A 35-year-old man presents with fever for 14 days, along with fatigue, malaise, generalized arthralgia and myalgia, and a diffuse headache for the same duration. No other symptoms are present. He has been self-medicating himself with acetaminophen and has not sought medical attention thus far.
He returned from a week-long hiking trip in rural Massachusetts around three weeks ago. He does not recall being bitten by insects. The several friends and family who traveled with him are healthy.
There is no contact history with people with similar symptoms. He has a single stable long-term sexual partner. His medical, surgical and family histories are unremarkable. He does not smoke and only drinks socially.
His basic investigations are as follows:
WBC: 5,100/mm3 (4,600-11,00)
Neu: 45% Lym: 37%
Hb: 10.5 g/dL (11-18)
MCV: 90 fL (80-96)
MCH: 30 pg/cell (27-33)
Plt: 196,000/mm3 (150,000-450,000)
ALT: 80 IU/L (7-45)
AST: 72 IU/L (8-48)
Tot. bilirubin: 1.5 mg/dL (0.2-1.2)
Dir. bilirubin: 0.3 mg/dL (0.1-0.4)
Reticulocyte count: 8%
Serum LDH: 800 IU/L (105-333)
Direct antiglobulin test: negative
Indirect antiglobulin test: negative
Renal functions, chest x-rays, and a urinalysis are all normal.