION
The etiologic agents of human ehrlichioses include Ehrlichia chaffeen-
sis (human monocytotropic ehrlichiosis or HME) which is character-
ized by cytoplasmic inclusions (morulae) within monocytes1; Ehrlichia
ewingii, which produces inclusions in neutrophils2; Ehrlichia canis (rare
cases reported in the literature as HME)3; and the newly described,
and still unnamed Ehrlichia muris-­like agent (EMLA), associated with
cases of HME in the upper Midwest.4 Morulae within circulating
monocytes in humans were first observed in 1987 and diagnosed ini-
tially as E. canis.5 However, further characterization of the infectious
agent revealed that a new pathogen, later named E. chaffeensis, was
responsible for the human case in 1987.6 In 1994, morulae in neutro-
phils were noted in a case of ehrlichiosis in the upper midwest that
was negative by polymerase chain reaction analysis (PCR) for E. chaf-
feensis and E. canis.7,8 This agent was initially named Ehrlichia phago-
cytophilum but further genetic analysis based on DNA sequencing
reclassified the agent as Anaplasma phagocytophilum, a closely related
bacterium within the family Anaplasmataceae.9 Subsequently in 1999,
E. ewingii was discovered by PCR assay in immuno-­compromised pa-
tients with ehrlichiosis.2,10,11 Amblyomma americanum, the “lone star
tick” is the most common vector of transmission, and its distribution is
in southeastern and south central United States.10 While tick exposure
heightens suspicion for tick-­borne illness, it is not reported in ~30% of
cases.12 In summer months, outdoor activities in areas of vegetation
are considered high risk.10 We report a case of E. ewingii infection in a
lung transplant (LT) recipient whose blood smear demonstrated moru-
lae in neutrophils leading to an early diagnosis.
2 | CASE
In June 2015, a 69-­year-­old woman presented to a University hospital
in Missouri with fever, chills, nausea, non-­bilious vomiting, and retching
of 1 day’s duration. Thirteen years earlier, she had undergone bilateral
deceased-­donor lung transplantation (cytomegalovirus-­positive re-
cipient) for end-­stage chronic obstructive pulmonary disease (COPD),
and she had been receiving photopheresis for chronic rejection for the
past 3-­4 years through a right subclavian Port-­a-­cath. Her immunosup-
pressive regimen included mycophenolate mofetil 250 mg twice daily,
tacrolimus 1 mg twice daily, and prednisone 5 mg once daily. Other
medications included warfarin (for a history of pulmonary embolism),

Transpl Infect Dis. 2017;19:e12652. wileyonlinelibrary.com/journal/tid © 2017 John Wiley & Sons A/S.  |  1 of 5
https://doi.org/10.1111/tid.12652 Published by John Wiley & Sons Ltd
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2 of 5       REGUNATH et al.

and diltiazem, clonidine, lisinopril, and pravastatin. Acyclovir 200 mg

twice daily, azithromycin 250 mg twice weekly, and trimethoprim-­
sulfamethoxazole (TMP-­SMX) (800/160) twice weekly were given for
prophylaxis. Other co-­morbidities were chronic kidney disease, ane-
mia, and a history of multiple skin cancers. One year earlier she had
a Port-­a-­cath-­related coagulase-­negative Staphylococcus bacteremia,
treated with port removal and intravenous antibiotics. Family history
was significant for COPD in her mother.
She lived with her husband, in her son’s house. Her side of the
house is protected from two healthy dogs that lived with her grand-
children. Initially, she denied any illness among family members or con-
tacts within the few days or weeks prior to the onset of her symptoms.
She had a 30 pack-­year smoking history before lung transplantation,
occasionally consumed alcohol, and denied insect bites (ticks and mos-
quitoes) or travel.
On examination, temperature was 37.2°C, heart rate 74/min,
F I G U R E   1   Peripheral smear demonstrating cytoplasmic inclusions
blood pressure 145/61 mmHg, respiratory rate 16/min, and oxygen
(morulae) within granulocytes. Ehrlichia ewingii morula, present in
saturation 94% on room air. She had bilateral lower extremity symmet-
a granulocyte, is morphologically indistinguishable from Ehrlichia
ric pitting pedal edema, and chest auscultation revealed bilateral expi- chaffeensis (Wright’s stained blood film, original magnification 400×)
ratory rhonchi, coarse breath sounds, and heart sounds were normal.
