Ehrlichiosis
| Ehrlichiosis | |
| ICD-10 | A79.8 |
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| ICD-9 | 082.4 |
| DiseasesDB | 31663 |
| MedlinePlus | 001381 |
| MeSH | D016873 |
This page is about clinical aspects of the disease. For microbiologic aspects of the causative organism(s), see Ehrlichia.
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Ehrlichiosis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Ehrlichiosis On the Web |
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American Roentgen Ray Society Images of Ehrlichiosis |
For patient information on this page, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Synonyms and keywords: Sennetsu fever; human granulocytic ehrlichiosis; Anaplasma phagocytophilum; Ehrlichia phagocytophila; human monocytic ehrlichiosis
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Ehrlichiosis from other Diseases
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Other Imaging Findings | Other Diagnostic Studies
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Future or Investigational Therapies
Case Studies
Historical Perspective
- In 2008, human infection by Panola Mountain (Georgia, USA) Ehrlichia species was reported.[1]
- On August 3, 2011, infection by a yet-unnamed bacterium in the genus Ehrlichia carried by deer ticks that has caused flu-like symptoms in at least 25 people in Minnesota and Wisconsin was reported; human ehrlichiosis was thought to be very rare or absent in Minnesota and Wisconsin.[2] The new species, which is very similar genetically to an Ehrlichia species found in Eastern Europe and Japan called E. muris, was identified at Mayo Clinic Health System's Eau Claire hospital.[2]
- In 1991 Dr. Aileen Marty of the AFIP was able to demonstrate the bacteria in human tissues using standard stains, and later proved that the organisms were indeed Ehrlichia using immunoperoxidase stains.
Pathophysiology
- Ehrlichia are transported between cells through the host cell filopodia during initial stages of infection, whereas, in the final stages of infection the pathogen ruptures the host cell membrane.[3]
- Most of the symptoms of Ehrlichiosis can likely be ascribed to the immune dysregulation that it causes.
- Early in infection, production of TNF-alpha, a cellular product that promotes inflammation and immune response, is suppressed. Experiments in mouse models further supports this hypothesis, as mice lacking TNF-alpha I/II receptors are resistant to liver injury caused by ehrlichia infection.[4]
- Late in infection, however, production of this substance can be upregulated by 30 fold, which is likely responsible for the "toxic shock-like" syndrome seen in some severe cases of ehrlichiosis.
Causes
Five species of the genus Ehrlichia have been shown to cause human infection:[5]
- Anaplasma phagocytophilum (which causes human granulocytic anaplasmosis, formerly known as human granulocytic ehrlichiosis).
- Ehrlichia ewingii (which causes human ewingii ehrlichiosis). E. ewingii primarily infects deer and dogs (see Ehrlichiosis (canine)).[6]
- Ehrlichia chaffeensis (which causes human monocytic ehrlichiosis).
- Ehrlichia canis
- Neorickettsia sennetsu
The latter two infections are not well studied.
Epidemiology and Demographics
- The average reported annual incidence is 0.7 cases per million population.[6]
- A. phagocytophilium is endemic to New England and the north central and Pacific regions of the United States.
- E. chaffeensis is most common in the south central and southeastern states.
- E. ewingii is most common in the south central and southeastern states.
The lone star tick (Amblyomma americanum) is the primary vector of both Ehrlichia chaffeensis and Ehrlichia ewingii in the United States [7].
Risk Factors
Risk factors for ehrlichiosis include:
- Living near an area with a lot of ticks
- Owning a pet that may bring a tick home
- Walking or playing in high grasses
Natural History, Complications and Prognosis
Complications
- Respiratory distress syndrome
- Hepatitis
- Kidney damage
- Lung damage
- Other organ damage
- Seizure
- Candidiasis
- Opportunistic nosocomial infections[8]
- Death
Diagnosis
Symptoms
Other possible symptoms include:
- Diarrhea
- Fine pinhead-sized areas of bleeding in the skin (petechial rash)
- Flat red rash (maculopapular rash)
- General ill feeling (malaise)
A rash appears in fewer than half of cases.
