Ehrlichia-induced hemophagocytic lymphohistiocytosis in a pediatric kidney transplant recipient.

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.

Donor-derived Ehrlichiosis: 2 Clusters Following Solid Organ Transplantation.

Ehrlichiosis has been infrequently described as transmissible through organ transplantation. Two donor-derived clusters of ehrlichiosis are described here. During the summer of 2020, 2 cases of ehrlichiosis were reported to the Organ Procurement and Transplantation Network (OPTN) and the Centers for Disease Control and Prevention (CDC) for investigation. Additional transplant centers were contacted to investigate similar illness in other recipients and samples were sent to the CDC. Two kidney recipients from a common donor developed fatal ehrlichiosis-induced hemophagocytic lymphocytic histiocytosis. Two kidney recipients and a liver recipient from another common donor developed ehrlichiosis. All 3 were successfully treated. Clinicians should consider donor-derived ehrlichiosis when evaluating recipients with fever early after transplantation after more common causes are ruled out, especially if the donor has epidemiological risk factors for infection. Suspected cases should be reported to the organ procurement organization and the OPTN for further investigation by public health authorities.

Tick-Borne Diseases in the United States.

BACKGROUND: Tick-borne diseases are an important cause of human morbidity and mortality in the United States. The past several decades have witnessed an increase in both the number of recognized tick-borne pathogens and the number of tick-borne disease cases, whereas tick surveys have revealed substantial geographic expansions of tick populations throughout the country. Multiple laboratory testing options exist for diagnosis of tick-borne diseases, including serology, microscopy, and molecular-based methods. The preferred approach varies by the specific disease, locally available test options, and the stage of illness at patient presentation. Accurate and timely detection of tick-borne illness is of utmost importance, as prompt treatment is strongly linked to better outcomes. CONTENT: This review covers the clinical manifestations and preferred diagnostic approaches for important bacterial, viral, and parasitic tick-borne diseases in the United States, including Lyme disease, tick-borne relapsing fever, anaplasmosis, ehrlichiosis, spotted fever rickettsioses, and babesiosis. Infection with emerging pathogens such as Borrelia miyamotoi, Powassan virus, Heartland virus, Colorado tick fever virus, and Bourbon virus are also covered. SUMMARY: Our understanding of tick-borne diseases in the United States continues to improve with the detection of novel pathogens and development of new diagnostic modalities. While conventional diagnostic methods, including serology and microscopy, will play an ongoing role in the diagnosis of tick-borne diseases, implementation of advanced molecular diagnostics will further broaden our understanding of these diseases by facilitating detection of emerging pathogens and providing more accurate and timely diagnosis.

Human ehrlichiosis at a tertiary-care academic medical center: Clinical associations and outcomes of transplant patients and patients with hemophagocytic lymphohistiocytosis.

BACKGROUND: Ehrlichiosis is an acute febrile tick-borne disease which can rarely be a trigger for secondary hemophagocytic lymphohistiocytosis (HLH). METHODS: We reviewed our experience with Ehrlichia infections at a tertiary-care academic medical center. RESULTS: Over 10 years, 157 cases of ehrlichiosis were identified. Ten patients (6.4%) had infection with E. ewingii, 7(4.5%) of whom were transplant patients as compared to 3(1.9%) non-transplant patients (p = .035). Transplant patients were more likely to have leukopenia and elevated creatinine compared to immunocompetent patients; length of hospital stay and early mortality were not different between the two groups. Ten patients met the HLH-2004 diagnosis criteria, which could be an underestimation of HLH occurrence as most patients were not completely evaluated for these criteria. We calculated the H-Score to find the probability of HLH; 25 patients scored high making the occurrence rate of HLH at least 16%. Ehrlichia-induced HLH patients (N = 25) had more anemia, thrombocytopenia, elevated creatinine and AST. Moreover, they had a significantly longer hospital stay (median 9 days) compared to patients without HLH (median 4 days) (p = .006). CONCLUSIONS: Ehrlichia-induced HLH is a potential serious complication with relatively high occurrence rate; patients manifest severe disease with end-organ damage requiring longer hospital stay.

Seroprevalence and risk factors associated with Ehrlichia canis, Anaplasma spp., Borrelia burgdorferi sensu lato, and D. immitis in hunting dogs from southern Italy.

