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Gygax L, Schudel S, Kositz C, Kuenzli E, Neumayr A. Human monocytotropic ehrlichiosis-A systematic review and analysis of the literature. PLoS Negl Trop Dis 2024; 18:e0012377. [PMID: 39093857 PMCID: PMC11324158 DOI: 10.1371/journal.pntd.0012377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 08/14/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024] Open
Abstract
Human monocytotropic ehrlichiosis (HME) is a tick-borne bacterial infection caused by Ehrlichia chaffeensis. Most available data come from case reports, case series and retrospective studies, while prospective studies and clinical trials are largely lacking. To obtain a clearer picture of the currently known epidemiologic distribution, clinical and paraclinical presentation, diagnostic aspects, complications, therapeutic aspects, and outcomes of HME, we systematically reviewed the literature and analyzed and summarized the data. Cases of HME are almost exclusively reported from North America. Human infections due to other (non-chaffeensis) Ehrlichia spp. are rare. HME primarily presents as an unspecific febrile illness (95% of the cases), often accompanied by thrombocytopenia (79.1% of the cases), leukopenia (57.8% of the cases), and abnormal liver function tests (68.1% of the cases). Immunocompromized patients are overrepresented among reviewed HME cases (26.7%), which indicates the role of HME as an opportunistic infection. The incidence of complications is higher in immunocompromized compared to immunocompetent cases, with ARDS (34% vs 19.8%), acute renal failure (34% vs 15.8%), multi organ failure (26% vs 14.9%), and secondary hemophagocytic lymphohistiocytosis (26% vs 14.9%) being the most frequent reported. The overall case fatality is 11.6%, with a significant difference between immunocompetent (9.9%) and immunocompromized (16.3%) cases, and sequelae are rare (4.2% in immunocompetent cases, 2.5% in immunocompromised cases).
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Affiliation(s)
- Larissa Gygax
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Sophie Schudel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Kositz
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Esther Kuenzli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Andreas Neumayr
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia
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Do Not Forget About the Ticks: An Unusual Cause of Fever, GI Distress, and Cytopenias in a Child With ALL. J Pediatr Hematol Oncol 2022; 44:e901-e904. [PMID: 34935737 DOI: 10.1097/mph.0000000000002369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/26/2021] [Indexed: 11/25/2022]
Abstract
We report the case of a 5-year-old male with B-cell acute lymphoblastic leukemia in remission, receiving maintenance chemotherapy, who presented with fever, emesis, diarrhea, headache, and lethargy. He developed rapidly progressive cytopenias and was found to have acute human granulocytic anaplasmosis as well as evidence of past infection with Babesia microti. The case highlights the need to maintain a broad differential for infection in children undergoing chemotherapy or other immunosuppressive therapies with possible or known tick exposure.
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Ismail N, Sharma A, Soong L, Walker DH. Review: Protective Immunity and Immunopathology of Ehrlichiosis. ZOONOSES (BURLINGTON, MASS.) 2022; 2:10.15212/zoonoses-2022-0009. [PMID: 35876763 PMCID: PMC9300479 DOI: 10.15212/zoonoses-2022-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Human monocytic ehrlichiosis, a tick transmitted infection, ranges in severity from apparently subclinical to a fatal toxic shock-like fatal disease. Models in immunocompetent mice range from an abortive infection to uniformly lethal depending on the infecting Ehrlichia species, dose of inoculum, and route of inoculation. Effective immunity is mediated by CD4+ T lymphocytes and gamma interferon. Lethal infection occurs with early overproduction of proinflammatory cytokines and overproduction of TNF alpha and IL-10 by CD8+ T lymphocytes. Furthermore, fatal ehrlichiosis is associated with signaling via TLR 9/MyD88 with upregulation of several inflammasome complexes and secretion of IL-1 beta, IL-1 alpha, and IL-18 by hepatic mononuclear cells, suggesting activation of canonical and noncanonical inflammasome pathways, a deleterious role for IL-18, and the protective role for caspase 1. Autophagy promotes ehrlichial infection, and MyD88 signaling hinders ehrlichial infection by inhibiting autophagy induction and flux. Activation of caspase 11 during infection of hepatocytes by the lethal ehrlichial species after interferon alpha receptor signaling results in the production of inflammasome-dependent IL-1 beta, extracellular secretion of HMGB1, and pyroptosis. The high level of HMGB1 in lethal ehrlichiosis suggests a role in toxic shock. Studies of primary bone marrow-derived macrophages infected by highly avirulent or mildly avirulent ehrlichiae reveal divergent M1 and M2 macrophage polarization that links with generation of pathogenic CD8 T cells, neutrophils, and excessive inflammation or with strong expansion of protective Th1 and NKT cells, resolution of inflammation and clearance of infection, respectively.
