1. Presented by: Eitan Halper-Stromberg, MD

An adult patient with a past medical history of HgSS, alloimmunization to several red cell antigens, functional asplenia, iron overload, and transfusion dependence presents to the clinic with headache and fever. They have not traveled in the last six months. They live in a grassy locale; however, are not given to hikes or wooded excursions. Several weeks ago, the patient developed neck pain and daily fevers. In the last week the neck pain has become progressively worse and is accompanied by decreased range of motion of the neck and jaw, as well as photophobia. Physical exam is positive for fever (103 F). Review of systems is positive for fevers, chills, loss of appetite, and headache. Labs are notable for WBC 5.6, Hgb 11.2, MCV 75, AST 112, ALT 123, CRP 6.4, ESR 30, and LDH 542. Lyme and Hepatitis serologies are negative. Red cell antibody screen is positive. Ehrlichia IgG is positive. EBV IgG is positive for both nuclear and capsid antigens. The peripheral smear is shown.



What is the likely diagnosis?