Differential Diagnosis in the Age of COVID-19 and the Need to Maintain a Broad Differential

Amandeep S. Saini¹ and Jacob Schwartz^1,

¹Lenox Hill Hospital, Department of Internal Medicine New York, NY

Cite this paper

Amandeep S. Saini and Jacob Schwartz. Differential Diagnosis in the Age of COVID-19 and the Need to Maintain a Broad Differential. American Journal of Medical Case Reports. 2021; 9(1):62-64. doi: 10.12691/AJMCR-9-1-15

Abstract

During the coronavirus pandemic, patients admitted to emergency departments (ED) with constitutional symptoms, respiratory complaints, and/or history of sick contacts have high clinical suspicion for COVID-19 regardless of whether initial screening tests are negative. Although communities seek daily coronavirus infection rates of less than one percent, physicians can be highly focused on narrow differentials despite adequate history and physical exams. This case report focuses on an elderly patient with a past medical history of hypertension, chronic kidney disease (CKD), and gout who presented with three days of fevers, chills, body aches, and shortness of breath and reported a home oxygen saturation of 89%. The patient was a health care worker with high risk of contracting COVID-19, and on admission was febrile and found to have lymphopenia. Nevertheless, COVID-19 Polymerase Chain Reaction (PCR) testing returned negative on two separate occasions prompting the team to broaden their differential. Leukopenia, thrombocytopenia and mildly elevated transaminases can all be due to COVID-19, but should also lead medical teams to include tick-borne illnesses as a potential etiology. Parasite serology returned positive for Babesia microti via IgG antibodies (1:512) and Anaplasma phagocytophilum via PCR and the patient was discharged on appropriate antimicrobial therapy. It is important for providers to understand and recognize the following: 1) overlapping symptoms of tick-borne disease and COVID-19, 2) proper diagnosis and management of babesiosis and anaplasmosis, and 3) benefits of broad differentials for patient care during the COVID-19 pandemic.

Keywords

coronavirus, COVID-19, d-dimer, babesiosis, anaplasmosis, tick-borne

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance - United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(24): 759-765.
[2]	Woloshin S, Patel N, Kesselheim AS. False Negative Tests for SARS-CoV-2 Infection - Challenges and Implications. New England Journal of Medicine. 2020; 383(6).
[3]	Chen L-D, Li H, Ye Y-M, et al. A COVID-19 patient with multiple negative results for PCR assays outside Wuhan, China: a case report. BMC Infectious Diseases. 2020; 20(1).
[4]	Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2007 Oct 1; 45(7): 941]. Clin Infect Dis. 2006; 43(9): 1089-1134.
[5]	Swanson SJ, Neitzel D, Reed KD, et al. Coinfections acquired from ixodes ticks. Clin Microbiol Rev. 2006; 19(4): 708-727.
[6]	Vannier EG, Diuk-Wasser MA, Ben Mamoun C, et al. Babesiosis. Infect Dis Clin North Am. 2015; 29(2): 357-370.
[7]	Dahlgren FS, Heitman KN, Drexler NA, et al. Human granulocytic anaplasmosis in the United States from 2008 to 2012: a summary of national surveillance data. Am J Trop Med Hyg. 2015; 93(1): 66-72.
[8]	Aguero-Rosenfeld ME, Horowitz HW, Wormser GP, et al. Human granulocytic ehrlichiosis: a case series from a medical center in New York State. Ann Intern Med. 1996; 125(11): 904-908.
[9]	Bakken JS, Krueth J, Wilson-Nordskog C, et al. Clinical and Laboratory Characteristics of Human Granulocytic Ehrlichiosis. JAMA. 1996; 275(3): 199-205.
[10]	Krause PJ, Spielman A, Telford SR 3rd, et al. Persistent parasitemia after acute babesiosis. N Engl J Med. 1998; 339(3): 160-165.
[11]	Ruebush TK 2nd, Chisholm ES, Sulzer AJ, Healy GR. Development and persistence of antibody in persons infected with Babesia microti. Am J Trop Med Hyg. 1981; 30(1): 291-292.
[12]	Dawson JE, Fishbein DB, Eng TR, et al. Diagnosis of human ehrlichiosis with the indirect fluorescent antibody test: kinetics and specificity. J Infect Dis. 1990; 162(1): 91-95.