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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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Xu S, He K. Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians. Transpl Immunol 2024; 83:102007. [PMID: 38307154 DOI: 10.1016/j.trim.2024.102007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.
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Affiliation(s)
- Shanshan Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China.
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3
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Other bacterial agents (4th section). Transfusion 2024; 64 Suppl 1:S243-S270. [PMID: 38394037 DOI: 10.1111/trf.17695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 02/25/2024]
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Otrock ZK, Eby CS. Zoonotic Bacterial Infections Triggering Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:285-291. [PMID: 39117822 DOI: 10.1007/978-3-031-59815-9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Zoonotic infections can result in life-threatening complications that can manifest with hemophagocytic lymphohistiocytosis (HLH)/cytokine storm syndrome (CSS). Bacteria constitute the largest group of zoonotic infection-related HLH cases. The growing list of zoonotic bacterial infections associated with HLH/CSS include Brucella spp., Rickettsia spp., Ehrlichia, Coxiella burnetii, Mycobacterium spp., and Bartonella spp. Patients most commonly present with fever, cytopenias, hepatosplenomegaly, myalgias, and less frequently with rash, jaundice, and lymphadenopathy.
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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
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Eloseily EM, Cron RQ. Bacteria-Associated Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:275-283. [PMID: 39117821 DOI: 10.1007/978-3-031-59815-9_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
While viruses are considered the most common infectious triggers for cytokine storm syndromes (CSS), a growing list of bacterial pathogens, particularly intracellular organisms, have been frequently reported to be associated with this syndrome. Both familial and sporadic cases of CSS are often precipitated by acute infections. It is also important to note that an underlying precipitating infection might not be clinically obvious as the CSS clinical picture can mimic an infectious process or an overwhelming septicemia. It is important to detect such an underlying treatable condition. In addition, infections can also be acquired during the course of CSS due to the concurrent immune suppression with treatment. Optimal CSS outcomes require treating bacterial infections when recognized.CSS should always be suspected in patients presenting with a sepsis-like or multi-organ dysfunction picture. There are many criteria proposed to diagnose CSS in general, with HLH-2004 being the most commonly used. Alternatively, criteria have been proposed for CSS occurring in specific underlying conditions such as systemic lupus erythematosus (SLE) or systemic juvenile idiopathic arthritis (sJIA). However, waiting for many of these criteria to be fulfilled could lead to significant delay in diagnosis, and the physician needs a high index of suspicion for CSS in critically ill febrile hospitalized patients in order to properly recognize the condition. Thus, there should be diagnostic equipoise between CSS and infections, including bacterial, in this population. In this chapter, we discuss the more common bacterial precipitants of CSS with many of the cases being discussed in the pediatric age group.
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Affiliation(s)
| | - Randy Q Cron
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL, USA.
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Flea-Borne Typhus Causing Hemophagocytic Lymphohistiocytosis: An Autopsy Case. Infect Dis Rep 2023; 15:132-141. [PMID: 36826354 PMCID: PMC9956947 DOI: 10.3390/idr15010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/05/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
Infection with members of the order Rickettsiales (the genera Rickettsia, Anaplasma, Orientia, and Ehrlichia) is known to cause hemophagocytic lymphohistiocytosis (HLH). The literature is scant on flea-borne typhus (FBT) being implicated in this process. We present a case of autopsy-proven HLH caused by FBT in a 71-year-old diabetic female who was initially suspected of having diabetic ketoacidosis who rapidly suffered decompensated multi-organ failure. Although she was suspected of having FBT and HLH pre-mortem, due to her rapid progression to multi-organ failure, she was transitioned to comfort care by her family five days after admission. A literature search yielded five other cases of HLH secondary to FBT, which are analyzed in this review. The literature on HLH occurring with infection due to other members of the order Rickettsiales is also surveyed.
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Ehrlichiosis-Associated Hemophagocytic Lymphohistiocytosis: A Case Series and Review of the Literature. Case Rep Hematol 2023; 2023:5521274. [PMID: 36846547 PMCID: PMC9946753 DOI: 10.1155/2023/5521274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/18/2023] Open
Abstract
Background Human monocytic ehrlichiosis (HME) is a potentially life-threatening tick-borne illness. HME-associated hemophagocytic lymphohistiocytosis (HLH) is a rare entity with a paucity of published literature regarding treatment and outcome. We present the clinical features, treatment, and outcomes of 4 patients at our institutions with HME-associated HLH. This review also summarizes the current literature regarding the presentation, treatment, and outcome of this infection-related HLH. Methods We searched the PubMed database for case reports and case series. All cases were diagnosed according to the HLH-04 criteria. Results Four cases of HME-associated HLH were included from our institutions. The literature review yielded 30 additional cases. About 41% of the cases were in the pediatric population; 59% were female; and all patients had fever, cytopenia, and elevated ferritin. Most patients were immunocompetent; all but one patient with available data were treated with doxycycline, and eight of the patients with available data received the HLH-94 treatment protocol. The mortality rate was 17.6%. Conclusions HME-associated HLH is a rare but serious syndrome with significant mortality. Early treatment with doxycycline is critical, but the role of immunosuppressive therapy is individualized.
