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Liu H, Knox CA, Jakkula LUMR, Wang Y, Peddireddi L, Ganta RR. Evaluating EcxR for Its Possible Role in Ehrlichia chaffeensis Gene Regulation. Int J Mol Sci 2022; 23:12719. [PMID: 36361509 PMCID: PMC9657007 DOI: 10.3390/ijms232112719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 04/14/2024] Open
Abstract
Ehrlichia chaffeensis, a tick-transmitted intraphagosomal bacterium, is the causative agent of human monocytic ehrlichiosis. The pathogen also infects several other vertebrate hosts. E. chaffeensis has a biphasic developmental cycle during its growth in vertebrate monocytes/macrophages and invertebrate tick cells. Host- and vector-specific differences in the gene expression from many genes of E. chaffeensis are well documented. It is unclear how the organism regulates gene expression during its developmental cycle and for its adaptation to vertebrate and tick host cell environments. We previously mapped promoters of several E. chaffeensis genes which are recognized by its only two sigma factors: σ32 and σ70. In the current study, we investigated in assessing five predicted E. chaffeensis transcription regulators; EcxR, CtrA, MerR, HU and Tr1 for their possible roles in regulating the pathogen gene expression. Promoter segments of three genes each transcribed with the RNA polymerase containing σ70 (HU, P28-Omp14 and P28-Omp19) and σ32 (ClpB, DnaK and GroES/L) were evaluated by employing multiple independent molecular methods. We report that EcxR binds to all six promoters tested. Promoter-specific binding of EcxR to several gene promoters results in varying levels of gene expression enhancement. This is the first detailed molecular characterization of transcription regulators where we identified EcxR as a gene regulator having multiple promoter-specific interactions.
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Affiliation(s)
| | | | | | | | | | - Roman R. Ganta
- Center of Excellence for Vector-Borne Diseases (CEVBD), Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506, USA
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2
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Jabr R, El Atrouni W. Ehrlichiosis mimicking acute leukemia. IDCases 2022; 28:e01480. [PMID: 35402161 PMCID: PMC8987808 DOI: 10.1016/j.idcr.2022.e01480] [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: 12/20/2021] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/27/2022] Open
Abstract
Human monocytic ehrlichiosis is a tickborne disease with a spectrum of presentations ranging from asymptomatic, mild to fatal. Ehrlichiosis can transiently cause white blood cells abnormalities that mimic leukemia/lymphoma and cases have been, on rare occasions, initially mistaken for hematological malignancies. We report a case of Ehrlichia chaffeensis infection suspected to be acute promyelocytic leukemia at presentation, prompting therapy with all-trans-retinoic acid. Physicians should keep tickborne transmitted illnesses on the differential in patients presenting with pancytopenia, especially in endemic areas.
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3
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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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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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5
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"Ain't She a Bute?": The Importance of Proper History Taking in a Case of Inappropriate Use of Horse NSAID in a Human. Clin Pract 2021; 11:455-458. [PMID: 34287244 PMCID: PMC8293124 DOI: 10.3390/clinpract11030060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 11/16/2022] Open
Abstract
A 41-year-old woman with no significant past medical history presented to the hospital with complaints of nausea, vomiting, and generalized weakness over two weeks. The patient did not seek medical attention as she assumed that her symptoms willwould resolve. Following her initial denial of drug abuse and her abnormal urine drug screening, we discussed the findings with the patient. She later admitted to using both amphetamines and marijuana. This led us to take a detailed social history that revealed an unexpected event.
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Ladzinski AT, Baker M, Dunning K, Patel PP. Human Granulocytic Anaplasmosis presenting as Subacute Abdominal Pain and Hyponatremia. IDCases 2021; 25:e01183. [PMID: 34189035 PMCID: PMC8220232 DOI: 10.1016/j.idcr.2021.e01183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/18/2021] [Accepted: 06/09/2021] [Indexed: 12/03/2022] Open
Abstract
Human Granulocytic Anaplasmosis (HGA) is an acute febrile tick-borne illness caused by the organism Anaplasma phagocytophilum. Patients often present with fever and a flu-like symptoms following a tick bite. In this case, the patient presented with subacute abdominal pain and severe hyponatremia consistent with SIADH. The patient was started on appropriate empiric antibiotics given the patient’s tick exposure. Blood smear confirmed findings consistent with HGA and the patient continued antibiotic treatment with resolution of his symptoms. This case is unique in that the patient presented with severe hyponatremia that improved with treatment of the HGA. He also had subacute abdominal pain which is also a rare presentation of HGA. Our hope is that our case highlights the value of empiric treatment with appropriate monitoring to prevent downstream, severe sequelae from undiagnosed HGA. In the setting of climate change, increased duration of Ixodes spp. tick life cycles with emerging regional distribution of the ticks, coinfections with Borrelia burgdorferi and increased incidence of HGA in the last two decades, it is important to recognize this entity.