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Affiliation(s)
- Nahed Ismail
- Clinical Microbiology, Laboratory Medicine, University of Illinois at Chicago-College of Medicine, University of Illinois Hospitals & Health Science System, Chicago, IL
| | - Aditya Sharma
- Clinical Microbiology, Laboratory Medicine, University of Illinois at Chicago-College of Medicine, University of Illinois Hospitals & Health Science System, Chicago, IL
| | - Lynn Soong
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX
- Department of Pathology, Center for Biodefense & Emerging Infectious Diseases, University of Texas Medical Branch, Galveston, TX
| | - David H. Walker
- Department of Pathology, Center for Biodefense & Emerging Infectious Diseases, University of Texas Medical Branch, Galveston, TX
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Dixon DM, Branda JA, Clark SH, Dumler JS, Horowitz HW, Perdue SS, Pritt BS, Sexton DJ, Storch GA, Walker DH. Ehrlichiosis and anaplasmosis subcommittee report to the Tick-borne Disease Working Group. Ticks Tick Borne Dis 2021; 12:101823. [PMID: 34517150 DOI: 10.1016/j.ttbdis.2021.101823] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/18/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
Ehrlichioses and anaplasmosis have undergone dramatic increases in incidence, and the geographic ranges of their occurrence and vectors have also expanded. There is marked underreporting of these diseases owing to deficient physician awareness and knowledge of the illnesses as well as limited access to appropriate diagnostic tests. Human monocytic ehrlichiosis and anaplasmosis are life threatening diseases with estimated case fatality rates of 2.7 and 0.3%, respectively. However, knowledge of their full range of signs and symptoms is incomplete, and the incidence of subclinical infections is unknown. Currently available laboratory diagnostic methods are poorly utilized, and with the exception of nucleic acid amplification tests are not useful for diagnosis during the acute stage of illness when timely treatment is needed. The Ehrlichiosis and Anaplasmosis Subcommittee of the Tick-Borne Disease Working Group recommended active clinical surveillance to determine the true incidence, full clinical spectrum, and risk factors for severe illness, as well as standardized surveillance of ticks for these pathogens, and enhanced education of primary medical caregivers and the public regarding these diseases. The subcommittee identified the needs to develop sensitive, specific acute stage diagnostic tests for local clinical laboratories and point-of-care testing, to develop approaches for utilizing electronic medical records, data mining, and artificial intelligence for assisting early diagnosis and treatment, and to develop adjunctive therapies for severe disease.
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Affiliation(s)
| | - John A Branda
- Massachusetts General Hospital and Harvard Medical School, 55 Fruit St., Boston, MA 02114, United States.
| | - Stephen H Clark
- University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032, United States
| | - J Stephen Dumler
- Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Joint Pathology Center, 4301 Jones Bridge Road, Building B, Room 3152, Bethesda, MD 20814, United States.
| | - Harold W Horowitz
- Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, United States.
| | | | - Bobbi S Pritt
- Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, United States.
| | - Daniel J Sexton
- Duke University Medical Center, Durham, NC 27710, United States.
| | - Gregory A Storch
- Washington University School of Medicine, 425 South Euclid Avenue, St. Louis, MO 63110, United States.
| | - David H Walker
- The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555-0609, United States.
