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Holzbauer SM, Schrodt CA, Prabhu RM, Asch-Kendrick RJ, Ireland M, Klumb C, Firestone MJ, Liu G, Harry K, Ritter JM, Levine MZ, Orciari LA, Wilkins K, Yager P, Gigante CM, Ellison JA, Zhao H, Niezgoda M, Li Y, Levis R, Scott D, Satheshkumar PS, Petersen BW, Rao AK, Bell WR, Bjerk SM, Forrest S, Gao W, Dasheiff R, Russell K, Pappas M, Kiefer J, Bickler W, Wiseman A, Jurantee J, Reichard RR, Smith KE, Lynfield R, Scheftel J, Wallace RM, Bonwitt J. Fatal Human Rabies Infection With Suspected Host-Mediated Failure of Post-Exposure Prophylaxis Following a Recognized Zoonotic Exposure-Minnesota, 2021. Clin Infect Dis 2023; 77:1201-1208. [PMID: 36988328 PMCID: PMC11097918 DOI: 10.1093/cid/ciad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/03/2023] [Accepted: 02/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND No human rabies post-exposure prophylaxis (PEP) failure has been documented in the United States using modern cell culture-based vaccines. In January 2021, an 84-year-old male died from rabies 6 months after being bitten by a rabid bat despite receiving timely rabies PEP. We investigated the cause of breakthrough infection. METHODS We reviewed medical records, laboratory results, and autopsy findings and performed whole-genome sequencing (WGS) to compare patient and bat virus sequences. Storage, administration, and integrity of PEP biologics administered to the patient were assessed; samples from leftover rabies immunoglobulin were evaluated for potency. We conducted risk assessments for persons potentially exposed to the bat and for close patient contacts. RESULTS Rabies virus antibodies present in serum and cerebrospinal fluid were nonneutralizing. Antemortem blood testing revealed that the patient had unrecognized monoclonal gammopathy of unknown significance. Autopsy findings showed rabies meningoencephalitis and metastatic prostatic adenocarcinoma. Rabies virus sequences from the patient and the offending bat were identical by WGS. No deviations were identified in potency, quality control, administration, or storage of administered PEP. Of 332 persons assessed for potential rabies exposure to the case patient, 3 (0.9%) warranted PEP. CONCLUSIONS This is the first reported failure of rabies PEP in the Western Hemisphere using a cell culture-based vaccine. Host-mediated primary vaccine failure attributed to previously unrecognized impaired immunity is the most likely explanation for this breakthrough infection. Clinicians should consider measuring rabies neutralizing antibody titers after completion of PEP if there is any suspicion for immunocompromise.
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Affiliation(s)
- Stacy M Holzbauer
- Minnesota Department of Health, St. Paul, Minnesota, USA
- Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Caroline A Schrodt
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Malia Ireland
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Carrie Klumb
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Melanie J Firestone
- Minnesota Department of Health, St. Paul, Minnesota, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Gongping Liu
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Katie Harry
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Jana M Ritter
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Min Z Levine
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lillian A Orciari
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kimberly Wilkins
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pamela Yager
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Crystal M Gigante
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - James A Ellison
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hui Zhao
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Niezgoda
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yu Li
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robin Levis
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Dorothy Scott
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Panayampalli S Satheshkumar
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brett W Petersen
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Agam K Rao
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - W Robert Bell
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | | | | | | | | | | | | | - R Ross Reichard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kirk E Smith
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Ruth Lynfield
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Joni Scheftel
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Ryan M Wallace
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jesse Bonwitt
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Hornung N, Frank M, Dragano N, Dürig J, Dührsen U, Moebus S, Erbel R, Stang A, Jöckel KH, Schmidt B. Monoclonal gammopathy of undetermined significance is associated with prostate cancer in a population-based cohort study. Sci Rep 2021; 11:19266. [PMID: 34588555 PMCID: PMC8481402 DOI: 10.1038/s41598-021-98803-1] [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: 03/30/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022] Open
Abstract
Register-based studies indicate a possible association of monoclonal gammopathy of undetermined significance (MGUS) and prostate cancer (PCa). Aim of the present study was to investigate the relationship between MGUS and PCa considering potentially shared risk factors. Data from the prospective population-based Heinz Nixdorf Recall cohort study of 2.385 men (age 45–85) were analyzed. MGUS was determined at three points in time; cases of cancer were assessed annually. Potentially shared risk factors were assessed at baseline. Hazard ratios (HR), adjusted for age and educational attainment, and corresponding 95%-confidence intervals (95%-CI) were calculated. 157 cases of MGUS and 143 incident cases of PCa were detected. Of 19 participants diagnosed with both, MGUS and incident PCa, only in one case MGUS did not clearly occur before PCa. MGUS was associated with PCa presenting a HR of 2.00 (95%-CI: 1.23–3.25). Stratified by isotype, IgM-MGUS showed the strongest association with PCa. There was no relevant change of the effect estimate when adjusting for potentially shared risk factors. We were able to give supporting evidence for an association between MGUS and PCa and pointed out its temporality. There was no indication that the observed association is due to shared risk factors. The present study indicated that different isotypes of MGUS differ in the strength of the effect on PCa-risk. Based on these findings, future studies investigating the pathophysiological background of the association will be needed.
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Affiliation(s)
- Nicola Hornung
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Mirjam Frank
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Nico Dragano
- Department of Medical Sociology, University Clinic Düsseldorf, Düsseldorf, Germany
| | - Jan Dürig
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Dührsen
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Susanne Moebus
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany.
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