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Baradaran H, Hashem Zadeh A, Dashti-Khavidaki S, Laki B. Management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation: A comprehensive review. J Clin Pharm Ther 2022; 47:1895-1912. [PMID: 36250775 DOI: 10.1111/jcpt.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Advances in the development of more effective immunosuppressive drugs have increased graft survival and drug induced adverse effects. Haematological complications including neutropenia, thrombocytopenia, and anaemia are common side effects that affect the grafts' and patients' outcomes. Several studies have stated the important role of various medications in haematological complications after transplantation. They have reported the incidence and different mechanisms of drug induced cytopenia, as well as an overview of possible treatment modalities. However, there is no comprehensive protocol for the management of these complications following transplantation. This narrative review was performed to develop a comprehensive practical approach for management of drug induced haematological complications following solid organ transplantation. METHOD PubMed, Embase, Cochrane library, Web of Science, and Google scholar databases were searched without time limitations until March, 2021. In addition, some valid drug information data bases (Uptodate and Micromedex) were searched for detailed information until October, 2021. RESULTS AND DISCUSSION Several immunosuppressive and antimicrobial medications may induce neutropenia, thrombocytopenia or anaemia following transplantation. Most of these agents cause dose-related cytopenia, which resolves with dose reduction or drug withdrawal. However, any change in medications may result in negative consequences such as severe infections, bleeding, cardiovascular complications, acute allograft rejection, and graft or patient loss. Thus, cautious evaluation of the patient's condition and the pharmacological properties of the culprit medication are required. WHAT IS NEW AND CONCLUSION Three algorithms are presented to guide healthcare providers in the stepwise management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation.
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Affiliation(s)
- Hananeh Baradaran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Simin Dashti-Khavidaki
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahareh Laki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Singh NS, Pagano AL, Hays AJ, Kats A, Dahl SM, Warady BA, Beins NT, Yin DE. Ehrlichia-induced hemophagocytic lymphohistiocytosis in a pediatric kidney transplant recipient. Pediatr Transplant 2022; 26:e14134. [PMID: 34595809 DOI: 10.1111/petr.14134] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/03/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Kidney transplant patients are susceptible to a variety of infections in the post-transplant period due to the use of immunosuppressant medications. Ehrlichiosis is a rare infection in solid organ transplant recipients with signs and symptoms that mimic rejection and other viral infections. Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyperinflammatory syndrome that can be triggered by infections. METHODS We describe a pediatric kidney transplant recipient who experienced secondary HLH due to ehrlichiosis within the initial post-transplant month. RESULT Our patient improved after treatment with doxycycline, corticosteroids, and intravenous immunoglobulin (IVIG). CONCLUSION Clinicians should consider infections such as ehrlichiosis as a potential cause of illness in febrile solid organ transplant recipients in immediate post-transplant period, especially when accompanied by a compatible exposure history.
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Affiliation(s)
- Nisha S Singh
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Alexa L Pagano
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Kansas, USA
| | - Allyson J Hays
- Department of Pediatric Hematology and Oncology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Alexander Kats
- Division of Pathology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Steven M Dahl
- Divisions of Infectious Diseases and Clinical Pharmacology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Nathan T Beins
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Dwight E Yin
- Divisions of Infectious Diseases and Clinical Pharmacology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
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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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Challenges of Diagnosing Severe Ehrlichiosis in Orthotopic Liver Transplant Recipients. Case Rep Transplant 2021; 2021:8285326. [PMID: 34840851 PMCID: PMC8612778 DOI: 10.1155/2021/8285326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022] Open
Abstract
In recent solid organ transplant recipients, acute febrile illness is usually a source of grave concern and a diagnostic dilemma, especially if no response is noted after initiation of broad antimicrobial therapy. Human Monocytic Ehrlichiosis (HME) is a tick-borne illness caused by Ehrlichia chaffeensis and is not considered an opportunistic infection in immunocompromised patients such as solid organ transplant patients. Ehrlichiosis in immunocompromised patients can be life-threatening, and a strong index of suspicion is needed, especially in patients who live in endemic areas, for proper treatment initiation with doxycycline. We report a case of a 40-year-old male who received an orthotopic liver transplant six months earlier secondary to primary sclerosing cholangitis, on chronic immunosuppressive medication, who presented with complaints of sudden onset fever associated with nausea, vomiting, and diarrhea. Initial extensive infectious workup was negative and no response to empiric antimicrobials. There was suspicion for ehrlichiosis prompting empiric doxycycline use. Subsequently, E. chaffeensis polymerase chain reaction (PCR) was positive, and the antibiotic regimen was de-escalated to only doxycycline with complete resolution of his symptoms and progressive improvement in previously abnormal biochemical indices.