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Sanchez-Vicente S, Tagliafierro T, Coleman JL, Benach JL, Tokarz R. Polymicrobial Nature of Tick-Borne Diseases. mBio 2019; 10:e02055-19. [PMID: 31506314 PMCID: PMC6737246 DOI: 10.1128/mbio.02055-19] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/07/2019] [Indexed: 01/08/2023] Open
Abstract
Tick-borne diseases have doubled in the last 12 years, and their geographic distribution has spread as well. The clinical spectrum of tick-borne diseases can range from asymptomatic to fatal infections, with a disproportionate incidence in children and the elderly. In the last few years, new agents have been discovered, and genetic changes have helped in the spread of pathogens and ticks. Polymicrobial infections, mostly in Ixodes scapularis, can complicate diagnostics and augment disease severity. Amblyomma americanum ticks have expanded their range, resulting in a dynamic and complex situation, possibly fueled by climate change. To document these changes, using molecular biology strategies for pathogen detection, an assessment of 12 microbes (9 pathogens and 3 symbionts) in three species of ticks was done in Suffolk County, New York. At least one agent was detected in 63% of I. scapularis ticksBorrelia burgdorferi was the most prevalent pathogen (57% in adults; 27% in nymphs), followed by Babesia microti (14% in adults; 15% in nymphs), Anaplasma phagocytophilum (14% in adults; 2% in nymphs), Borrelia miyamotoi (3% in adults), and Powassan virus (2% in adults). Polymicrobial infections were detected in 22% of I. scapularis ticks, with coinfections of B. burgdorferi and B. microti (9%) and of B. burgdorferi and A. phagocytophilum (7%). Three Ehrlichia species were detected in 4% of A. americanum ticks. The rickettsiae constituted the largest prokaryotic biomass of all the ticks tested and included Rickettsia amblyommatis, Rickettsia buchneri, and Rickettsia montanensis The high rates of polymicrobial infection in ticks present an opportunity to study the biological interrelationships of pathogens and their vectors.IMPORTANCE Tick-borne diseases have increased in prevalence in the United States and abroad. The reasons for these increases are multifactorial, but climate change is likely to be a major factor. One of the main features of the increase is the geographic expansion of tick vectors, notably Amblyomma americanum, which has brought new pathogens to new areas. The clinical spectrum of tick-borne diseases can range from asymptomatic to fatal infections, with a disproportionate incidence in children and the elderly. In addition, new pathogens that are cotransmitted by Ixodes scapularis have been discovered and have led to difficult diagnoses and to disease severity. Of these, Borrelia burgdorferi, the agent of Lyme disease, continues to be the most frequently transmitted pathogen. However, Babesia microti, Borrelia miyamotoi (another spirochete), Anaplasma phagocytophilum, and Powassan virus are frequent cotransmitted agents. Polymicrobial infection has important consequences for the diagnosis and management of tick-borne diseases.
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Affiliation(s)
- Santiago Sanchez-Vicente
- Department of Molecular Genetics and Microbiology and Center for Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
| | - Teresa Tagliafierro
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - James L Coleman
- Department of Molecular Genetics and Microbiology and Center for Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
| | - Jorge L Benach
- Department of Molecular Genetics and Microbiology and Center for Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
| | - Rafal Tokarz
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, New York, USA
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Abstract
Rickettsiae are globally encountered pathogens with foci of endemicity and epidemic exacerbations under circumstances of crowding and decline of sanitation. Diagnosis is often missed due to misconceptions about epidemiology, confusing terminology and nonspecific clinical presentation. Rickettsioses should be considered in children with febrile illnesses exceeding the usual duration of a viral infection, in particular in children with rash, lymphadenopathy and nearly normal first-line laboratory tests, who reside in or return from endemic areas, recall a compatible contact history, have a constellation of symptoms starting after an arthropod bite, live under troubled social circumstances, or are part of a cluster of similar cases.
