Abstract. From 2001to 2003 farms in Florida, California, and South Carolina experienced epizootics of a systemic disease causing mortality. The fish exhibited lethargy, occasional exophthalmia, and skin petechia. The gills were often necrotic, with a patchy white and red appearance. Grossly, the spleen and kidneys were granular with whitish irregular nodules throughout. Granulomatous infiltrates were observed in kidney, spleen, testes, and ovary tissues, but not in the liver. The granulomas contained pleomorphic coccoid bacteria, measuring 0.57 Ϯ 0.1 ϫ 0.8 Ϯ 0.2 m, that were Giemsa-positive, acid-fast-negative, and Gram-negative. The bacteria had a double cell wall, variable electron-dense and -lucent areas, and were present in the cytoplasm and within phagolysosomes. The syndrome was associated with cold stress and poor water conditions. These findings are consistent with an infectious process caused by a Piscirickettsia-like bacterium described previously in tilapia in Taiwan and Hawaii. This report involves the first identified cases of a piscirickettsiosis-like syndrome affecting tilapia in the continental United States.Key words: Piscirickettsiosis; Piscirickettsia-like organisms; piscirickettsiosis-like syndrome; Tilapia.Since the identification of Piscirickettsia salmonis as the first rickettsia-like organism recognized as a fish pathogen, 9 a number of Piscirickettsia-like organisms (PLOs) have been observed microscopically or isolated in cell culture from a variety of marine and fresh-water piscine species from locations worldwide. 5,11,12,16 Piscirickettsiosis or piscirickettsiosis-like syndromes can be severe, resulting in high mortality and significant economic losses.The number of reports of piscirickettsiosis, with significant associated economic losses, have been increasing for the last 5-10 years in British Columbia, 2,8 Ireland, 16 and Scotland. 10 PLOs have also been observed in and isolated from seabass in Europe 1,7 and California 3 during epizootics characterized by high mortality and severe economic losses. Tilapia in Taiwan 4,6 and Hawaii 15 have also been severely affected by PLO epizootics. Here we report on the first identified cases of PLO epizootics in tilapia in the continental United States.Between 2001 and 2003, 3 facilities in the continental United States (California, South Carolina, and Florida) reported epizootics with signs consistent with a piscirickettsiosis-like syndrome. All 3 facilities had increased mortalities during times of fish stress due to lowered temperature or water quality. The fish appeared lethargic, with darkened color, and would crowd toward the middle of the pond or tank. Occasionally, petechia were observed on the sides of the fish. Fins had light fraying, some exophthalmia was observed, and gills were necrotic, with a patchy white and red appearance. Internally, the spleen and kidneys were extremely granular with whitish irregular nodules throughout. The liver was a pale reddish tan with patchy lighter areas.In hematoxylin and eosin (HE) sections, the spl...