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Saha A, Browning C, Dandamudi R, Barton K, Graepel K, Cullity M, Abusalah W, Christine D, Rossi C, Drexler N, Basavaraju S, Annambhotia P, Guillamet RV, Eid AJ, Maliakkal J, Miller A, Hugge C, Dharnidharka VR, Kandula P, Moritz MJ. Donor-derived ehrlichiosis: two clusters following solid organ transplantation. Clin Infect Dis 2021; 74:918-923. [PMID: 34329411 DOI: 10.1093/cid/ciab667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 11/14/2022] Open
Abstract
Ehrlichiosis has been infrequently described as transmissible through organ transplantation. Two donor derived clusters of ehrlichiosis are described here. During the summer of 2020, two cases of ehrlichiosis were reported to the Organ Procurement and Transplantation Network (OPTN) and the Centers for Disease Control and Prevention (CDC) for investigation. Additional transplant centers were contacted to investigate similar illness in other recipients and samples were sent to CDC. Two kidney recipients from a common donor developed fatal ehrlichiosis-induced hemophagocytic lymphocytic histiocytosis (HLH). Two kidney recipients and a liver recipient from another common donor developed ehrlichiosis. All three were successfully treated. Clinicians should consider donor-derived ehrlichiosis when evaluating recipients with fever early after transplantation after more common causes are ruled out, especially if the donor has epidemiological risk factors for infection. Suspected cases should be reported to the organ procurement organization (OPO) and the OPTN for further investigation by public health authorities.
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Affiliation(s)
- Aditi Saha
- Renal and Pancreas Transplant Division and Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Charles Browning
- Department of Transplant Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Raja Dandamudi
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Kevin Barton
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Kevin Graepel
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Madeline Cullity
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wala Abusalah
- Renal and Pancreas Transplant Division and Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Du Christine
- Department of Transplant Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Carla Rossi
- Department of Infectious Disease, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Naomi Drexler
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sridhar Basavaraju
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pallavi Annambhotia
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Albert J Eid
- Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph Maliakkal
- Division of Pediatric Nephrology, Saint Louis University, Missouri, USA
| | - Aaron Miller
- Division of Pediatric Infectious Disease, Saint Louis University, Missouri, USA
| | - Christopher Hugge
- Division of Pediatric Hematology Oncology, Saint Louis University, Missouri, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Praveen Kandula
- Renal and Pancreas Transplant Division and Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Michael J Moritz
- Department of Transplant Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
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Kuriakose K, Pettit AC, Schmitz J, Moncayo A, Bloch KC. Assessment of Risk Factors and Outcomes of Severe Ehrlichiosis Infection. JAMA Netw Open 2020; 3:e2025577. [PMID: 33201233 PMCID: PMC7672514 DOI: 10.1001/jamanetworkopen.2020.25577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Ehrlichiosis cases in the US have increased more than 8-fold since 2000. Up to 57% of patients with ehrlichiosis require hospitalization and 11% develop a life-threatening complication; however, risk factors for serious disease are not well documented. OBJECTIVE To examine risk factors associated with severe ehrlichiosis. DESIGN, SETTING, AND PARTICIPANTS An analytic cross-sectional study of patients diagnosed with ehrlichiosis by polymerase chain reaction (PCR) between January 1, 2007, and December 31, 2017, was conducted in a single tertiary-care center in a region endemic for ehrlichiosis. Analysis was performed from February 27, 2018, to September 9, 2020. A total of 407 positive Ehrlichia PCR results were identified from 383 unique patients, with 155 unique patients meeting study criteria. Patients hospitalized at other institutions who had a positive Ehrlichia PCR performed as a reference test (n = 222) were excluded as no clinical data were available. Electronic medical record review was performed to collect demographic, clinical, laboratory, treatment, and outcomes data. Cases were excluded when there were insufficient clinical data to assess the severity of illness (n = 3) and when the clinical illness did not meet the case definition for ehrlichiosis (n = 3). EXPOSURES Date of presentation, onset of symptoms, date of PCR testing, date of treatment initiation, site of care, age, birth sex, race/ethnicity, Charlson Comorbidity Index, trimethoprim with sulfamethoxazole use within