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Affiliation(s)
- Adam Timothy Ladzinski
- Department of Internal Medicine, Western Michigan University Homer Stryker M D School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, USA
| | - Melissa Baker
- Department of Internal Medicine, Western Michigan University Homer Stryker M D School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, USA
| | - Karla Dunning
- Pathology Services of Kalamazoo, 601 John St., Kalamazoo, MI, USA
| | - Prashant P Patel
- Department of Internal Medicine, Western Michigan University Homer Stryker M D School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, USA
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Radhika SR, Shilpa K, Hongal AA, Revathi TN. "TOPONYM" conditions in dermatology. Indian J Dermatol Venereol Leprol 2021; 88:123-127. [PMID: 33969665 DOI: 10.25259/ijdvl_664_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 02/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
| | - Kanathur Shilpa
- Department of Dermatology, Veneorology, Leprosy, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Amrita Anandkumar Hongal
- Department of Dermatology, Veneorology, Leprosy, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - T N Revathi
- Department of Dermatology, Veneorology, Leprosy, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
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8
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Lessner K, Krawiec C. Tick-Borne-Associated Illnesses in the Pediatric Intensive Care Unit. J PEDIAT INF DIS-GER 2020. [DOI: 10.1055/s-0040-1717149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractWhen unrecognized and antibiotic delay occurs, Lyme disease, Rocky Mountain–spotted fever, babesiosis, and human ehrlichiosis and anaplasmosis can result in multiorgan system dysfunction and potentially death. This review focuses on the early recognition, evaluation, and stabilization of the rare life-threatening sequelae seen in tick-borne illnesses that require admission in the pediatric intensive care unit.
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Affiliation(s)
- Kaila Lessner
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia, United States
| | - Conrad Krawiec
- Department of Pediatrics, Penn State Children's Hospital, Pediatric Critical Care Medicine, Hershey, Pennsylvania, United States
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9
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Cabler SS, Hogan PG, Fritz SA, Bednarski JJ, Hunstad DA. Incidence and treatment of hemophagocytic lymphohistiocytosis in hospitalized children with Ehrlichia infection. Pediatr Blood Cancer 2020; 67:e28436. [PMID: 32706439 DOI: 10.1002/pbc.28436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/23/2022]
Abstract
We report a large cohort of pediatric patients with human monocytic ehrlichiosis (HME), enabling an estimated incidence of secondary hemophagocytic lymphohistiocytosis (HLH) in hospitalized children with HME. Among 49 children with PCR-confirmed Ehrlichia infection, 8 (16%) met current criteria for HLH. Those with HLH had more significant hematologic abnormalities and longer durations from symptom onset to admission and definitive anti-infective therapy. Among these eight, three received chemotherapy plus doxycycline, one of whom died; the other five were treated with doxycycline without chemotherapy, and all survived without HLH recurrence. Our findings demonstrate that antimicrobial therapy alone can successfully resolve Ehrlichia-associated HLH.
