Fatal Seronegative Ehrlichiosis in a Patient with HIV Infection

Paddock, Christopher D.; Suchard, David P.; Grumbach, Kevin; Hadley, W K; Kerschmann, Russell; Abbey, Nancy W.; Dawson, Jacqueline E.; Anderson, Burt; Sims, Kimetha G.; Dumler, J. Stephen; Herndier, Brian

doi:10.1056/nejm199310143291605

Cited by 97 publications

(67 citation statements)

References 21 publications

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“…This delay in therapy is known to have an increased risk of poor outcome in RMSF. 18 Although patients with concomitant ehrlichiosis and significant underlying diseases have been described in adults, 19,20 with the exception of one child with Down syndrome, 7 all the children described previously have been healthy. [7][8][9][10][11][12][13][14][15][16] Of the two children with underlying disorders presented in this study, an African-American child with sickle ␤-thalassemia required mechanical ventilation and prolonged hospitalization with resulting hypertension.…”

Section: Discussionmentioning

confidence: 97%

Human Monocytic Ehrlichiosis in Children

Schutze

Jacobs

1997

Pediatrics

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ABSTRACT. Background. Much of what is known about human monocytic ehrlichiosis (HME) is based upon studies with adult patients.Purpose. To review our experience with HME to better understand the epidemiology, clinical manifestations, and outcome of this disease in children.Methods. Demographic, clinical, and laboratory data were gathered after review of the medical records of patients identified with HME.Results. Twelve patients with an median age of 7.4 years (range, 7 months to 13.7 years) were identified with HME; 10 were white, 7 were male, and 10 were from hometowns of <800 people. Eight patients presented from May through July, and 8 had a history of tick bites. Symptoms demonstrated by the patients during their illness included fever (100%), rash (67%), myalgias (58%), and vomiting, diarrhea, and headache (25%). On presentation, patients demonstrated thrombocytopenia (92%), elevated liver function tests (91%), lymphopenia (75%), hyponatremia (67%), leukopenia (58%), and anemia (42%) on the initial laboratory examination. Four patients presented in shock and 3 required blood pressure support and mechanical ventilation for a median of 10 days (8 to 37 days). These complicated patients required longer hospitalization (19.5 days vs 5.5 days) and attained higher blood urea nitrogen levels (42.5 mg/dL vs 10 mg/dL) than the patients not presenting with shock. Morbidity associated with HME patients included a decrease in cognitive and neurologic performance.Conclusions. More information and long-term follow-up is required to understand the full spectrum of disease and morbidity associated with HME in children. Pediatrics 1997;100(1). URL: http://www.pediatrics.org/ cgi/content/full/100/1/e10; erlichiosis, children, rickettsia, ticks.ABBREVIATIONS. HME, human monocytic ehrlichiosis; RMSF, Rocky Mountain spotted fever. I n the 10 years that human monocytic ehrlichiosis (HME) has been recognized in the United States, much of our knowledge concerning the clinical presentation and outcome of this illness has been obtained from experience with adult patients.1,2 This is because only approximately 10% of the patients described to date have been children. 3 As our knowledge of HME increases, it is imperative that we continue to gather data which will allow us to better understand the epidemiology and natural history, the clinical manifestations and the role of therapy, the prognostic indicators for outcome, and the longterm morbidity and mortality of this illness. The purpose of this study was to review our experience with HME to gain a better understanding of the features of ehrlichiosis in children. MATERIAL AND METHODSA retrospective review of all medical and laboratory records from Arkansas Children's Hospital from 1990 to 1996 were reviewed in an attempt to identify all patients infected with Ehrlichia chaffeensis. Patients were considered to have a diagnosis of HME if the patient had a clinically compatible history with a minimum titer to E chaffeensis of Ն1:64 or a fourfold or greater change in antibody titers fro...

