A 64-year-old man was admitted with hypotension and respiratory failure after 3 weeks of fever, cough, fatigue, and headache. 7 years earlier he had an unrelated bone marrow transplant but was off immunosuppressive therapy. He resided in New England and was an avid hunter. He had multiple tick exposures. His WBC was 19.27 × 109/L with 84% neutrophils and 14% bands, with normal hemoglobin and platelets. Granulocytes contained intracytoplasmic inclusions (see figure). PCR was positive for Anaplasma phagocytophilum. A phagocytophilum is the etiologic agent for human granulocytic anaplasmosis (HGA), a tick-borne illness that is endemic to New England. Intracytoplasmic morulae are seen in neutrophils in 60% to 80% of cases.