First report of pediatric ehrlichiosis in Mexico.

BACKGROUND: Ehrlichia chaffeensis is responsible for most cases of human ehrlichiosis, an acute febrile tick-borne disease. This clinical entity is more commonly reported in adults from the United States. Therefore, it is of special interest to characterize this disease in children, given that very few cases in children have been reported outside of this country. CASE REPORT: We describe the case of a 15-year-old female from northeastern Mexico with a five-day history of myalgias, arthralgias, fever, abdominal pain, rash, and somnolence. The possibility of tick-borne disease was suspected considering that she lived with three tick-infested dogs that had recently died and a neighbor with similar symptoms who deteriorated rapidly and died a week earlier. Ehrlichia spp. was detected in blood samples by polymerase chain reaction. The patient completed a seven-day course of doxycycline and was discharged with complete resolution of symptoms. CONCLUSIONS: This case is the first report of ehrlichiosis in a pediatric patient in Mexico, illustrating the importance of considering tick-borne diseases as a differential diagnosis in patients with rash, fever, and altered level of consciousness. This initial clinical presentation may be indistinct from other conditions such as dengue, meningococcemia, and multisystem inflammatory syndrome in children (MIS-C), among others.

INTRODUCCIÓN: Ehrlichia chaffeensis es responsable de la mayoría de los casos de ehrlichiosis humana, una enfermedad febril aguda transmitida por garrapatas. Esta entidad clínica se reporta con mayor frecuencia en adultos de Estados Unidos. Por lo tanto, es de especial interés caracterizarla en niños, dado que se han reportado muy pocos casos en niños fuera de este país. CASO CLÍNICO: Se describe el caso de una paciente de sexo femenino de 15 años, originaria y residente del noreste de México con una historia de cinco días de mialgias, artralgias, fiebre, dolor abdominal, erupción cutánea y somnolencia. Se sospechó la posibilidad de una enfermedad transmitida por garrapatas considerando que convivió con tres perros infestados de garrapatas que habían muerto recientemente y una vecina con síntomas similares, quien se deterioró rápidamente y murió una semana antes. Ehrlichia spp. se detectó en una muestra sérica mediante reacción en cadena de la polimerasa. La paciente completó un curso de siete días de doxiciclina y fue dada de alta con resolución de los síntomas. CONCLUSIONES: Este caso es el primer reporte de ehrlichiosis en un paciente pediátrico en México que ilustra la importancia de considerar enfermedades transmitidas por garrapatas dentro del diagnóstico diferencial de pacientes con exantema, fiebre y alteración del estado de conciencia. Esta presentación clínica inicial puede ser indistinguible de otras entidades como dengue, meningococcemia y síndrome multisistémico inflamatorio, entre otras.

Multiple coinfections and Guillain Barré syndrome following outdoor travel to the American Northeast.

A 66-year-old immunocompetent man with preceding travel through the Northeastern United States developed Guillain-Barré syndrome. A broad search for infections revealed intraerythrocytic parasites on blood smear and positive polymerase chain reaction for Babesia microti; elevated IgM/IgG serologies for Ehrlichia chaffeensis; elevated IgM/IgG serologies and qualitative polymerase chain reaction for Epstein-Barr virus; and fecal culture growth of Arcobacter butzleri. In this report, we discuss the known or suspected association of these infectious agents with Guillain-Barré syndrome. This case also highlights the importance, in the setting of endemic exposure, of screening for multiple coinfections that can be transmitted by the same arthropod vector.

First report of pediatric ehrlichiosis in Mexico / Primer reporte de ehrlichiosis pediátrica en México

Abstract Background: Ehrlichia chaffeensis is responsible for most cases of human ehrlichiosis, an acute febrile tick-borne disease. This clinical entity is more commonly reported in adults from the United States. Therefore, it is of special interest to characterize this disease in children, given that very few cases in children have been reported outside of this country. Case report: We describe the case of a 15-year-old female from northeastern Mexico with a five-day history of myalgias, arthralgias, fever, abdominal pain, rash, and somnolence. The possibility of tick-borne disease was suspected considering that she lived with three tick-infested dogs that had recently died and a neighbor with similar symptoms who deteriorated rapidly and died a week earlier. Ehrlichia spp. was detected in blood samples by polymerase chain reaction. The patient completed a seven-day course of doxycycline and was discharged with complete resolution of symptoms. Conclusions: This case is the first report of ehrlichiosis in a pediatric patient in Mexico, illustrating the importance of considering tick-borne diseases as a differential diagnosis in patients with rash, fever, and altered level of consciousness. This initial clinical presentation may be indistinct from other conditions such as dengue, meningococcemia, and multisystem inflammatory syndrome in children (MIS-C), among others.