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Affiliation(s)
- Stephanie S Cabler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick G Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie A Fritz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey J Bednarski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - David A Hunstad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
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10
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Raibin K, Levy I, Atiya Nasagi Y, Ashkenazi‐Hoffnung L, Sherman G, Avneri L, Landau D, Scheuerman O. Atypical presentation of human ehrlichiosis and anaplasmosis in children in Israel. Acta Paediatr 2019; 108:1727-1728. [PMID: 31140643 DOI: 10.1111/apa.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Karine Raibin
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
| | - Itzhak Levy
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | | | - Liat Ashkenazi‐Hoffnung
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Gilad Sherman
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Liad Avneri
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Department of Pediatrics C Schneider Children's Medical Center of Israel Petach Tikva Israel
| | - Daniel Landau
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Oded Scheuerman
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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11
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Affiliation(s)
- Jennifer S Read
- Department of Pediatrics, University of Vermont Medical Center, Burlington, VT.,Infectious Disease Epidemiology, Vermont Department of Health, Burlington, VT
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12
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Mylonakis ME, Harrus S, Breitschwerdt EB. An update on the treatment of canine monocytic ehrlichiosis (Ehrlichia canis). Vet J 2019; 246:45-53. [PMID: 30902188 DOI: 10.1016/j.tvjl.2019.01.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/26/2019] [Accepted: 01/30/2019] [Indexed: 12/14/2022]
Abstract
Canine monocytic ehrlichiosis (CME), caused by Ehrlichia canis, a gram-negative, obligate intracellular bacterium, is a tick-borne disease of worldwide distribution. Experimentally, the course of E. canis infection can be sequentially divided into acute, subclinical and chronic phases, although distinction of these phases is challenging in the clinical setting. Spontaneous clinical recovery of acutely infected dogs is common; however, dogs at this stage require medical treatment in order to hasten their clinical recovery, and to prevent clinical exacerbation or death. An unpredictable proportion of subclinically infected dogs will eventually develop the chronic, severe form of ehrlichiosis, characterized by aplastic pancytopenia and high mortality. The aims of antimicrobial treatment in CME include the achievement of clinical remission, resolution of the clinicopathologic abnormalities, and eradication of the infection, although the latter is not always feasible or diagnostically confirmable. Treatment of dogs with aplastic pancytopenia should be undertaken with the clear understanding that medical management will require long-term care, will be expensive, and may eventually prove ineffective. This manuscript reviews the current state of knowledge regarding treatment of ehrlichiosis, caused by E. canis infection in dogs, provides expert opinion guidelines for the management of the CME-associated aplastic pancytopenia, and outlines methods for evaluation of treatment outcomes.
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Affiliation(s)
- Mathios E Mylonakis
- Companion Animal Clinic, School of Veterinary Medicine, Aristotle University of Thessaloniki, 11 Stavrou Voutyra st., Thessaloniki 54627, Greece.
| | - Shimon Harrus
- Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, P.O. Box 12, Rehovot 76100, Israel
| | - Edward B Breitschwerdt
- Intracellular Pathogens Research Laboratory, Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University (NCSU-CVM),1060 William Moore Drive, Raleigh, NC 27607 USA
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13
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Samson M, Wilcox SR, Liu SW. Rash and Thrombocytopenia. J Emerg Med 2018; 55:710-713. [PMID: 30262250 DOI: 10.1016/j.jemermed.2018.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/20/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Margot Samson
- University of Central Florida College of Medicine, Orlando, Florida
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Shan W Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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15
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Abstract
Human ehrlichiosis and anaplasmosis are acute febrile tick-borne infectious diseases caused by various members from the genera Ehrlichia and Anaplasma. Ehrlichia chaffeensis is the major etiologic agent of human monocytotropic ehrlichiosis (HME), while Anaplasma phagocytophilum is the major cause of human granulocytic anaplasmosis (HGA). The clinical manifestations of HME and HGA ranges from subclinical to potentially life-threatening diseases associated with multi-organ failure. Macrophages and neutrophils are the major target cells for Ehrlichia and Anaplasma, respectively. The threat to public health is increasing with newly emerging ehrlichial and anaplasma agents, yet vaccines for human ehrlichioses and anaplasmosis are not available, and therapeutic options are limited. This article reviews recent advances in the understanding of HME and HGA.
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Abstract
We present a previously healthy 16-year-old male with ehrlichiosis-induced aseptic meningitis and subsequent second-degree heart block.
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Minasyan H. Mechanisms and pathways for the clearance of bacteria from blood circulation in health and disease. PATHOPHYSIOLOGY 2016; 23:61-6. [DOI: 10.1016/j.pathophys.2016.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/03/2016] [Accepted: 03/05/2016] [Indexed: 01/13/2023] Open
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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: 286] [Impact Index Per Article: 35.8] [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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Hanson HR, Pomerantz WJ. History of Tick Bite: A Gift or a Red Herring? Pediatr Emerg Care 2015; 31:844-5. [PMID: 26626892 DOI: 10.1097/pec.0000000000000630] [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] [Indexed: 11/25/2022]
Abstract
Fever of unknown origin can be challenging to the emergency medicine physician and the array of both benign and potentially life-threatening diagnoses on the differential can lead to a costly, time-consuming work-up. In this article, we present a case of potentially fatal tick-borne illness with a focus on history, physical exam, and laboratory findings that would differentiate this diagnosis from other causes of fever of unknown origin and aid in early and efficient initiation of treatment for patients.
