An ordinary day began with a patient transfer from a rural hospital in Eastern Kentucky. The 26-year-old woman presented to the outside hospital with a 2-day history of shortness of breath and productive cough, which had been preceded by several days of generalized fatigue, subjective fever, and chills. She denied recent travel, exposure to animals, or sick contacts but reported exposure to tick bites. She had a 6 pack-year smoking history and did not use alcohol or illicit drugs. The time of year was not typical for the flu, and the patient had been in perfect health prior to the current presentation.

She arrived at our institution several hours after the morning phone call. Her vital signs were as follows: temperature, 99.7°F (37.6°C); heart rate, 116 beats/minute; blood pressure, 99/43 mmHg; and respiratory rate, 28 breaths/minute. Oxygen saturation was 93% on 3L/min via nasal cannula. Physical examination revealed periorbital ecchymosis and subconjunctival hemorrhages. The patient was alert and oriented to person, place, and time and exhibited no focal neurological deficits. Auscultation of her chest disclosed reduced breath sounds and crackles bilaterally, especially in the bases. Examinations of the heart and abdomen were normal.

A chest x-ray and computed tomography (CT) demonstrated bilateral pulmonary infiltrates in an airspace pattern (Figure 1). Laboratory data identified a leukocyte count of 2.2 × 103 cells/μL, hemoglobin count of 10.8 g/dL, and platelet count of 37,000 platelets/uL. Blood chemistry measured sodium at 130 mmol/L, potassium at 3.8 mmol/L, chloride at 98 mmol/L, bicarbonate at 18 mmol/L, blood urea nitrogen at 26 mg/dL, and creatinine at 1.63 mg/dL. Liver enzymes were markedly elevated with an aspartate aminotransferase level of 1312 U/L, and alanine aminotransferase level of 581 U/L. Total bilirubin was 2.7 mg/dL, with 2.2 mg/dL constituting the conjugated fraction, and alkaline phosphatase was 320 U/L. The international normalized ratio was 1.8; prothrombin time, 18 sec. Tylenol, salicylate, alcohol, methanol, and ethylene glycol levels were all negative, and a urine drug screen was unremarkable.