Canine vector-borne diseases (CVBDs) are caused by a range of pathogens transmitted to dogs by arthropods. The present study investigates Ehrlichia canis, Anaplasma spp., Borrelia burgdorferi sensu lato, and Dirofilaria immitis seroprevalences in hunting dogs from southern Italy. Dogs (no. 1335) were tested using a commercial in-clinic enzyme-linked immunosorbent assay kit. Odds ratios (ORs) were calculated by logistic regression analysis to identify risk factors. Overall, 138/1335 dogs (10.3%) were seroreactive to at least one CVBD pathogen. E. canis, Anaplasma spp., B. burgdorferi s.l., and D. immitis seroprevalences were 7.6, 4.4, 0.3, and 0.2%, respectively. E. canis and Anaplasma spp. co-exposures were found in 30 dogs (2.2%), compared with Anaplasma spp. and B. burgdorferi s.l. co-exposures in 2 dogs (0.1%). Adult age was a risk factor for E. canis (OR 2.35) seroreactivity whereas hunting fur-bearing animals for E. canis (OR 4.75) and Anaplasma spp. (OR 1.87), respectively. The historical presence of tick infestation was identified as a risk factor for positivity to E. canis (OR 2.08) and Anaplasma spp. (OR 2.15). Finally, larger dog pack size was significantly associated with E. canis (OR 1.85) and Anaplasma spp. (OR 2.42) exposures. The results of the present survey indicated that hunting dog populations are at relative risk of CVBDs in southern Italy. Further studies are needed to evaluate the role of hunting dogs in the epidemiology of vector-borne organisms due to sharing common environments with wild, sympatric animal populations.

Low risk of seroconversion or clinical disease in humans after a bite by an Anaplasma phagocytophilum-infected tick.

The risk of contracting human granulocytic anaplasmosis (HGA) after a tick bite is mainly unknown. In this study we investigated the clinical and serological response in 30 humans bitten by ticks positive for Anaplasma phagocytophilum (Group A), 30 humans bitten by Borrelia burgdorferi sensu lato (s.l.)-positive ticks (Group B), and 30 humans bitten by ticks negative for both A. phagocytophilum and B. burgdorferi s.l. (Group C). Ticks, blood samples and questionnaires were collected from tick-bitten humans at 34 primary healthcare centres in Sweden and in the Åland Islands, Finland, at the time of the tick bite and after three months. A total of 2553 ticks detached from humans in 2007-2009 were analyzed by polymerase chain reaction, and 31 (1.2%) were positive for A. phagocytophilum, 556 (21.8%) were positive for B. burgdorferi s.l., and eight (0.3%) were co-infected by A. phagocytophilum and B. burgdorferi s.l. The overall prevalence of Anaplasma IgG antibodies in the included participants (n=90) was 17%, and there was no significant difference between the groups A-C. Only one of the participants (in Group C) showed a four-fold increase of IgG antibodies against A. phagocytophilum at the three-month follow-up, but reported no symptoms. The frequency of reported symptoms did not differ between groups A-C, and was unrelated to the findings of A. phagocytophilum and B. burgdorferi s.l. in the detached ticks. We conclude that the risk for HGA or asymptomatic seroconversion after a tick bite in Sweden or in the Åland Islands is low, even if the tick is infected by A. phagocytophilum.

Canine tick-borne pathogens and associated risk factors in dogs presenting with and without clinical signs consistent with tick-borne diseases in northern Australia.