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Affiliation(s)
- Holly R Hanson
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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20
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Otrock ZK, Gonzalez MD, Eby CS. Ehrlichia-Induced Hemophagocytic Lymphohistiocytosis: A Case Series and Review of Literature. Blood Cells Mol Dis 2015; 55:191-3. [DOI: 10.1016/j.bcmd.2015.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
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Mukkada S, Buckingham SC. Recognition of and Prompt Treatment for Tick-Borne Infections in Children. Infect Dis Clin North Am 2015; 29:539-55. [PMID: 26188606 DOI: 10.1016/j.idc.2015.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Tick-borne infections create diagnostic challenges because they tend to present with nonspecific findings. Because clinicians often fail to recognize tick-borne illnesses in early stages, therapy is frequently delayed or omitted. This is especially problematic for rickettsial infections (Rocky Mountain spotted fever, ehrlichiosis, and anaplasmosis), because the risk of long-term morbidity and mortality increases with delayed treatment. We emphasize the need for clinicians to maintain a high index of suspicion for tick-borne infections; to diagnose these illnesses presumptively, without waiting for confirmatory laboratory test results; and to promptly start therapy with doxycycline, even in young children, when rickettsial infections are suspected.
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Affiliation(s)
- Sheena Mukkada
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee College of Medicine, 50 North Dunlap Street, Memphis, TN 38103, USA; Department of Infectious Diseases, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Steven C Buckingham
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee College of Medicine, 50 North Dunlap Street, Memphis, TN 38103, USA.
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Buckingham SC. Tick-borne diseases of the USA: Ten things clinicians should know. J Infect 2015; 71 Suppl 1:S88-96. [DOI: 10.1016/j.jinf.2015.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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Statler VA, Marshall GS. Hemophagocytic lymphohistiocytosis induced by monocytic ehrlichiosis. J Pediatr 2015; 166:499-99.e1. [PMID: 25449215 DOI: 10.1016/j.jpeds.2014.09.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Victoria A Statler
- Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
| | - Gary S Marshall
- Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
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24
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Vijayan V, Thambundit A, Sukumaran S. Hemophagocytic lymphohistiocytosis secondary to ehrlichiosis in a child. Clin Pediatr (Phila) 2015; 54:84-6. [PMID: 24691079 DOI: 10.1177/0009922814529183] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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25
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Abstract
A 65-year-old female with a history of multiple tick bites presented with fever and pancytopenia. Intracytoplasmic rickettsial morulae were detected on peripheral smear and bone marrow biopsy specimens, and PCR amplified Ehrlichia ewingii DNA from both specimens. To our knowledge, this is the first report of E. ewingii infection of human bone marrow.
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26
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Minasyan H. Erythrocyte and blood antibacterial defense. Eur J Microbiol Immunol (Bp) 2014; 4:138-43. [PMID: 24883200 DOI: 10.1556/eujmi.4.2014.2.7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 04/10/2014] [Indexed: 12/30/2022] Open
Abstract
UNLABELLED It is an axiom that blood cellular immunity is provided by leukocytes. As to erythrocytes, it is generally accepted that their main function is respiration. Our research provides objective video and photo evidence regarding erythrocyte bactericidal function. Phase-contrast immersion vital microscopy of the blood of patients with bacteremia was performed, and the process of bacteria entrapping and killing by erythrocytes was shot by means of video camera. Video evidence demonstrates that human erythrocytes take active part in blood bactericidal action and can repeatedly engulf and kill bacteria of different species and size. Erythrocytes are extremely important integral part of human blood cellular immunity. COMPARED WITH PHAGOCYTIC LEUKOCYTES, THE ERYTHROCYTES a) are more numerous; b) are able to entrap and kill microorganisms repeatedly without being injured; c) are more resistant to infection and better withstand the attacks of pathogens; d) have longer life span and are produced faster; e) are inauspicious media for proliferation of microbes and do not support replication of chlamidiae, mycoplasmas, rickettsiae, viruses, etc.; and f) are more effective and uncompromised bacterial killers. Blood cellular immunity theory and traditional view regarding the function of erythrocytes in human blood should be revised.
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Abstract
Rocky Mountain spotted fever is typically undifferentiated from many other infections in the first few days of illness. Treatment should not be delayed pending confirmation of infection when Rocky Mountain spotted fever is suspected. Doxycycline is the drug of choice even for infants and children less than 8 years old.