The rest of the examination was unremarkable.
Laboratory studies at admission were as follows: white blood cell Our pathologist reviewed her peripheral blood smear from day 4,
−9 and reported cytoplasmic inclusions within neutrophils consistent with
count (WBC) 3.8×10 /L (granulocytes 80.1%, lymphocytes 10.9%,
monocytes 7.2%), hemoglobin 12.2 g/dL, platelets 143×10−9/L, pro- morulae (Figure 1). Prophylactic TMP-­SMX and intravenous antibiot-
thrombin time 20.7 seconds (INR 1.7); sodium 138 mmol/L, potassium ics were immediately stopped. On day 7, Ehrlichia PCR confirmed the
3.7 mmol/L, chloride 103 mmol/L, bicarbonate 22 mmol/L, serum cal- presence of Ehrlichia species, and Rocky Mountain spotted fever serol-
cium 9.4 mg/dL, blood urea nitrogen 28 mg/dL, creatinine 1.78 mg/dL, ogy was negative. She improved clinically (became afebrile), WBC im-
total bilirubin 0.29 mg/dL, aspartate aminotransferase 19 U/L, alanine proved to 3.15×10−9/L, and serum creatinine declined to 0.87 mg/dL
aminotransferase 11 U/L, alkaline phosphatase 50 U/L, total protein and she was discharged to complete a 2-­week course of oral doxycy-
5.8 g/dL, and albumin 3.6 g/dL. Tacrolimus level was 3.6 ng/mL. cline. At a 3 week clinic follow up, she was noted to have fully recov-
A non-­contrast computed tomography of the chest showed a ered and TMP-­SMX was resumed by primary care physician a week
left lower lobe atelectasis, a new small left pleural effusion, and air after completion of doxycycline therapy.
bronchograms in left lower lobe. An ultrasound-­guided diagnos- As in-­house studies for molecular detection of Ehrlichia are not
tic thoracentesis yielded <10 mL of pleural fluid, which was enough species specific, molecular testing by PCR followed by gene sequenc-
only for limited studies: WBC 227/μL, red blood cells 5000/μL, pH ing was performed at the Rickettsial and Ehrlichial Laboratory at the
8.0; Gram stain and culture were negative. Results of analysis using University of Texas Medical Branch in Galveston. PCR primers tar-
a FilmArray (BioFire Diagnostics Inc., Salt Lake City, UT, USA) respi- geted the dsb ehrlichial gene and sequencing confirmed the presence
ratory viral panel were negative. Blood cultures were also negative. of E. ewingii DNA amplicons (J.P.O., Jere W. McBride).
Cytomegalovirus PCR and Epstein-­Barr virus immunoglobulin (Ig)M
were negative (Epstein-­Barr virus IgG positive).
She was treated with intravenous vancomycin and meropenem. 3 | DISCUSSION
On day 3, Infectious Diseases was consulted for persistent fever. At
that time, her WBC was 1.78×10−9/L (granulocytes 69.6%, lympho- The first case of human ehrlichiosis in an LT recipient was reported
cytes 18.5%, monocytes 7.9%), hemoglobin 9.9 g/dL, and platelets in 2002.13 The causative agent was E. chaffeensis, and the clinical
−9 course was severe and complicated by thrombotic thrombocyto-
113×10 /L. It was suggested to add empiric doxycycline for atypical
coverage and also because of fever, leukopenia, thrombocytopenia penic purpura and renal failure requiring dialysis. Nevertheless, he
and the active “tick season” (early summer). PCR for Ehrlichia species, improved without sequelae following treatment with doxycycline for
and serology for Rocky Mountain spotted fever IgG/IgM were sent on 2 weeks.13 In a retrospective review of solid organ transplant recipi-
day 4. On day 5, her husband remembered that his son and grandson ents with ehrlichiosis diagnosed by PCR (E. chaffeensis or E. ewingii),