Resumen Introducción: Ehrlichia chaffeensis es responsable de la mayoría de los casos de ehrlichiosis humana, una enfermedad febril aguda transmitida por garrapatas. Esta entidad clínica se reporta con mayor frecuencia en adultos de Estados Unidos. Por lo tanto, es de especial interés caracterizarla en niños, dado que se han reportado muy pocos casos en niños fuera de este país. Caso clínico: Se describe el caso de una paciente de sexo femenino de 15 años, originaria y residente del noreste de México con una historia de cinco días de mialgias, artralgias, fiebre, dolor abdominal, erupción cutánea y somnolencia. Se sospechó la posibilidad de una enfermedad transmitida por garrapatas considerando que convivió con tres perros infestados de garrapatas que habían muerto recientemente y una vecina con síntomas similares, quien se deterioró rápidamente y murió una semana antes. Ehrlichia spp. se detectó en una muestra sérica mediante reacción en cadena de la polimerasa. La paciente completó un curso de siete días de doxiciclina y fue dada de alta con resolución de los síntomas. Conclusiones: Este caso es el primer reporte de ehrlichiosis en un paciente pediátrico en México que ilustra la importancia de considerar enfermedades transmitidas por garrapatas dentro del diagnóstico diferencial de pacientes con exantema, fiebre y alteración del estado de conciencia. Esta presentación clínica inicial puede ser indistinguible de otras entidades como dengue, meningococcemia y síndrome multisistémico inflamatorio, entre otras.

CtrA activates the expression of glutathione S-transferase conferring oxidative stress resistance to Ehrlichia chaffeensis.

Ehrlichia chaffeensis, the causative agent of human monocytic ehrlichiosis (HME), is a Gram-negative obligatory intracellular bacterium, which infects and multiplies in human monocytes and macrophages. Host immune cells produce reactive oxygen species (ROS) to eliminate E. chaffeensis upon infection. E. chaffeensis global transcriptional regulator CtrA activates the expression of GshA and GshB to synthesize glutathione (GSH), the most potent natural antioxidant, upon oxidative stress to combat ROS damage. However, the mechanisms exploited by E. chaffeensis to utilize GSH are still unknown. Here, we found that in E. chaffeensis CtrA activated the expression of glutathione S-transferase (GST) upon oxidative stress, and E. chaffeensis GST utilizes GSH to eliminate ROS and confers the oxidative stress resistance to E. chaffeensis. We found that CtrA bound to the promoter regions of 211 genes, including gst, in E. chaffeensis using chromatin immunoprecipitation coupled to deep sequencing (ChIP-seq). Recombinant E. chaffeensis CtrA directly bound to the gst promoter region determined with electrophoretic mobility shift assay (EMSA), and activated the gst expression determined with reporter assay. Recombinant GST showed GSH conjugation activity towards its typical substrate 2,4-dinitrochlorobenzene (CDNB) in vitro and peptide nucleic acid (PNA) transfection of E. chaffeensis, which can knock down the gst transcription level, reduced bacterial survival upon oxidative stress. Our results demonstrate that E. chaffeensis CtrA regulates GSH utilization, which plays a critical role in resistance to oxidative stress, and aid in the development of new therapeutics for HME.

Molecular Detection of Anaplasma phagocytophilum and Ehrlichia Species in Ticks Removed from Humans in the Republic of Korea.

Human granulocytic anaplasmosis (HGA) and human monocytic ehrlichiosis (HME) are zoonotic tick-borne diseases transmitted via tick bites. To determine the state of human Anaplasma and Ehrlichia infections caused by tick bites in the Republic of Korea (ROK), we conducted a nationwide investigation of human cases of tick bites in 2020. A total of 180 ticks were obtained, comprising Haemaphysalis longicornis (70.0%), Amblyomma testudinarium (17.8%), Ixodes nipponensis (6.1%), H. flava (4.4%), and I. persulcatus (1.7%). In three cases (1.7%; 95% CI: 0.3-4.9), A. phagocytophilum was detected in Ixodes ticks using primers for Anaplasma-specific genes (16s rRNA, ankA, and msp4). Conversely, Ehrlichia sp. was only detected in H. longicornis, in two cases (1.1%; 95% CI: 0.1-4.0). To the best of our knowledge, this is the first record of Ehrlichia sp. in ticks parasitizing humans in the ROK. As concerns remain about the possibility of HGA and HME transmission, continuous monitoring and management of the pathogens and vectors are necessary.