OBJECTIVES: To estimate the proportion of canine tick-borne disease (CTBD) pathogens in dogs from northern states of Australia presenting with and without clinical signs/laboratory abnormalities suggestive of CTBD and to evaluate associated risk factors. DESIGN: Client-owned dogs presented to a general practice clinic in the Northern Territory (NT; n = 138) and five referral hospitals in south-east Queensland (SEQ; n = 100) were grouped into CTBD-suspect and -control groups based on clinical and laboratory criteria. Blood and sera were screened for haemotropic Mycoplasma spp., Babesia spp., Anaplasma spp., Ehrlichia spp. and Hepatozoon spp. using microscopic examination, in-clinic ELISA testing and PCR assays. Dog-specific risk factors associated with the presence of CTBD pathogens were evaluated. RESULTS: Overall, 24.4% of the suspect group and 12.2% of the control group dogs were infected. The proportions of M. haemocanis, B. vogeli, A. platys, Candidatus Mycoplasma haematoparvum, and C. Mycoplasma haemobos were 7.1%, 5.0%, 3.8%, 1.7% and 0.4%, respectively. Dogs originating from the NT were 3.6-fold (95% confidence interval (CI) 1.51-8.62; P = 0.004) more likely to be infected with CTBD pathogens than those from SEQ. Male dogs were 2.3-fold (95% CI 1.17-4.80, P = 0.024) more likely to be PCR-positive to CTBD pathogens than female dogs. Dogs presenting with clinical signs consistent with CTBD and thrombocytopenia were more likely to be infected by CTBD pathogens (odds ratio 2.85; 95% CI 1.16, 7.02; P = 0.019). CONCLUSIONS: Haemotropic mycoplasmas were the most common tick-borne pathogen infecting client-owned dogs. Subclinical cases were common in dogs from the NT. Veterinary practitioners should be aware of the proportion of CTBD pathogens and the presenting features of clinical and subclinical disease in their area.

Severe life-threatening Ehrlichia chaffeensis infections transmitted through solid organ transplantation.

BACKGROUND: Donor-derived infections from organ transplantation are rare occurrences with preoperative screening practices. Ehrlichia chaffeensis, a tick-borne illness, transmitted through solid organ transplantation has not been reported previously to our knowledge. We present cases of 2 renal allograft recipients who developed severe E. chaffeensis infection after receipt of organs from a common deceased donor. METHODS: The 2 renal transplant patients who developed E. chaffeensis infection are reported in case study format with review of the literature. RESULTS: Approximately 3 weeks after renal transplantation, both patients developed an acute febrile illness and rapid clinical decline. Recipient A underwent an extensive infectious workup that revealed positive E. chaffeensis DNA from polymerase chain reaction on peripheral blood. Recipient B's clinical team obtained acute and convalescent antibody titers for E. chaffeensis, which demonstrated acute infection. Recipients A and B were treated with doxycycline and tigecycline, respectively, with clinical cure. CONCLUSIONS: These cases demonstrate that tick-borne pathogens, such as E. chaffeensis, can be transmitted through renal transplantation. E. chaffeensis can be associated with excessive morbidity and mortality, commonly owing to delay in diagnosis and poor response to non-tetracycline antibiotics. In populations with endemic tick-borne illness, donors should be questioned about tick exposure, and appropriate antibiotics can be administered if indicated.

Identifying requirements for the invasion of a tick species and tick-borne pathogen through TICKSIM.

Ticks and tick-borne diseases have been on the move throughout the United State over the past twenty years. We use an agent-based model, TICKSIM, to identify the key parameters that determine the success of invasion of the tick and if that is successful, the succees of the tick-borne pathogen. We find that if an area has competent hosts, an initial population of ten ticks is predicted to always establish a new population. The establishment of the tick-borne pathogen depends on three parameters: the initial prevalence in the ten founding ticks, the probability that a tick infects the longer-lived hosts and the probability that a tick infects the shorter-lived hosts. These results indicate that the transmission rates to hosts in the newly established area can be used to predict the potential risk of disease to humans.

Ehrlichia canis infection in a dog with no history of travel outside the United Kingdom.

A two-year-old female neutered Tibetan terrier was referred following a one-month history of lethargy, inappetence and pancytopenia, which had been poorly responsive to immunosuppressive and fluoroquinolone treatment. The dog was diagnosed with pure red cell aplasia and was found to be positive for Ehrlichia canis by both antibody titre measurement and polymerase chain reaction. The dog lived in London and had not travelled outside the UK. The dog was treated with doxycycline, prednisolone and ciclosporin, but died as a result of gastrointestinal tract haemorrhage. To the authors' knowledge, this represents the first reported case of Ehrlichia canis in a dog in the UK with no previous travel history.

TLR2 and Nod2 mediate resistance or susceptibility to fatal intracellular Ehrlichia infection in murine models of ehrlichiosis.