the prior 2 weeks, and immunosuppression. MAIN OUTCOMES AND MEASURES Requirement for intensive care unit (ICU) admission. RESULTS Of the 155 patients who met inclusion criteria, 99 patients (63.9%) were men, and 145 patients (93.5%) identified as non-Hispanic White; median age was 50 years (interquartile range, 23-64 years). Intensive care unit admission was indicated in 43 patients (27.7%), 94 patients (60.6%) were hospitalized on general medical floors, and 18 patients (11.6%) received care as outpatients. In adjusted analysis, time to treatment initiation was independently associated with an increased risk for ICU admission (adjusted prevalence ratio [aPR], 1.09; 95% CI, 1.04-1.14; P < .001). Documentation of tick exposure was independently associated with a decreased risk for ICU admission (aPR, 0.54; 95% CI, 0.34-0.86; P = .01). There appeared to be a nonsignificant change toward a decreased need for ICU care among immunosuppressed persons (aPR, 0.51; 95% CI, 0.26-1.00; P = .05). CONCLUSIONS AND RELEVANCE This study suggests that delay in initiation of doxycycline therapy is a significant factor associated with severe ehrlichiosis. Increased recognition of infection by front-line clinicians to promote early treatment may improve outcomes associated with this increasingly common and life-threatening infection.
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Affiliation(s)
- Kevin Kuriakose
- Section of Infectious Disease, Renown Health, Reno, Nevada
- Department of Medicine, School of Medicine, University of Nevada, Reno
| | - April C. Pettit
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Schmitz
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Abelardo Moncayo
- Vector-Borne Disease Section, Tennessee Department of Health, Nashville
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen C. Bloch
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Agudelo Higuita NI, Yuen C. Hemophagocytic Lymphohistiocytosis Secondary to Ehrlichia Chaffeensis in Adults: A Case Series From Oklahoma. Am J Med Sci 2020; 361:269-273. [PMID: 32928497 DOI: 10.1016/j.amjms.2020.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation that occurs as either a familial disorder or as a sporadic condition in association with a variety of triggers. Infections are the most common cause of HLH in adults and should be searched for as early treatment usually results in a favorable outcome. Human monocytotropic ehrlichiosis (HME) is a very rare cause of HLH. Failure to consider ehrlichiosis can result in misdiagnosis and an increased length of hospitalization and healthcare cost as described in our report. Treatment for secondary HLH is aimed at reducing hypercytokinemia and eradicating inflammatory and infected cells. It is important to promptly initiate doxycycline when tick-borne diseases are being entertained as a possible trigger, as the antibiotic is effective, safe and inexpensive.
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Affiliation(s)
- Nelson Iván Agudelo Higuita
- Section of Infectious Diseases, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Carrie Yuen
- Section of Hematology and Oncology, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Masterson EM, Gupta S, Jakharia N, Peacock JE. Ehrlichiosis in a recent kidney transplant recipient: The repellent that did not repel! A case report and literature review of ehrlichiosis in solid organ transplant patients. Transpl Infect Dis 2020; 22:e13299. [PMID: 32306509 DOI: 10.1111/tid.13299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/05/2020] [Accepted: 04/13/2020] [Indexed: 11/29/2022]
Abstract
Ehrlichiosis has been infrequently reported in immunosuppressed patients such as solid organ transplants (SOT). We report a case of Ehrlichia chaffeensis infection in an immunosuppressed woman four months after deceased donor kidney transplantation. The diagnosis was confirmed by PCR testing in serum, and the patient responded promptly to treatment with doxycycline. To supplement our Case Report, a literature review encompassing 1995 to present was also performed using PubMed as the search vehicle. Search terms that were utilized include: ehrlichiosis, HME, E chaffeensis, kidney transplant(ation), renal transplant(ation), solid organ transplant(ation), and immunosuppression. The diagnosis of ehrlichiosis can be challenging in SOT patients since ehrlichiosis is not a classic opportunistic infection in SOT. Transplant physicians must have a high clinical suspicion for the diagnosis in patients with an acute febrile illness accompanied by headache, worsening cytopenias, and transaminitis who live in endemic areas, especially if they have tick exposure.
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Affiliation(s)
| | - Siddhi Gupta
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Niyati Jakharia
- Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Internal Medicine, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - James E Peacock
- Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Internal Medicine, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
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