Glutathione Synthesis Regulated by CtrA Protects Ehrlichia chaffeensis From Host Cell Oxidative Stress.

Ehrlichia chaffeensis, a small Gram-negative obligatory intracellular bacterium, infects human monocytes or macrophages, and causes human monocytic ehrlichiosis, one of the most prevalent, life-threatening emerging zoonoses. Reactive oxygen species are produced by the host immune cells in response to bacterial infections. The mechanisms exploited by E. chaffeensis to resist oxidative stress have not been comprehensively demonstrated. Here, we found that E. chaffeensis encodes two functional enzymes, GshA and GshB, to synthesize glutathione that confers E. chaffeensis the oxidative stress resistance, and that the expression of gshA and gshB is upregulated by CtrA, a global transcriptional regulator, upon oxidative stress. We found that in E. chaffeensis, the expression of gshA and gshB was upregulated upon oxidative stress using quantitative RT-PCR. Ehrlichia chaffeensis GshA or GshB restored the ability of Pseudomonas aeruginosa GshA or GshB mutant to cope with oxidative stress, respectively. Recombinant E. chaffeensis CtrA directly bound to the promoters of gshA and gshB, determined with electrophoretic mobility shift assay, and activated the expression of gshA and gshB determined with reporter assay. Peptide nucleic acid transfection of E. chaffeensis, which reduced the CtrA protein level, inhibited the oxidative stress-induced upregulation of gshA and gshB. Our findings provide insights into the function and regulation of the two enzymes critical for E. chaffeensis resistance to oxidative stress and may deepen our understanding of E. chaffeensis pathogenesis and adaptation in hosts.

Ehrlichiosis mimicking acute leukemia.

Human monocytic ehrlichiosis is a tickborne disease with a spectrum of presentations ranging from asymptomatic, mild to fatal. Ehrlichiosis can transiently cause white blood cells abnormalities that mimic leukemia/lymphoma and cases have been, on rare occasions, initially mistaken for hematological malignancies. We report a case of Ehrlichia chaffeensis infection suspected to be acute promyelocytic leukemia at presentation, prompting therapy with all-trans-retinoic acid. Physicians should keep tickborne transmitted illnesses on the differential in patients presenting with pancytopenia, especially in endemic areas.

Insights into the mechanism regulating the differential expression of the P28-OMP outer membrane proteins in obligatory intracellular pathogen Ehrlichia chaffeensis.

Ehrlichia chaffeensis causes human monocytic ehrlichiosis (HME), which is one of the most prevalent, life-threatening emerging infectious zoonoses. The life cycle of E. chaffeensis includes ticks and mammals, in which E. chaffeensis proteins are expressed differentially contributing to bacterial survival and infection. Among the E. chaffeensis P28-OMP outer membrane proteins, OMP-1B and P28 are predominantly expressed in tick cells and mammalian macrophages, respectively. The mechanisms regulating this differential expression have not been comprehensively studied. Here, we demonstrate that the transcriptional regulators EcxR and Tr1 regulate the differential expression of omp-1B and p28 in E. chaffeensis. Recombinant E. chaffeensis Tr1 bound to the promoters of omp-1B and p28, and transactivated omp-1B and p28 promoter-EGFP fusion constructs in Escherichia coli. The consensus sequence of Tr1 binding motifs was AC/TTATA as determined with DNase I footprint assay. Tr1 showed a higher affinity towards the p28 promoter than the omp-1B promoter as determined with surface plasmon resonance. EcxR activated the tr1 expression in response to a temperature decrease. At 37°C low level of Tr1 activated the p28 expression. At 25°C high level of Tr1 activated the omp-1B expression, while repressing the p28 expression by binding to an additional site upstream of the p28 gene. Our data provide insights into a novel mechanism mediated by Tr1 regulating E. chaffeensis differential gene expression, which may aid in the development of new therapeutics for HME.

Human Monocytic Ehrlichiosis, Mexico City, Mexico.

Little information is available about human infections by the members of the genus Ehrlichia in Mexico. Only 2 species, Ehrlichia canis and E. chaffensis, are known to cause disease in this country. We report a fatal case of human monocytic ehrlichiosis in Mexico City in a man who was homeless.

An Entry-Triggering Protein of Ehrlichia Is a New Vaccine Candidate against Tick-Borne Human Monocytic Ehrlichiosis.