Our murine models of human monocytic ehrlichiosis (HME) have shown that severe and fatal ehrlichiosis is due to generation of pathogenic T cell responses causing immunopathology and multi-organ failure. However, the early events in the liver, the main site of infection, are not well understood. In this study, we examined the liver transcriptome during the course of lethal and nonlethal infections caused by Ixodes ovatus Ehrlichia and Ehrlichia muris, respectively. On day 3 post-infection (p.i.), although most host genes were down regulated in the two groups of infected mice compared to naïve counterparts, lethal infection induced significantly higher expression of caspase 1, caspase 4, nucleotide binding oligomerization domain-containing proteins (Nod1), tumor necrosis factor-alpha, interleukin 10, and CCL7 compared to nonlethal infection. On day 7 p.i., lethal infection induced highly significant upregulation of type-1 interferon, several inflammatory cytokines and chemokines, which was associated with increased expression levels of Toll-like receptor-2 (TLR2), Nod2, MyD88, nuclear factor-kappa B (NF-kB), Caspase 4, NLRP1, NLRP12, Pycard, and IL-1ß, suggesting enhanced TLR signals and inflammasomes activation. We next evaluated the participation of TLR2 and Nod2 in the host response during lethal Ehrlichia infection. Although lack of TLR2 impaired bacterial elimination and increased tissue necrosis, Nod2 deficiency attenuated pathology and enhanced bacterial clearance, which correlated with increased interferon-γ and interleukin-10 levels and a decreased frequency of pathogenic CD8(+) T cells in response to lethal infection. Thus, these data indicate that Nod2, but not TLR2, contributes to susceptibility to severe Ehrlichia-induced shock. Together, our studies provide, for the first time, insight into the diversity of host factors and novel molecular pathogenic mechanisms that may contribute to severe HME.

Anaplasma phagocytophilum outer membrane protein A interacts with sialylated glycoproteins to promote infection of mammalian host cells.

Anaplasma phagocytophilum is the tick-transmitted obligate intracellular bacterium that causes human granulocytic anaplasmosis (HGA). A. phagocytophilum binding to sialyl Lewis x (sLe(x)) and other sialylated glycans that decorate P selectin glycoprotein 1 (PSGL-1) and other glycoproteins is critical for infection of mammalian host cells. Here, we demonstrate the importance of A. phagocytophilum outer membrane protein A (OmpA) APH_0338 in infection of mammalian host cells. OmpA is transcriptionally induced during transmission feeding of A. phagocytophilum-infected ticks on mice and is upregulated during invasion of HL-60 cells. OmpA is presented on the pathogen's surface. Sera from HGA patients and experimentally infected mice recognize recombinant OmpA. Pretreatment of A. phagocytophilum organisms with OmpA antiserum reduces their abilities to infect HL-60 cells. The OmpA N-terminal region is predicted to contain the protein's extracellular domain. Glutathione S-transferase (GST)-tagged versions of OmpA and OmpA amino acids 19 to 74 (OmpA(19-74)) but not OmpA(75-205) bind to, and competitively inhibit A. phagocytophilum infection of, host cells. Pretreatment of host cells with sialidase or trypsin reduces or nearly eliminates, respectively, GST-OmpA adhesion. Therefore, OmpA interacts with sialylated glycoproteins. This study identifies the first A. phagocytophilum adhesin-receptor pair and delineates the region of OmpA that is critical for infection.

Molecular and cellular pathobiology of Ehrlichia infection: targets for new therapeutics and immunomodulation strategies.

Ehrlichia are small obligately intracellular bacteria in the order Rickettsiales that are transmitted by ticks and associated with emerging life-threatening human zoonoses. Vaccines are not available for human ehrlichiosis, and therapeutic options are limited to a single antibiotic class. New technologies for exploring host-pathogen interactions have yielded recent advances in understanding the molecular interactions between Ehrlichia and the eukaryotic host cell and identified new targets for therapeutic and vaccine development, including those that target pathogen virulence mechanisms or disrupt the processes associated with ehrlichial effector proteins. Animal models have also provided insight into immunopathological mechanisms that contribute significantly to understanding severe disease manifestations, which should lead to the development of immunomodulatory approaches for treating patients nearing or experiencing severe disease states. In this review, we discuss the recent advances in our understanding of molecular and cellular pathobiology and the immunobiology of Ehrlichia infection. We identify new molecular host-pathogen interactions that can be targets of new therapeutics, and discuss prospects for treating the immunological dysregulation during acute infection that leads to life-threatening complications.