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Otrock ZK, Eby CS, Burnham CAD. Human ehrlichiosis at a tertiary-care academic medical center: Clinical associations and outcomes of transplant patients and patients with hemophagocytic lymphohistiocytosis. Blood Cells Mol Dis 2019; 77:17-22. [PMID: 30913447 DOI: 10.1016/j.bcmd.2019.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ehrlichiosis is an acute febrile tick-borne disease which can rarely be a trigger for secondary hemophagocytic lymphohistiocytosis (HLH). METHODS We reviewed our experience with Ehrlichia infections at a tertiary-care academic medical center. RESULTS Over 10 years, 157 cases of ehrlichiosis were identified. Ten patients (6.4%) had infection with E. ewingii, 7(4.5%) of whom were transplant patients as compared to 3(1.9%) non-transplant patients (p = .035). Transplant patients were more likely to have leukopenia and elevated creatinine compared to immunocompetent patients; length of hospital stay and early mortality were not different between the two groups. Ten patients met the HLH-2004 diagnosis criteria, which could be an underestimation of HLH occurrence as most patients were not completely evaluated for these criteria. We calculated the H-Score to find the probability of HLH; 25 patients scored high making the occurrence rate of HLH at least 16%. Ehrlichia-induced HLH patients (N = 25) had more anemia, thrombocytopenia, elevated creatinine and AST. Moreover, they had a significantly longer hospital stay (median 9 days) compared to patients without HLH (median 4 days) (p = .006). CONCLUSIONS Ehrlichia-induced HLH is a potential serious complication with relatively high occurrence rate; patients manifest severe disease with end-organ damage requiring longer hospital stay.
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Affiliation(s)
- Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA.
| | - Charles S Eby
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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8
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Yong JSE, Loh KS, Petersson BF, Thong M. Multinodular goiter: A study of malignancy risk in nondominant nodules. EAR, NOSE & THROAT JOURNAL 2018; 96:336-342. [PMID: 28846789 DOI: 10.1177/014556131709600821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The long-standing belief that multinodular goiters are associated with a lower risk of developing into carcinoma has been challenged by the results of some recent studies. In addition, we have noticed in our practice that a sizable proportion of cancers have been arising from nondominant nodules. We performed a retrospective study of 223 cases to determine (1) the incidence of carcinoma in multinodular goiters that required surgical management in our local, predominantly Asian population and (2) the incidence of carcinoma arising from nondominant nodules. We reviewed the records of all patients with a multinodular goiter who had undergone a thyroidectomy over a period of more than 10 years in our Department of Otolaryngology-Head and Neck Surgery. We examined the histopathology reports for (1) the presence of carcinoma, (2) whether the carcinoma was isolated/unifocal or multifocal, (3) the histologic type of cancer, and (4) whether the isolated/unifocal cancers arose from the dominant or nondominant nodule. Our study population was made up of 47 males and 176 females, aged 15 to 90 years (mean: 53). We found that the incidence of malignancy in surgically treated multinodular goiters was 14.3% (32 of 223 patients). Of the 32 malignancies, 18 (56.3%) were isolated/unifocal and 14 (43.8%) were multifocal. In the isolated/unifocal group, 9 malignancies (50.0%) arose from nondominant nodules and 8 (44.4%) from dominant nodules; in the remaining case, the nodule of origin could not be determined. Our findings corroborate those in the recent literature in that the risk of malignancy associated with multinodular goiters is comparable to that of single thyroid nodules. We recommend that physicians be equally vigilant when monitoring dominant and nondominant nodules.
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Affiliation(s)
- Jenica Su-Ern Yong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074.
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Sullivan KE, Bassiri H, Bousfiha AA, Costa-Carvalho BT, Freeman AF, Hagin D, Lau YL, Lionakis MS, Moreira I, Pinto JA, de Moraes-Pinto MI, Rawat A, Reda SM, Reyes SOL, Seppänen M, Tang MLK. Emerging Infections and Pertinent Infections Related to Travel for Patients with Primary Immunodeficiencies. J Clin Immunol 2017; 37:650-692. [PMID: 28786026 PMCID: PMC5693703 DOI: 10.1007/s10875-017-0426-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/21/2017] [Indexed: 12/18/2022]
Abstract
In today's global economy and affordable vacation travel, it is increasingly important that visitors to another country and their physician be familiar with emerging infections, infections unique to a specific geographic region, and risks related to the process of travel. This is never more important than for patients with primary immunodeficiency disorders (PIDD). A recent review addressing common causes of fever in travelers provides important information for the general population Thwaites and Day (N Engl J Med 376:548-560, 2017). This review covers critical infectious and management concerns specifically related to travel for patients with PIDD. This review will discuss the context of the changing landscape of infections, highlight specific infections of concern, and profile distinct infection phenotypes in patients who are immune compromised. The organization of this review will address the environment driving emerging infections and several concerns unique to patients with PIDD. The first section addresses general considerations, the second section profiles specific infections organized according to mechanism of transmission, and the third section focuses on unique phenotypes and unique susceptibilities in patients with PIDDs. This review does not address most parasitic diseases. Reference tables provide easily accessible information on a broader range of infections than is described in the text.
