A 49 year old female from Connecticut was in her usual 
                    state of health until August when she presented with a 1 
                    week history of fever, headache, chills, nausea and 
                    malaise. She was seen by a local physician who suspected 
                    sinusitis and treated her initially with an oral 
                    cephalosporin. Other than scleral icterus, head, neck, 
                    heart and lungs were normal. Her presenting symptoms 
                    continued. She had been in the woods 2 weeks prior to the 
                    onset of her symptoms but knew of no tickbite. 
                    Medications on admission included pindolol, conjugated 
                    estrogens, aspirin, hydrochlorothiazide.
                    
                    Past medical history:
                     
                    Splenectomy 17 years prior following trauma 
                    Pancreatitis 30 years prior following cholecystectomy 
                    Hypertension
                     
                    Social history:
                     
                    She did not use tobacco, alcohol, or illicit drugs. She 
                    had vacationed in the Caribbean 10 months earlier. Review 
                    of systems was otherwise negative.
                     
                    Physical Exam:
                     
                    The temperature was 99.4, pulse 95 min, respiratory rate 
                    20minute and blood pressure 109/54. She appeared  
                    jaundiced and diaphoretic. Other than scleral icterus, 
                    head and neck were normal. She had two ecchymotic lesions 
                    on her right upper arm but no other skin abnormalities 
                    were noted. She had minimal right upper quadrant 
                    tenderness but the liver was not enlarged. The spleen was 
                    absent. She had no palpable lymphadenopathy.
                    
                    Laboratory Results
                     
                    The hematocrit was 32%; platelet count was 136,000 mm3; 
                    and the white blood cell count 13,000 mm3 with a 
                    differential of 5% band forms, 51% PMNs, 28% lymphocytes, 
                    14% monocytes, 1% basophils. Serum electrolytes were 
                    remarkable for a potassium of 2.9 meq Liter, blood urea 
                    nitrogen of 41 and serum creatinine of 1.7. Serum 
                    chemistries were notable for the following: Total 
                    bilirubin of 15.3 mg/dL; direct bilirubin of 11.9mg/dL; 
                    AST 55 IU/L; alkaline phosphatase 247 IU/L; lactose 
                    dehydrogenase 900 IU/L. Urinanalysis showed the presence 
                    of hemoglobin. Her chest radiograph was normal.