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Affiliation(s)
- James W Antoon
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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29
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Ehrlichia Myocarditis in an Adolescent. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2012. [DOI: 10.1097/ipc.0b013e318248f168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Hamlen R. Tick-borne infections--a growing public health treat to school-age children. Prevention steps that school personnel can take. NASN Sch Nurse 2012; 27:94-100. [PMID: 22567784 DOI: 10.1177/1942602x11427928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
School nurses are experts in school health services and frequently front-line providers of care for school-age children presenting with symptoms of physical illness or behavioral, cognitive, learning, and/or psychological problems possibly due to tick-borne infections. School nurses need to know how to protect children on school property and during school sponsored outdoor activities from being bitten by ticks that can transmit diseases. Since infection prevention is a primary objective in health care, this article will empower school nurses with key information about how to accomplish this goal.
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Affiliation(s)
- Ronald Hamlen
- Lyme Disease Association of Southeastern Pennsylvania, Inc., Kennett Square, PA, USA
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31
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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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32
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Answer to July 2011 Photo Quiz. J Clin Microbiol 2011. [DOI: 10.1128/jcm.r00081-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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33
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Affiliation(s)
- Julie E Reznicek
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Abstract
Human ehrlichiosis and anaplasmosis are acute febrile tick-borne diseases caused by various members of the genera Ehrlichia and Anaplasma (Anaplasmataceae). Human monocytotropic ehrlichiosis has become one of the most prevalent life-threatening tick-borne disease in the United States. Ehrlichiosis and anaplasmosis are becoming more frequently diagnosed as the cause of human infections, as animal reservoirs and tick vectors have increased in number and humans have inhabited areas where reservoir and tick populations are high. Ehrlichia chaffeensis, the etiologic agent of human monocytotropic ehrlichiosis (HME), is an emerging zoonosis that causes clinical manifestations ranging from a mild febrile illness to a fulminant disease characterized by multiorgan system failure. Anaplasma phagocytophilum causes human granulocytotropic anaplasmosis (HGA), previously known as human granulocytotropic ehrlichiosis. This article reviews recent advances in the understanding of ehrlichial diseases related to microbiology, epidemiology, diagnosis, pathogenesis, immunity, and treatment of the 2 prevalent tick-borne diseases found in the United States, HME and HGA.
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Abstract
PURPOSE OF REVIEW Fever and a rash following a tick bite can signify a true medical emergency. Ticks are important vectors of disease worldwide, including Rocky Mountain spotted fever, Lyme disease, and Congo-Crimean hemorrhagic fever. This paper will review the major ticks of medical importance and the diseases they transmit, including important emerging pathogens. RECENT FINDINGS Rocky Mountain spotted fever continues to be the most lethal tick-borne illness in the United States and is emerging as an important disease in South America. Other important emerging diseases include human anaplasmosis, southern tick associated rash illness, human monocytic ehrlichiosis, and a variety of rickettsial fevers including those caused by Rickettsia parkeri and Rickettsia amblyommii. SUMMARY Most tick-borne illnesses respond readily to doxycycline therapy. In the case of Rocky Mountain spotted fever, therapy should be started when the disease is suspected and should never be delayed for confirmatory tests. Accurate identification of tick vectors can help establish a diagnosis and can help guide preventive measures to reduce the burden of disease.
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Esbenshade A, Esbenshade J, Domm J, Williams J, Frangoul H. Severe ehrlichia infection in pediatric oncology and stem cell transplant patients. Pediatr Blood Cancer 2010; 54:776-8. [PMID: 20052776 DOI: 10.1002/pbc.22392] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Ehrlichiosis, a tickborne illness transmitted by tick vectors Amblyomma americanum and Ixodes scapularis, can be acquired in endemic areas. Clinical manifestations range from asymptomatic to fulminant in nature. We report three cases of ehrlichiosis in pediatric oncology patients, one of whom was a stem cell transplant recipient. Early symptoms included fever, malaise, and vague gastrointestinal symptoms. Laboratory abnormalities were initially attributed to chemotherapy toxicity. Illness was severe in all three patients and one patient died even after initiation of doxycycline. These cases emphasize the need for a high index of suspicion for tickborne illness in oncology patients, and the importance of a low threshold for starting empiric treatment before confirming the diagnosis.
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Affiliation(s)
- Adam Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.