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Affiliation(s)
- Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Hamid Bassiri
- Division of Infectious Diseases and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3501 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ahmed A Bousfiha
- Clinical Immunology Unit, Infectious Department, Hopital d'Enfant Abderrahim Harouchi, CHU Ibn Rochd, Laboratoire d'Immunologie Clinique, d'Inflammation et d'Allergie LICIA, Faculté de Médecine et de Pharmacie, Université Hassan II, Casablanca, Morocco
| | - Beatriz T Costa-Carvalho
- Department of Pediatrics, Federal University of São Paulo, Rua dos Otonis, 725, São Paulo, SP, 04025-002, Brazil
| | - Alexandra F Freeman
- NIAID, NIH, Building 10 Room 12C103, 9000 Rockville, Pike, Bethesda, MD, 20892, USA
| | - David Hagin
- Division of Allergy and Immunology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239, Tel Aviv, Israel
| | - Yu L Lau
- Department of Paediatrics & Adolescent Medicine, The University of Hong Kong, Rm 106, 1/F New Clinical Building, Pok Fu Lam, Hong Kong.,Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
| | - Michail S Lionakis
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), 9000 Rockville Pike, Building 10, Room 11C102, Bethesda, MD, 20892, USA
| | - Ileana Moreira
- Immunology Unit, Hospital de Niños Ricardo Gutiérrez, Gallo 1330, 1425, Buenos Aires, Argentina
| | - Jorge A Pinto
- Division of Immunology, Department of Pediatrics, Federal University of Minas Gerais, Av. Alfredo Balena 190, room # 161, Belo Horizonte, MG, 30130-100, Brazil
| | - M Isabel de Moraes-Pinto
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Federal University of São Paulo, Rua Pedro de Toledo, 781/9°andar, São Paulo, SP, 04039-032, Brazil
| | - Amit Rawat
- Pediatric Allergy and Immunology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shereen M Reda
- Pediatric Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Saul Oswaldo Lugo Reyes
- Immunodeficiencies Research Unit, National Institute of Pediatrics, Av Iman 1, Torre de Investigacion, Piso 9, Coyoacan, 04530, Mexico City, Mexico
| | - Mikko Seppänen
- Harvinaissairauksien yksikkö (HAKE), Rare Disease Center, Helsinki University Hospital (HUH), Helsinki, Finland
| | - Mimi L K Tang
- Murdoch Children's Research Institute, The Royal Children's Hospital, University of Melbourne, Melbourne, Australia
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Nitzan O, Blum A, Marva E, Katz A, Tzadok BS, Nachum-Biala Y, Baneth G, Peretz A. Case Report: Infectious Diseases in Pilgrims Visiting the Holy Land. Am J Trop Med Hyg 2017; 97:611-614. [PMID: 28722620 DOI: 10.4269/ajtmh.17-0097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Every year Christian pilgrims from around the world visit the holy sites located around the Sea of Galilee. Some become ill during their stay with infectious diseases that were acquired in their country of origin, and are hospitalized at Poriya Medical Center. They pose a diagnostic challenge due to language barriers, the rarity of these infections in Israel, and the fact that diagnostic tests are not readily available. All patient records from 2015 of Holy Land tourists hospitalized at Poriya Medical Center were screened for the diagnosis of imported zoonotic diseases that are not commonly diagnosed in Israel. Three patients who were on a Holy Land tour were hospitalized during 2015 with laboratory-confirmed diagnostically challenging zoonotic infectious diseases: a 91-year-old priest from Ethiopia diagnosed with relapsing fever due to Borrelia recurrentis, an 85-year-old retired mountaineer from New Hampshire diagnosed with human granulocytic anaplasmosis, and a 57-year-old farmer from central Brazil diagnosed with leptospirosis. These case reports emphasize the importance of considering imported zoonotic infectious diseases and obtaining appropriate diagnostic tests when treating Holy Land travelers to Israel.