were recently treated for tick-­borne illness with doxycycline. She then LT recipients had severe outcomes—they needed more intensive care,
recalled ticks, consistent with A. americanum, crawling on her body prolonged hospitalization, and had higher risk to develop acute lung
when the family was clearing a piece of land 1-­2 weeks prior to her injury or acute respiratory distress syndrome.14 In this series of five
illness. LT recipients, one had E. ewingii infection about 7 years after lung
REGUNATH et al. |
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T A B L E   1   Ehrlichiosis in lung transplant recipients13–15

a
Lawrence et al.14 Safdar et al.13 a
Thomas et al.15

Number of cases 5 1 1
b
Age, years 58 (26-­68) 38 65
Gender Male:Female = 1:4 Male Male
Time since lung 30 (9-­126) 48 73
­transplantation, monthsb
Ehrlichia species E. ewingii (20%) Not identified E. ewingii
E. chaffeensis (80%)
Intake of sulfonamides 100% 100% Not specified for the lung transplant
recipient.c
Symptoms Fever (100%), headache (60%), cough Fever, myalgias, headache Fever, headache, nausea and
(40%) vomiting
Abdominal pain, nausea and vomiting
(20% each)
Symptom duration 2-­21 days 3 days 7 days
Complications Acute renal failure (60%) Encephalopathy, pancytopenia, No data available
Acute lung Injury/Acute respiratory micro-­angiopathic anemia,
distress syndrome (60%) acute renal failure
Time to doxycycline therapy, 0-­4 days 4 days Not specified
days
Outcome All survived Survived Survived
a
Only data on lung transplant recipient(s) is displayed in this Table.
b
Age and Time since transplantation expressed as median (range) for Lawrence et al.14 only.
c
In this case series involving a total of 15 transplant recipients with ehrlichiosis (7 renal transplants, 6 heart transplants, 1 each with liver and lung transplant
respectively), 80% were on sulfonamide prophylaxis at presentation with ehrlichiosis. Whether the 1 lung transplant recipient was on sulfonamide prophy-
laxis was not separately elucidated by the authors.

transplantation. The presenting symptoms were fever and cough of
3 weeks’ duration, illness was mild, and similar to our case. The char-
acteristics of all three published cases of ehrlichiosis in LT recipients
13–15
are summarized in Table 1.
In our patient, mild leukopenia and thrombocytopenia were
present at admission and these worsened by day 3 when Infectious
Diseases was consulted. Following treatment with doxycycline, the
cell counts improved. Leukopenia and thrombocytopenia are common
laboratory findings in human ehrlichiosis. For patients presenting with
a febrile illness, these findings should prompt testing for ehrlichiosis in
endemic regions during summer months.16 Lymphopenia usually oc-
curs in early stages of infection followed by lymphocytosis during re-
17
covery. Severe illness can cause anemia, acute renal failure, elevated
liver function tests, and abnormalities in cerebrospinal fluid such as
lymphocytic pleocytosis and elevated protein.18,19 In our case, serum
creatinine was elevated at admission and this normalized by day 7.
Transplant recipients with ehrlichiosis had more leukopenia, anemia,
and renal dysfunction in one case series.15
Morulae are basophilic cytoplasmic inclusions seen on Wright-­
Giemsa stain and are composed of small gram-­negative obligate-­
intracellular bacteria characteristic of Ehrlichia and Anaplasma
infections in humans. Morulae are seen in monocytes and neutrophils
depending on the etiologic agent (neutrophils for A. phagocytophilum
20–22
and E. ewingii; and monocytes for E. chaffeensis and E. muris).