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Section: Discussionmentioning

confidence: 97%

Human Monocytic Ehrlichiosis in Children

Schutze

Jacobs

1997

Pediatrics

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“…29 It is possible that individuals who are HIV-positive have a diminished capacity to produce antibodies to spotted fever group rickettsiae, a finding supported by the decreasing spotted fever group rickettsiae antibody response with progressively lower CD4ϩ cell counts. Also, individuals who are HIV-positive and who have antibodies to spotted fever group rickettsiae may be selectively removed from the population because of complications associated with HIV infection.…”

Section: Discussionmentioning

confidence: 99%

Serologic evidence of rickettsialpox (Rickettsia akari) infection among intravenous drug users in inner-city Baltimore, Maryland.

Comer

Tzianabos²,

Flynn

et al. 1999

The American Journal of Tropical Medicine and Hygiene

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Abstract. We tested single serum samples from 631 intravenous (IV) drug users from inner-city Baltimore, Maryland for serologic evidence of exposure to spotted fever group rickettsiae. A total of 102 (16%) individuals had titers Ն 64 to Rickettsia rickettsii by an indirect immunofluorescence assay. Confirmation that infection was caused by R. akari was obtained by cross-adsorption studies on a subset of serum samples that consistently resulted in higher titers to R. akari than to R. rickettsii. Current IV drug use, increased frequency of injection, and shooting gallery use were significant risk factors for presence of group-specific antibodies reactive with R. rickettsii. There was a significant inverse association with the presence of antibodies reactive to R. rickettsii and antibodies reactive to the human immunodeficiency virus. This study suggests that IV drug users are at an increased risk for R. akari infections. Clinicians should be aware of rickettsialpox, as well as other zoonotic diseases of the urban environment, when treating IV drug users for any acute febrile illness of undetermined etiology.

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“…10 Few reports use immunohistochemistry (IHC) to detect E. chaffeensis infection have been published, and with the exception of one study that was limited to bone marrow, all reports have been single cases. [11][12][13][14][15] Furthermore, PCR diagnosis based on testing of formalin-fixed, paraffin-embedded tissues (PET) has been reported for only one case. 14 In the present study, we developed probes specific for ehrlichiae and used these probes to detect E. chaffeensis in various tissues from 4 patients with fatal disease.…”

Section: Introductionmentioning

confidence: 99%

Tissue diagnosis of Ehrlichia chaffeensis in patients with fatal ehrlichiosis by use of immunohistochemistry, in situ hybridization, and polymerase chain reaction.

Dawson¹,

Paddock²,

Warner³

et al. 2001

The American Journal of Tropical Medicine and Hygiene

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Abstract. In the United States, human ehrlichiosis is a complex of emerging tick-borne diseases caused by 3 distinct Ehrlichia species: Ehrlichia chaffeensis, Ehrlichia ewingii, and the human granulocytotropic ehrlichiosis agent. Ehrlichioses are characterized by a mild to severe illness, and ϳ 4% of cases are fatal. Because these obligate intracellular bacteria are difficult to resolve with routine histologic techniques, their distribution in tissues has not been well described. To facilitate the visualization and detection of ehrlichiae, immunohistochemistry (IHC), in situ hybridization (ISH), and polymerase chain reaction (PCR) assays were developed by use of tissues from 4 fatal cases of E. chaffeensis infection. Evidence of E. chaffeensis via IHC, ISH, and PCR was documented in all 4 cases. Abundant immunostaining and in situ nucleic acid hybridization were observed in spleen and lymph node from all 4 patients. Significantly, in 2 of these patients, serologic evidence of infection was absent. Use of IHC, ISH, and PCR to visualize and detect Ehrlichia in tissues can facilitate diagnosis of ehrlichial infections.

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Fatal Seronegative Ehrlichiosis in a Patient with HIV Infection

Cited by 97 publications

References 21 publications

Human Monocytic Ehrlichiosis in Children

Human Monocytic Ehrlichiosis in Children

Serologic evidence of rickettsialpox (Rickettsia akari) infection among intravenous drug users in inner-city Baltimore, Maryland.

Tissue diagnosis of Ehrlichia chaffeensis in patients with fatal ehrlichiosis by use of immunohistochemistry, in situ hybridization, and polymerase chain reaction.

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