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Affiliation(s)
- Orna Nitzan
- Faculty of Medicine in the Galilee, Bar Ilan University, Ramat Gan, Israel.,Infectious Disease Unit, Baruch Padeh Medical Center, Poriya, Israel
| | - Arnon Blum
- Department of Surgery A, Baruch Padeh Medical Center, Poriya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Ramat Gan, Israel
| | - Esther Marva
- Central Public Health Laboratories, Ministry of Health, Jerusalem, Israel
| | - Adina Katz
- Hematology Laboratory, Baruch Padeh Medical Center, Poriya, Israel
| | - Bat-Sheva Tzadok
- Emergency Department, Baruch Padeh Medical Center, Poriya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Ramat Gan, Israel
| | | | - Gad Baneth
- Koret School of Veterinary Medicine, Hebrew University, Rehovot, Israel
| | - Avi Peretz
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Ramat Gan, Israel
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Castagnola E, Ruberto E, Guarino A. Gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy in the years 2000. World J Gastroenterol 2016; 22:5853-5866. [PMID: 27433098 PMCID: PMC4932220 DOI: 10.3748/wjg.v22.i25.5853] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/27/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To review gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy. To look at gut microflora features in oncology children.
METHODS: We selected studies published after year 2000, excluding trials on transplanted pediatric patients. We searched English language publications in MEDLINE using the keywords: “gastrointestinal infection AND antineoplastic chemotherapy AND children”, “gastrointestinal infection AND oncology AND children”, “liver infection AND antineoplastic chemotherapy AND children”, “liver abscess AND chemotherapy AND child”, “neutropenic enterocolitis AND chemotherapy AND children”, “thyphlitis AND chemotherapy AND children”, “infectious diarrhea AND children AND oncology”, “abdominal pain AND infection AND children AND oncology”, “perianal sepsis AND children AND oncology”, “colonic pseudo-obstruction AND oncology AND child AND chemotherapy”, “microflora AND children AND malignancy”, “microbiota AND children AND malignancy”, “fungal flora AND children AND malignancy”. We also analysed evidence from several articles and book references.
RESULTS: Gastrointestinal and liver infections represent a major cause of morbidity and mortality in children undergoing antineoplastic chemotherapy. Antineoplastic drugs cause immunosuppression in addition to direct toxicity, predisposing to infections, although the specific risk is variable according to disease and host features. Common pathogens potentially induce severe diseases whereas opportunistic microorganisms may attack vulnerable hosts. Clinical manifestations can be subtle and not specific. In addition, several conditions are rare and diagnostic process and treatments are not standardized. Diagnosis may be challenging, however early diagnosis is needed for quick and appropriate interventions. Interestingly, the source of infection in those children can be exogenous or endogenous. Indeed, mucosal damage may allow the penetrance of endogenous microbes towards the bowel wall and their translocation into the bloodstream. However, only limited knowledge of intestinal dysbiosis in oncology children is available.
CONCLUSION: The diagnostic work-up requires a multimodal approach and should be implemented (also by further studies on new biomarkers) for a prompt and individualized therapy.
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12
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Biggs HM, Behravesh CB, Bradley KK, Dahlgren FS, Drexler NA, Dumler JS, Folk SM, Kato CY, Lash RR, Levin ML, Massung RF, Nadelman RB, Nicholson WL, Paddock CD, Pritt BS, Traeger MS. Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States. MMWR Recomm Rep 2016; 65:1-44. [PMID: 27172113 DOI: 10.15585/mmwr.rr6502a1] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.
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Affiliation(s)
- Holly M Biggs
- National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
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Galanakis E, Bitsori M. Rickettsioses in children: a clinical approach. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 719:145-62. [PMID: 22125042 DOI: 10.1007/978-1-4614-0204-6_13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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