Human ehrlichiosis and anaplasmosis.

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.

[Ehrlichiosis and human anaplasmosis]. / Ehrlichiosis y anaplasmosis humana.

Human ehrlichiosis and anaplasmosis are acute febrile tick-borne diseases caused by various species of the genera Ehrlichia and Anaplasma (Anaplasmataceae). To date, only cases of human granulocytic anaplasmosis (HGA) caused by Anaplasma phagocytophilum (formerly human granulocytic Ehrlichia, Ehrlichia phagocytophila, and E. equi) have been diagnosed in Europe. HGA and Lyme borreliosis are closely related diseases that share vector and reservoirs. In addition to HGA, human monocytic ehrlichiosis caused by E. chaffeensis has been reported in North America, as well as cases of infection due to E. ewingii in immunocompromised hosts. Ehrlichia spp. and A. phagocytophilum have tropism for blood cells, especially leukocytes and platelets, causing a considerable decrease of both components in these patients. HGA should be suspected in tick-bitten patients or those who have visited an endemic area and show symptoms of flu-like fever, leukopenia and thrombocytopenia.

Interferon-gamma deficiency reveals that 129Sv mice are inherently more susceptible to Anaplasma phagocytophilum than C57BL/6 mice.

Immunocompetent mice 129Sv (129) and C57BL/6 (B6) mice are similarly susceptible to Anaplasma phagocytophilum. We now show that 129 mice lacking interferon-gamma (IFN-gamma) develop more severe infection with A. phagocytophilum than IFN-gamma deficient B6 mice. These data demonstrate that there is an inherent increased susceptibility of 129 mice, compared with B6 mice, to A. phagocytophilum that can only be discerned in the absence of IFN-gamma.

The risk of exposure to Anaplasma phagocytophilum infection in Mid-Eastern Poland.

Both the presence of Anaplasma phagocytophilum in ticks and the seroprevalence of human granulocytic anaplasmosis have been reported in different parts of Europe. There are few reports concerning this problem in Poland. The aim of the study was to assess the prevalence of Anaplasma phagocytophilum in ticks, and to detect antibodies against the HGE agent in serum of forest workers in the region of Mid-Eastern Poland. In our opinion, this should reflect the real probability of infection of people exposed to Ixodes tick bites. Seroactivity against Anaplasma phagocytophilum was detected in 20.6% of persons in the study group. Coexistence of anti-Borrelia burgdorferi was present in 84.6 % of individuals seropositive to A. phagocytophilum. The PCR test identifying Anaplasma phagocytophilum was positive in 13.1% of overall tick samples. The highest prevalence of infection (45.7%) was found in female ticks. Anaplasmal DNA was detected in 4.5% of male ticks and only in 0.9% of nymphs. The results of our study confirmed the existence of A. phagocytophilum in the natural environment of Mid-Eastern Poland. As the risk for infection exists, it should call the attention of public health services to the possibility of an increasing number of patients with this disease.

Ehrlichia chaffeensis: a prevalent, life-threatening, emerging pathogen.

Ehrlichia chaffeensis are small, obligately intracellular, endosomal bacteria with tropism for macrophages. Persistent infection in reservoir white-tailed deer is transmitted by lone star ticks. Flu-like illness can progress to severe multisystem disease with toxic shock-like syndrome, meningitis, or ARDS. The case-fatality rate is 2.7%. Leukopenia and thrombocytopenia are diagnostically useful. Granulomas are associated with control of the infection. Ehrlichial proteins and glycoproteins have been sequenced and expressed for diagnostic serology and vaccine development. Mouse models (mild disease and persistent infection with E. muris and fatal monocytotropic ehrlichiosis with a Japanese tick isolate) revealed that CD4 and CD8 T type 1 lymphocyte responses, IFN-gamma, TNF-alpha, and antibodies play roles in protective immunity, while a weak CD4 T-helper response, overproduction of TNF-alpha, and very high IL-10 are associated with toxic shock-like mortality. Protection against fatal ehrlichiosis was achieved by prior infection with low virulence E. muris. Acute clinical diagnosis is difficult except by PCR. Response to doxycycline is dramatic.