Although leukocyte tropism has been well described for different ehrli-
chiae, this is nonspecific as E. chaffeensis has also been associated with
granulocytic inclusions.18,23,24 E. ewingii infections are rarely reported,
usually associated with mild illness, and the morulae, when present,
were always within granulocytes.2,10,13,20 When morulae are detected
by blood smear exam, despite poor specificity for species identifica-
tion, it can serve as an effective tool for early diagnosis.18,24 One study
that explored the sensitivity of peripheral blood smear exam for human
ehrlichiosis reported that only 17% of immunocompetent patients
had morulae in blood smear (higher in Anaplasma infections owing
to greater numbers of neutrophils in peripheral smears), but among
immunocompromised hosts, all of them (100%) demonstrated moru-
lae in blood smear. This finding is significant because of the increased
risk for rapidly fatal ehrlichiosis in immunocompromised hosts.23 It is
likely that the underlying immunosuppressive medications or diseases
resulted in a higher level of ehrlichial organisms in blood with delayed
clearance and thus the increased rate of smear positivity.23
Isolation of Anaplasma and Ehrlichia species is difficult and time-­
consuming, and requires cell monolayers; serologic tests are usually
negative early in acute illness and only seroconversion or a four-­
fold rise during the convalescent period can make the diagnosis.25
Identification of Ehrlichia species by PCR is useful for rapid confirma-
tion of the clinical diagnosis, may be positive despite lack of morula
in smears, and should ideally be performed on a blood sample before
specific antibiotic treatment is initiated. A real-­time combined PCR
assay for rapid detection of A. phagocytophilum, E. chaffeensis, and
E. ewingii is available through reference laboratories and selected re-
search laboratories, but results are not available in a timely fashion.26,
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4 of 5       REGUNATH et al.
27
However, this test is seldom required as there is no real clinical ad-
vantage to species identification, as all ehrlichial organisms are sus-
ceptible to standard therapy.
Although donor-­derived ehrlichioses with substantial morbidity
and mortality have been described in the literature, transplant recipi-
ents acquire ehrlichiae more commonly through tick inoculation. The
spectrum of clinical manifestations varies from a flu-­like illness to full-­
blown sepsis with shock.10,28 In endemic areas, diagnosis of human
ehrlichiosis is often based on clinical presentation, and regional and
seasonal epidemiology.10 In cases with high index of suspicion based
on compatible clinical and laboratory findings, empiric therapy should
be promptly instituted because delayed therapy was associated with
worse outcomes.10,29 A sample submitted for molecular testing prior
to treatment is helpful to confirm the diagnosis. In our case, although
initial interview was non-­revealing for a history of tick bite, recognition
of endemicity of rickettsial/ehrlichial infections in Missouri during the
summer months (when nymph and adult stages of ticks are most ac-
tive) led to inclusion of empiric therapy with doxycycline for tick-­borne
illness. Contracting ehrlichiosis while on therapy with sulfonamides or
administering these type of antimicrobials to patients with ehrlichioses
(eg, TMP-­SMX) has been associated with worse outcomes, but the
exact underlying mechanism for this sulfonamide potentiation of se-
verity of ehrlichiosis has not yet been elucidated.30–32 Our patient was
taking prophylactic TMP-­SMX, which in addition to immunosuppres-
sion, could have contributed to symptomatic disease from E. ewingii.
In summary, a high index of suspicion based on history and ep-
idemiology is crucial in making a clinical diagnosis of ehrlichiosis in
transplant recipients in endemic areas. Our case stands out from other
published cases of ehrlichiosis in LT recipients because of arriving at
an early diagnosis by peripheral smear. This report highlights the fact
that, despite advanced testing modalities (PCR) available for accurate
diagnosis, peripheral blood smear examination should be an important
part of initial work-­up, especially because of its high yield in immuno-
suppressed patients.23 Ideally, this examination should be performed
on a sample obtained prior to initiation of treatment with doxycycline,
as its effects are rapid and the diagnostic cytoplasmic inclusions may
not be seen after 1-­2 days of treatment.23 Future studies aimed at de-
termining blood smear positivity in transplant recipients might provide
better insights into the sensitivity and specificity.
4 |  CONCLUSION
Ehrlichia ewingii infection in LT recipients can be diagnosed early by
blood smear exam by an experienced pathologist. This method is not
only cost effective, but also enables early treatment of this potentially
fatal illness in LT recipients.
AUTHOR CONTRI B UTI O N S
H.R. drafted the entire report, which was then critically edited and
revised by C.R.-­M. and W.S.; R.D.H. and J.P.O. added further signifi-
cant and critical revisions in regards to introduction, epidemiology,
laboratory studies, and discussion. R.D.H. provided the figure and
legend.
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How to cite this article: Regunath H, Rojas-Moreno C, Olano JP,
Hammer RD, Salzer W. Early diagnosis of Ehrlichia ewingii infection
in a lung transplant recipient by peripheral blood smear. Transpl
Infect Dis. 2017;19:e12652. https://doi.org/10.1111/tid.12652