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Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: A 53y/o male was admitted with septic shock and acute encephalopathy. Radiologic imaging of the brain was non-diagnostic and a subsequent lumbar puncture revealed that the patient was suffering from a rare cause of aseptic meningitis due to Ehrlichia. The patient responded very well to treatment with doxycycline and had a full neurological recovery. The diagnosis of ehrlichiosis without laboratory assistance is difficult as the signs and symptoms are non-specific. Diagnosis rests primarily on clinical suspicion and it is imperative to start treatment early to prevent complications. Methods: 53y/o male presented to the ER with left flank pain, dysuria, decreased PO intake, nausea, vomiting and loose stools. In the ER he was found to be hypotensive and had suprapubic tenderness on palpation. Labs showed pancytopenia, lactic acidosis, transaminitis and high BUN/Cr. CT chest/abd/pelvis was negative. The patient was started on vasopressors, antibiotics and admitted to the ICU for Septic shock. Blood/urine/stool cultures and HIV were ordered which all subsequently came back negative. The patient became increasingly encephalopathic and was subsequently intubated. A LP was done due to new nuchal rigidity. With new history about tick exposure, Doxycycline was started empirically and serum Lyme and Ehrlichiosis antibodies were ordered. LP results showed a monocytic lymphocytosis, low glucose and elevated protein. Ehrlichiosis was detected in the blood and CSF, however rest of the CSF viral studies and cultures were negative. The antibiotics except doxycycline were gradually discontinued. Patient completed a 14-day course of Doxycycline and had dramatic improvement in his mentation and made a full medical recovery. Results: Human Monocytic Ehrlichiosis (HME) caused by Ehrlichia chaffeensis is an emerging tickborne infection transmitted by the lonestar tick. Symptoms start one to two weeks after a tick bite. Patients typically present with fever, malaise, headache, body aches,GI symptoms rash and chills. CNS involvement can also occur in up to 20% of patients, including meningitis and meningoencephalitis. Some may progress to ARDS and Sepsis/ Septic Shock. Since the clinical manifestations of HME are nonspecific, lab abnormalities like Pancytopenia, elevated transaminases, CSF leukocytosis and mildly elevated protein provide diagnostic clues. Specific laboratory tests include IFA and detection of ehrlichial DNA by PCR of blood/CSF. Most patients with HME respond well to Doxycycline.