55F from the midwest presents with fatigue, fever, and myalgias. Pt recently took tmp/smx for a UTI. She is a cafeteria worker, sees her grandkids regularly, and has a kitten.
Traveled to Mexico 2 yrs ago and hikes in woods
T102F, LUQ pain, petechial lesions L ankle.
WBC 6.3, Cr 1.3, ALT 841, AST 584, BC neg. Peripheral smear shown