Ehrlichia chaffeensis is an obligatory intracellular bacterium that causes human monocytic ehrlichiosis, an emerging disease transmitted by the Lone Star tick, Amblyomma americanum. E. chaffeensis outer membrane protein entry triggering protein of Ehrlichia (EtpE) is necessary for bacterial entry into human cells. We investigated the role of EtpE in transmission of the bacteria from tick to human cells and whether or not vaccination with EtpE can prevent transmission of ehrlichiae from ticks to mammals. An antiserum against the recombinant C terminus of EtpE (rEtpE-C), which binds a mammalian cell-surface receptor and triggers bacterial entry, significantly inhibited E. chaffeensis transmission from infected tick cells to human monocytes in culture. Each of five specific-pathogen-free dogs were vaccinated with rEtpE-C along with an immunostimulating complex or were sham vaccinated with the complex alone. Dogs vaccinated with rEtpE-C developed high antibody titers against rEtpE-C and produced interferon-γ-secreting cells, as assessed with the ELISpot assay. All 10 dogs were challenged with A. americanum adult ticks infected as nymphs by syringe inoculation with E. chaffeensis Upon challenge, both the vaccinated and control dogs became infected by day 1 post-tick attachment, but the majority of rEtpE-C-vaccinated dogs rapidly cleared the infection from the bloodstream as soon as day 7, whereas most of sham-vaccinated dogs remained infected at day 35. Peripheral blood leukocytes from vaccinated dogs had significantly elevated interferon-γ mRNA levels and secreted significantly elevated interferon-γ soon after tick attachment. Thus, the EtpE-C vaccine represents the first ehrlichial protein vaccine demonstrated to reduce bacterial infection in mammals upon challenge with infected ticks.IMPORTANCE The incidence of tick-borne diseases has risen dramatically in the past two decades and continues to rise. Discovered in 1986 and designated a nationally notifiable disease in 1998 by the Centers for Disease Control and Prevention, human monocytic ehrlichiosis, which is caused by the bacterium Ehrlichia chaffeensis, is one of the most prevalent, life-threatening, emerging tick-borne zoonoses in the United States. We investigated the role of the E. chaffeensis protein EtpE in transmission of the bacterium from tick to human cells and in vaccinated dogs with EtpE to assess the efficacy of vaccination against E. chaffeensis-infected tick challenge. Our results help fill gaps in our understanding of E. chaffeensis-derived protective antigens that could be used in a candidate vaccine for immunization of humans to counter tick-transmitted ehrlichiosis.

Ehrlichiosis Presenting as Hemophagocytic Lymphohistiocytosis in an Immunocompetent Adult.

Hemophagocytic Lymphohistiocytosis (HLH) is a fatal, immunologic syndrome characterized by dysregulated tissue inflammation. HLH can be either primary or secondary; with the latter typically resulting from an infection. Diagnosis requires five or more of the following: fever, splenomegaly, cytopenia, hypertriglyceridemia, hemophagocytosis via biopsy, low natural killer (NK) cell activity, elevated ferritin and soluble CD25 level (sCD25). We present a case of HLH related to ehrlichiosis. In order to mount an effective immune response against microbes such as Ehrlichia chaffeensis, the host must have preserved NK cell function. Being that HLH Is characterized as a state of depleted NK cell function, It is crucial to investigate the role NK cell function has in the setting of HLH on the infectivity of Ehrlichia species.

Human Monocytic Ehrlichiosis Associated With Myocarditis and Hemophagocytic Lymphohistiocytosis.

We present 3 cases at a single institution of human monocytic ehrlichiosis resulting in myocarditis and hemophagocytic lymphohistiocytosis. Contrary to previously published studies in which case fatalities were only as high as 1%, 2 of the 3 patients we discuss experienced a fulminant course resulting in death despite appropriate doxycycline treatment. Human monocytic ehrlichiosis is rarely a cause of myocarditis and hemophagocytic lymphohistiocytosis, but a high degree of suspicion is important because early empirical therapy may decrease morbidity and mortality. (Level of Difficulty: Intermediate.).

Human Case of Ehrlichia chaffeensis Infection, Taiwan.

In 2018, an immunosuppressed woman in southern Taiwan had onset of fever, chills, myalgia, malaise, thrombocytopenia, lymphocytopenia, and elevated hepatic transaminases. Investigation revealed infection with Ehrlichia chaffeensis. This autochthonous case of human monocytotropic ehrlichiosis was confirmed by PCR, DNA sequencing, and seroconversion.