Physical Examination
Vitals
Skin
Head
Laboratory Findings
- Complete blood count (CBC)
- Granulocyte stain
- Fluorescent antibody test
Treatment
- Doxycycline is the drug of choice.
- For people allergic to drugs of the tetracycline class, rifampicin is an alternative.[6]
- Early clinical experience suggested that chloramphenicol may also be effective, however in vitro susceptibility testing revealed resistance.
Antimicrobial regimen
- 1. Human Monocytic Ehrlichiosis or Human Granulocytic Anaplasmosis (adult) [10]
- Preferred regimen: Doxycycline 100 mg PO/IV q12h for 7-14 days
- Note: Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement
- Alternative regimen (1): Chloramphenicol 500mg PO qid
- Alternative regimen (2): Rifampin 600 mg PO/IV qd for 7-10 days
- 2. Human Monocytic Ehrlichiosis or Human Granulocytic Anaplasmosis (pediatric)
- 2.1 ≥ 8 years old
- Preferred regimen: Doxycycline 2 mg/kg IV/PO q12h (Maximum, 200 mg/day) for 10 days
- 2.2 < 8 years old without Lyme disease
- Preferred regimen: Doxycycline 2 mg/kg IV/PO q12h (Maximum, 200 mg/day) for 4-5 days (or 3 days after resolution of fever)
- 2.3 co-infected with Lyme disease
- Preferred regimen: Doxycycline, then Amoxicillin 50 mg/kg in 3 divided doses (Maximum, 500 mg/dose) OR Cefuroxime 30 mg/kg in 2 divided doses (Maximum, 500 mg/dose) for 14 days
References
- ↑ Reeves WK, Loftis AD, Nicholson WL, Czarkowski AG (2008). "The first report of human illness associated with the Panola Mountain Ehrlichia species: a case report". Journal of medical case reports. 2: 139. doi:10.1186/1752-1947-2-139. PMC 2396651. PMID 18447934.
- ↑ 2.0 2.1 Julie Steenhuysen. 2011. New tick-borne bacterium found in upper Midwest. Reuters, 8/3/2011, http://www.trust.org/alertnet/news/new-tick-borne-bacterium-found-in-upper-midwest/, accessed August 4, 2011.
- ↑ Thomas S, Popov VL, Walker DH (2010). Kaushal, Deepak, ed. "Exit Mechanisms of the Intracellular Bacterium Ehrlichia". PLoS ONE. 5 (12): e15775. doi:10.1371/journal.pone.0015775. PMC 3004962. PMID 21187937.
- ↑ McBride, Jere W. (31 January 2011). "Molecular and cellular pathobiology of Ehrlichia infection: targets for new therapeutics and immunomodulation strategies". Expert Reviews in Molecular Medicine. 13. doi:10.1017/S1462399410001730. Unknown parameter
|coauthors=ignored (help) - ↑ Dumler JS, Madigan JE, Pusterla N, Bakken JS (2007). "Ehrlichioses in humans: epidemiology, clinical presentation, diagnosis, and treatment". Clin. Infect. Dis. 45 (Suppl 1): S45–51. doi:10.1086/518146. PMID 17582569. Unknown parameter
|month=ignored (help) - ↑ 6.0 6.1 6.2 Goddard J (September 1, 2008). "What Is New With Ehrlichiosis?". Infections in Medicine.
- ↑
- ↑ Thomas, Rachael J (1 August 2009). "Current management of human granulocytic anaplasmosis, human monocytic ehrlichiosis and ehrlichiosis". Expert Review of Anti-infective Therapy. 7 (6): 709–722. doi:10.1586/eri.09.44. PMC 2739015. PMID 19681699. Unknown parameter
|month=ignored (help); Unknown parameter|coauthors=ignored (help) - ↑ Marty AM, Dumler JS, Imes G, Brusman HP, Smrkovski LL, Frisman DM (1995). "Ehrlichiosis mimicking thrombotic thrombocytopenic purpura. Case report and pathological correlation". Hum. Pathol. 26 (8): 920–5. doi:10.1016/0046-8177(95)90017-9. PMID 7635455. Unknown parameter
|month=ignored (help) - ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.