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37
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Glaser C, Christie L, Bloch KC. Rickettsial and ehrlichial infections. HANDBOOK OF CLINICAL NEUROLOGY 2010; 96:143-158. [PMID: 20109680 DOI: 10.1016/s0072-9752(09)96010-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Rickettsial diseases represent a clinically homogeneous group of infections characterized by fever, headache myalgias, variable presence of a rash, and a broad spectrum of neurological manifestations. Epidemiological information including time of year, geography, history of arthropod exposure, and animal contact gives important clues to the diagnosis, and should be actively elicited. Abnormalities in hematological indices of liver function tests should also increase suspicion for illness. Delay in initiation of doxycycline therapy while awaiting laboratory confirmation of infection has been associated with progressive neurological impairment and death. Clinicians should maintain a low threshold to initiate empiric therapy for rickettsial diseases in any patient with neurological findings and compatible exposures, signs, or laboratories, as these syndromes represent readily treatable causes of neurological dysfunction.
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Affiliation(s)
- Carol Glaser
- Viral and Rickettsial Disease Laboratory, Richmond, VA, USA.
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Walker DH, Paddock CD, Dumler JS. Emerging and re-emerging tick-transmitted rickettsial and ehrlichial infections. Med Clin North Am 2008; 92:1345-61, x. [PMID: 19061755 DOI: 10.1016/j.mcna.2008.06.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Recently in the field of rickettsiology, an explosion of new isolates of pathogens have received species designation and new disease names, all of which have been relatively neglected by primary care and infectious disease physicians. A broad group of other tick-associated rickettsial and ehrlichial agents of unknown pathogenicity exist (eg, R amblyommii) that may cause confusion in interpreting serologic surveys or a single elevated antibody titer. Rickettsial and ehrlichial diseases are remarkable for their uniform susceptibility to doxycycline but are clinically difficult to distinguish from many viral infections and each another, and therefore misdiagnosis and failure to treat have unfortunate and sometimes tragic outcomes. Globally, many of these bacteria have been named but the genetic differences among them are often small, and many of their clinical manifestations may not be distinguishable diagnostically.
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Affiliation(s)
- David H Walker
- Department of Pathology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0609, USA.
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Martínez MC, Gutiérrez CN, Monger F, Ruiz J, Watts A, Mijares VM, Rojas MG, Triana-Alonso FJ. Ehrlichia chaffeensis in child, Venezuela. Emerg Infect Dis 2008; 14:519-20. [PMID: 18325283 PMCID: PMC2570823 DOI: 10.3201/eid1403.061304] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- María C. Martínez
- University of Carabobo, Aragua, Venezuela
- Biomedical Research Institute, Maracay, Venezuela
| | - Clara N. Gutiérrez
- University of Carabobo, Aragua, Venezuela
- Biomedical Research Institute, Maracay, Venezuela
| | | | - Johanny Ruiz
- Biomedical Research Institute, Maracay, Venezuela
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Regulatory roles of CD1d-restricted NKT cells in the induction of toxic shock-like syndrome in an animal model of fatal ehrlichiosis. Infect Immun 2008; 76:1434-44. [PMID: 18212072 DOI: 10.1128/iai.01242-07] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
CD1d-restricted NKT cells are key players in host defense against various microbial infections. Using a murine model of fatal ehrlichiosis, we investigated the role of CD1d-restricted NKT cells in induction of toxic shock-like syndrome caused by gram-negative, lipopolysaccharide-lacking, monocytotropic Ehrlichia. Our previous studies showed that intraperitoneal infection of wild-type (WT) mice with virulent Ehrlichia (Ixodes ovatus Ehrlichia [IOE]) results in CD8+ T-cell-mediated fatal toxic shock-like syndrome marked by apoptosis of CD4+ T cells, a weak CD4+ Th1 response, overproduction of tumor necrosis factor alpha and interleukin-10, and severe liver injury. Although CD1d-/- mice succumbed to high-dose IOE infection similar to WT mice, they did not develop signs of toxic shock, as shown by elevated bacterial burdens, low serum levels of tumor necrosis factor, normal serum levels of liver enzymes, and the presence of few apoptotic hepatic cells. An absence of NKT cells restored the percentages and absolute numbers of CD4+ and CD8+ T cells and CD11b+ cells in the spleen compared to WT mice and was also associated with decreased expression of Fas on splenic CD4+ lymphocytes and granzyme B in hepatic CD8+ lymphocytes. Furthermore, our data show that NKT cells promote apoptosis of macrophages and up-regulation of the costimulatory molecule CD40 on antigen-presenting cells, including dendritic cells, B cells, and macrophages, which may contribute to the induction of pathogenic T-cell responses. In conclusion, our data suggest that NKT cells mediate Ehrlichia-induced T-cell-mediated toxic shock-like syndrome, most likely via cognate and noncognate interactions with antigen-presenting cells.
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