Human Infection with Ehrlichia muris-like Pathogen, United States, 2007-2013(1).

An Ehrlichia muris-like (EML) pathogen was detected among 4 patients in Minnesota and Wisconsin during 2009. We characterized additional cases clinically and epidemiologically. During 2004-2013, blood samples from 75,077 patients from all 50 United States were tested by PCR from the groEL gene for Ehrlichia spp. and Anaplasma phagocytophilum. During 2007-2013, samples from 69 (0.1%) patients were positive for the EML pathogen; patients were from 5 states: Indiana (1), Michigan (1), Minnesota (33), North Dakota (3), and Wisconsin (31). Most (64%) patients were male; median age was 63 (range 15-94) years; and all 69 patients reported likely tick exposure in Minnesota or Wisconsin. Fever, malaise, thrombocytopenia, and lymphopenia were the most common symptoms. Sixteen (23%) patients were hospitalized (median 4 days); all recovered, and 96% received doxycycline. Infection with the EML pathogen should be considered for persons reporting tick exposure in Minnesota or Wisconsin.

Emergence of a new pathogenic Ehrlichia species, Wisconsin and Minnesota, 2009.

BACKGROUND: Ehrlichiosis is a clinically important, emerging zoonosis. Only Ehrlichia chaffeensis and E. ewingii have been thought to cause ehrlichiosis in humans in the United States. Patients with suspected ehrlichiosis routinely undergo testing to ensure proper diagnosis and to ascertain the cause. METHODS: We used molecular methods, culturing, and serologic testing to diagnose and ascertain the cause of cases of ehrlichiosis. RESULTS: On testing, four cases of ehrlichiosis in Minnesota or Wisconsin were found not to be from E. chaffeensis or E. ewingii and instead to be caused by a newly discovered ehrlichia species. All patients had fever, malaise, headache, and lymphopenia; three had thrombocytopenia; and two had elevated liver-enzyme levels. All recovered after receiving doxycycline treatment. At least 17 of 697 Ixodes scapularis ticks collected in Minnesota or Wisconsin were positive for the same ehrlichia species on polymerase-chain-reaction testing. Genetic analyses revealed that this new ehrlichia species is closely related to E. muris. CONCLUSIONS: We report a new ehrlichia species in Minnesota and Wisconsin and provide supportive clinical, epidemiologic, culture, DNA-sequence, and vector data. Physicians need to be aware of this newly discovered close relative of E. muris to ensure appropriate testing, treatment, and regional surveillance. (Funded by the National Institutes of Health and the Centers for Disease Control and Prevention.).

Prevalence of Borrelia burgdorferi and Anaplasma phagocytophilum in Ixodes scapularis (Acari: Ixodidae) nymphs collected in managed red pine forests in Wisconsin.

Changes in the structure of managed red pine forests in Wisconsin caused by interacting root- and stem-colonizing insects are associated with increased abundance of the blacklegged tick, Ixodes scapularis Say, in comparison with nonimpacted stands. However, the frequency and variability of the occurrence of tick-borne pathogens in this coniferous forest type across Wisconsin is unknown. Red pine forests were surveyed from 2009 to 2013 to determine the prevalence of Borrelia burgdorferi and Anaplasma phagocytophilum in questing I. scapularis nymphs. Polymerase chain reaction analysis revealed geographical differences in the nymphal infection prevalence (NIP) of these pathogens in red pine forests. In the Kettle Moraine State Forest (KMSF) in southeastern Wisconsin, NIP of B. burgdorferi across all years was 35% (range of 14.5-53.0%). At the Black River State Forest (BRSF) in western Wisconsin, NIP of B. burgdorferi across all years was 26% (range of 10.9-35.5%). Differences in NIP of B. burgdorferi between KMSF and BRSF were statistically significant for 2010 and 2011 and for all years combined (P < 0.05). NIP ofA. phagocytophilum (human agent) averaged 9% (range of 4.6-15.8%) at KMSF and 3% (range of 0-6.4%) at BRSF, and was significantly different between the sites for all years combined (P < 0.05). Differences in coinfection of B. burgdorferi and A. phagocytophilum were not statistically significant between KMSF and BRSF, with an average of 3.4% (range of 1.7-10.5%) and 2.5% (range of 0-5.5%), respectively. In 2013, the density of infected nymphs in KMSF and BRSF was 14 and 30 per 1000m2, respectively, among the highest ever recorded for the state. Differences in the density of nymphs and NIP among sites were neither correlated with environmental factors nor time since tick colonization. These results document significant unexplained variation in tick-borne pathogens between coniferous forests in Wisconsin that warrants further study.

Tickborne Powassan virus infections among Wisconsin residents.