Solution NMR structures of oxidized and reduced Ehrlichia chaffeensis thioredoxin: NMR-invisible structure owing to backbone dynamics.

Thioredoxins are small ubiquitous proteins that participate in a diverse variety of redox reactions via the reversible oxidation of two cysteine thiol groups in a structurally conserved active site. Here, the NMR solution structures of a reduced and oxidized thioredoxin from Ehrlichia chaffeensis (Ec-Trx, ECH_0218), the etiological agent responsible for human monocytic ehrlichiosis, are described. The overall topology of the calculated structures is similar in both redox states and is similar to those of other thioredoxins: a five-stranded, mixed ß-sheet (ß1-ß3-ß2-ß4-ß5) surrounded by four α-helices. Unlike other thioredoxins studied by NMR in both redox states, the 1H-15N HSQC spectrum of reduced Ec-Trx was missing eight additional amide cross peaks relative to the spectrum of oxidized Ec-Trx. These missing amides correspond to residues Cys35-Glu39 in the active-site-containing helix (α2) and Ser72-Ile75 in a loop near the active site, and suggest a change in backbone dynamics on the millisecond-to-microsecond timescale associated with the breakage of an intramolecular Cys32-Cys35 disulfide bond in a thioredoxin. A consequence of the missing amide resonances is the absence of observable or unambiguous NOEs to provide the distance restraints necessary to define the N-terminal end of the α-helix containing the CPGC active site in the reduced state. This region adopts a well defined α-helical structure in other reported reduced thioredoxin structures, is mostly helical in oxidized Ec-Trx and CD studies of Ec-Trx in both redox states suggests there is no significant difference in the secondary structure of the protein. The NMR solution structure of reduced Ec-Trx illustrates that the absence of canonical structure in a region of a protein may be owing to unfavorable dynamics prohibiting NOE observations or unambiguous NOE assignments.

Fatal Monocytic Ehrlichiosis in Woman, Mexico, 2013.

Human monocytic ehrlichiosis is a febrile illness caused by Ehrlichia chaffeensis, an intracellular bacterium transmitted by ticks. In Mexico, a case of E. chaffeensis infection in an immunocompetent 31-year-old woman without recognized tick bite was fatal. This diagnosis should be considered for patients with fever, leukopenia, thrombocytopenia, and elevated liver enzyme levels.

Successful Treatment of Human Monocytic Ehrlichiosis with Rifampin.

Currently recommended treatment regimens for human monocytic ehrlichiosis (HME) include doxycycline or tetracycline. Antibiotic susceptibility studies demonstrate that rifampin has in vitro bactericidal activity against Ehrlichia. Case reports have suggested clinical response with rifampin treatment of human granulocytic anaplasmosis (HGA). We report the first case of HME successfully treated with rifampin.

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.

Global proteomic analysis of two tick-borne emerging zoonotic agents: anaplasma phagocytophilum and ehrlichia chaffeensis.

Anaplasma phagocytophilum and Ehrlichia chaffeensis are obligatory intracellular α-proteobacteria that infect human leukocytes and cause potentially fatal emerging zoonoses. In the present study, we determined global protein expression profiles of these bacteria cultured in the human promyelocytic leukemia cell line, HL-60. Mass spectrometric (MS) analyses identified a total of 1,212 A. phagocytophilum and 1,021 E. chaffeensis proteins, representing 89.3 and 92.3% of the predicted bacterial proteomes, respectively. Nearly all bacterial proteins (≥99%) with known functions were expressed, whereas only approximately 80% of "hypothetical" proteins were detected in infected human cells. Quantitative MS/MS analyses indicated that highly expressed proteins in both bacteria included chaperones, enzymes involved in biosynthesis and metabolism, and outer membrane proteins, such as A. phagocytophilum P44 and E. chaffeensis P28/OMP-1. Among 113 A. phagocytophilum p44 paralogous genes, 110 of them were expressed and 88 of them were encoded by pseudogenes. In addition, bacterial infection of HL-60 cells up-regulated the expression of human proteins involved mostly in cytoskeleton components, vesicular trafficking, cell signaling, and energy metabolism, but down-regulated some pattern recognition receptors involved in innate immunity. Our proteomics data represent a comprehensive analysis of A. phagocytophilum and E. chaffeensis proteomes, and provide a quantitative view of human host protein expression profiles regulated by bacterial infection. The availability of these proteomic data will provide new insights into biology and pathogenesis of these obligatory intracellular pathogens.