A 24-year-old forest ranger-in-training from Minnesota comes to you in the ER with complaints of fever and left eye redness and pain that started about 3 days prior to admission. He initially went to see his primary care provider, who noted a temperature of 38.3 C and a WBC count of only 3,000. Platelets were 148,000 and Hgb was 10. The rest of his vitals were fine. He was admitted for further evaluation. Repeat CBC showed no acute changes, but AST and ALT were checked and mildly elevated. He also had a mild headache on arrival, otherwise the review of systems was as noted above.

He has no history of alcohol or drug use, and although he has a girlfriend he has never been sexually active. He has never been checked for STIs, including HIV. He has had no known sick contacts recently. He traveled to Hawaii and London, England in the last year. He does wear short-sleeved clothing, as it is hot outside, but is unsure of insect or tick exposures. He has a pet cat at home, but doesn’t recall any bites or scratches from the cat.

Physical exam shows uveitis of his affected eye, his vision and pupillary response are fortunately preserved. The rest of the exam is negative of any unique findings. Blood cultures are obtained. Peripheral smear interestingly shows neutrophils with intra-cytoplasmic inclusions. Based on the above data, a presumptive diagnosis is suspected, and appropriate therapy is initiated.

Based on the above information, what do you feel is the most likely diagnosis?

1. Acute Myelocytic Leukemia (AML)
2. Acute retro-viral syndrome
3. Bartonella hensla infection
4. EBV Infection
5. Human granulocytic anaplasmosis (HGA)
6. Lyme disease
7. Tularemia