A 41-year-old woman with no significant past medical history presented to the hospital with complaints of nausea, vomiting, and generalized weakness over two weeks. The patient was doing well prior to her presentation and she assumed that her symptoms would resolve without seeking medical attention. The patient reported subjective fevers with severe back pain during this period. The patient often had mild back pain; this is usually controlled by naproxen over the counter but provides little relief during this episode. The patient felt progressively worse and lost her appetite; thus, her husband suggested drinking large volumes of fluids. The patient reported drinking a gallon of cranberry juice, six 16oz bottles of water, and four 12oz cans of Sprite, leading to severe diarrhea and further weakness. The patient reported that she had a tick bite around the time of her initial symptoms which stayed on her skin for an hour. She avoided seeking medical attention as this was a normal occurrence given where she lives in the country. The patient denied smoking or illegal drug abuse.

On examination, the patient was tachycardiac at 132 bpm and borderline hypotensive at 95/60 mmhg with normal oxygen saturations. The patient looked sick and lethargic with dry mucous membranes but otherwise appeared normal in the exam. Admission labs (Table 1) were significant for leukopenia with white blood count (WBC) of 1.7 (4.5–11.0 K/uL), thrombocytopenia with platelets of 44 K (150–450 K/uL), hyponatremia at 125 (137–145 mmol/L), potassium of 3.7 (3.5–5.1 mmol/L), acute kidney injury with creatinine of 1.9 (0.7–1.2 mg/dL) (unknown baseline), and elevated liver enzymes with AST of 553 (14–36 U/L), ALT of 188 (0–34 U/L), and LDH 1120 (140–280 U/L). The thyroid function test was also normal. The acute hepatitis panel was negative. The urine drug screen was positive for amphetamines and marijuana. The computed tomography (CT) abdomen showed splenomegaly without any other abnormalities. Tick bite labs were sent including Ehrlichia, tularemia and Rocky Mountain spotted fever.

A urine drug screen was obtained for suspicion of drug abuse despite her initial denial. We discussed the findings with the patient, and she later admitted to using both amphetamines and marijuana. This led us to take a detailed social history that revealed an unexpected event. The patient raises horses at her ranch, one whom was in pain. The vet prescribed non-steroidal anti-inflammatory drug (NSAID) pain medication (phenylbutazone) for the horse, and she recognized that the horse had pain relief. The patient was frustrated as naproxen did not help her this time and took phenylbutazone to alleviate her pain. The patient admitted to taking three doses of a 400-pound horse equivalent dose of phenylbutazone about 3 days before the start of her symptoms.

Poison control and toxicology centers were notified but no antidote was recommended. Due to suspected acute liver damage from phenylbutazone, we decided to start an N-acetyl cysteine and sodium bicarbonate drip. She was three IV doses over the course of 21 h, a loading dose with 15 g over one hour, a second dose of 4 g over 4 h, and a third dose 8 g over 16 h. Patient also received two units of cryoprecipitate for suspected disseminated intravascular coagulation (DIC) as her fibrinogen was low at 80. Yet, her international normalized ratio (INR) and peripheral smear were normal. We also initiated empiric doxycycline to cover for tick-borne illness. The patient’s labs (Table 1) improved during her 3 days stay and was clinically feeling better but unfortunately decided to leave the hospital against medical advice before complete recovery occurred.

One week after her discharge, tick titers came back abnormal for Ehrlichia with positive IgM and IgG. Numerous calls attempted to notify the patient but were unsuccessful.