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.