Beware the tick: ehrlichiosis in a lung transplant recipient

Ehrlichiosis is a rare tick-borne zoonosis caused by Ehrlichia chaffeensis, E. ewingii and related species. In solid organ transplant recipients, immunosuppression can result in atypical presentations, delayed diagnosis and poor outcomes. The disease remains under-recognised among lung transplant recipients despite its potentially fatal course. A man in his early 70s with a history of bilateral lung transplantation for chronic obstructive pulmonary disease presented with a high-grade fever and shortness of breath. Bronchoalveolar lavage (BAL) culture grew Pseudomonas aeruginosa and meropenem was initiated. He subsequently developed severe thrombocytopenia, acute kidney injury and elevated liver transaminases. Disseminated intravascular coagulation (DIC) and thrombotic thrombocytopenic purpura (TTP) were excluded, while haemophagocytic lymphohistiocytosis (HLH) was considered but not confirmed. His condition rapidly progressed to multiorgan failure requiring mechanical ventilation and haemodialysis. E. chaffeensis was identified postmortem by next-generation sequencing. This case highlights diagnostic challenges and the importance of early empiric doxycycline therapy in endemic areas.