INTRODUCTION: Powassan virus (POWV) is a tickborne Flavivirus that causes a rare but potentially life-threatening illness. The first reported case of POWV infection in a Wisconsin resident occurred in 2003. Enhanced surveillance and testing detected 2 additional cases. METHODS: Patient specimens with a positive or equivocal immunoglobulin M (IgM) antibody to an arbovirus were sent from commercial laboratories to the Wisconsin State Laboratory of Hygiene and forwarded to the Centers for Disease Control and Prevention (CDC) for confirmatory testing. Patients with laboratory confirmed POWV infections were interviewed to obtain demographic, clinical, and epidemiologic information. RESULTS: POWV infections were confirmed in 3 adult Wisconsin residents in 2003, 2006, and 2007; illness onsets occurred during May and June. Two patients were hospitalized and all survived. One patient had a dual infection with POWV and Anaplasma phaghocytophilum. Specimens from all 3 patients were initially reported as positive for IgM antibody to either St Louis encephalitis or California serogroup viruses; POWV-specific antibody was detected during confirmatory testing at the CDC. Each patient had exposures to known or likely tick habitats in different counties within 30 days before illness onset. CONCLUSIONS: These are the first diagnosed human POWV infections in Wisconsin. Because all 3 patients were initially identified as having other arboviral infections using commercial screening kits, routine confirmatory testing is essential for proper diagnosis of most arboviral infections. Wisconsin residents should be educated regarding risks of acquiring and ways to prevent POWV infection and other tickborne diseases when spending time outdoors.

Prevalence and Distribution of Human and Tick Infections with the Ehrlichia muris-Like Agent and Anaplasma phagocytophilum in Wisconsin, 2009-2015.

Ehrlichiosis and anaplasmosis are important emerging tickborne zoonoses that affect both humans and animals. Knowledge of the geographic distribution and prevalence of Ehrlichia spp. and Anaplasma phagocytophilum in Wisconsin is important information as a baseline for future comparisons. Reported human cases between 2009 and 2015 were identified using the Wisconsin Electronic Disease Surveillance System (WEDSS) and mapped by county of residence. Vector surveillance was established using ticks collected from animals by partners, including veterinary medical clinics, domestic animal shelters, and wildlife rehabilitation centers from 40 Wisconsin counties. A total of 1835 Ixodes scapularis tick specimens (larvae, nymphs, and adults) were collected from 18 different domestic and wildlife species from July 2011 to November 2015. An additional 1136 nymphs were collected by drag sampling at 23 locations in 19 counties in 2015. A real-time PCR assay that detects and distinguishes several Ehrlichia species, including a pathogenic Ehrlichia muris-like agent (EMLA), and A. phagocytophilum was performed on adult and nymphal ticks. A total of 757 I. scapularis ticks (predominately adults) were tested from animal collections, with 67 (8.9%) individuals positive for A. phagocytophilum and 22 (2.9%) positive for EMLA DNA. Of the 1150 questing nymphs, 62 (5.4%) were positive for A. phagocytophilum and 10 (0.9%) were positive for EMLA DNA. Specimens of I. scapularis that were positive for A. phagocytophilum were found in 27 of the 33 counties surveyed. Specimens that were positive for EMLA were less common and were found in nine counties. This study provides the first statewide survey of I. scapularis ticks for these pathogens and indicates that the risk of human exposure is widely distributed.

Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: a descriptive study.

BACKGROUND: Lyme borreliosis is the most common tick-borne disease in the northern hemisphere. It is a multisystem disease caused by Borrelia burgdorferi sensu lato genospecies and characterised by tissue localisation and low spirochaetaemia. In this study we aimed to describe a novel Borrelia species causing Lyme borreliosis in the USA. METHODS: At the Mayo clinic, from 2003 to 2014, we tested routine clinical diagnostic specimens from patients in the USA with PCR targeting the oppA1 gene of B burgdorferi sensu lato. We identified positive specimens with an atypical PCR result (melting temperature outside of the expected range) by sequencing, microscopy, or culture. We collected Ixodes scapularis ticks from regions of suspected patient tick exposure and tested them by oppA1 PCR. FINDINGS: 100 545 specimens were submitted by physicians for routine PCR from Jan 1, 2003 to Sept 30, 2014. From these samples, six clinical specimens (five blood, one synovial fluid) yielded an atypical oppA1 PCR product, but no atypical results were detected before 2012. Five of the six patients with atypical PCR results had presented with fever, four had diffuse or focal rash, three had symptoms suggestive of neurological inclusion, and two were admitted to hospital. The sixth patient presented with knee pain and swelling. Motile spirochaetes were seen in blood samples from one patient and cultured from blood samples from two patients. Among the five blood specimens, the median oppA1 copy number was 180 times higher than that in 13 specimens that tested positive for B burgdorferi sensu stricto during the same time period. Multigene sequencing identified the spirochaete as a novel B burgdorferi sensu lato genospecies. This same genospecies was detected in ticks collected at a probable patient exposure site. INTERPRETATION: We describe a new pathogenic Borrelia burgdorferi sensu lato genospecies (candidatus Borrelia mayonii) in the upper midwestern USA, which causes Lyme borreliosis with unusually high spirochaetaemia. Clinicians should be aware of this new B burgdorferi sensu lato genospecies, its distinct clinical features, and the usefulness of oppA1 PCR for diagnosis. FUNDING: US Centers for Disease Control and Prevention Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement and Mayo Clinic Small Grant programme.