Clinical recognition and management of tularemia in Missouri: a retrospective records review of 121 cases.

BACKGROUND: Clinical recognition of tularemia is essential for prompt initiation of appropriate antibiotic treatment. Although fluoroquinolones have desirable attributes as a treatment option, limited data on efficacy in the US setting exist. METHODS: To define the epidemiology of tularemia in Missouri, and to evaluate practices and outcomes of tularemia management in general, we conducted a detailed retrospective review and analysis of clinical records for patients reported to the state from 2000 to 2007. RESULTS: We reviewed records of 121 of 190 patients (64%) reported with tularemia; 79 (65%) were males; the median age was 37 years. Most patients presented with ulceroglandular (37%) and glandular (25%) forms of tularemia, followed by pneumonic (12%), typhoidal (10%), oculoglandular (3%), and oropharyngeal (2%) forms. Most cases (69%) were attributed to tick bites. Median incubation period was 3 days (range, 1-9 days), and patients sought care after a median of 3 days of illness (range, 0-44 days). Systemic disease occurred more commonly in older patients. Patients were prescribed tetracyclines (49%), aminoglycosides (47%), and fluoroquinolones (41%). Nine of 10 patients treated with ciprofloxacin for ≥10 days recovered uneventfully, without accompanying aminoglycosides or tetracyclines. CONCLUSIONS: Tularemia is frequently initially misdiagnosed. A thorough exposure history, particularly for tick bites, and awareness of clinical features may prompt clinicians to consider tularemia and facilitate appropriate testing. Promising success with oral fluoroquinolones could provide an acceptable alternative to intravenous aminoglycosides or long courses of tetracyclines where clinically appropriate.

Zoonotic infections among employees from Great Smoky Mountains and Rocky Mountain National Parks, 2008-2009.

U.S. National Park Service employees may have prolonged exposure to wildlife and arthropods, placing them at increased risk of infection with endemic zoonoses. To evaluate possible zoonotic risks present at both Great Smoky Mountains (GRSM) and Rocky Mountain (ROMO) National Parks, we assessed park employees for baseline seroprevalence to specific zoonotic pathogens, followed by evaluation of incident infections over a 1-year study period. Park personnel showed evidence of prior infection with a variety of zoonotic agents, including California serogroup bunyaviruses (31.9%), Bartonella henselae (26.7%), spotted fever group rickettsiae (22.2%), Toxoplasma gondii (11.1%), Anaplasma phagocytophilum (8.1%), Brucella spp. (8.9%), flaviviruses (2.2%), and Bacillus anthracis (1.5%). Over a 1-year study period, we detected incident infections with leptospirosis (5.7%), B. henselae (5.7%), spotted fever group rickettsiae (1.5%), T. gondii (1.5%), B. anthracis (1.5%), and La Crosse virus (1.5%) in staff members at GRSM, and with spotted fever group rickettsiae (8.5%) and B. henselae (4.3%) in staff at ROMO. The risk of any incident infection was greater for employees who worked as resource managers (OR 7.4; 95% CI 1.4,37.5; p=0.02), and as law enforcement rangers/rescue crew (OR 6.5; 95% CI 1.1,36.5; p=0.03), relative to those who worked primarily in administration or management. The results of this study increase our understanding of the pathogens circulating within both parks, and can be used to inform the development of effective guidelines and interventions to increase visitor and staff awareness and help prevent exposure to zoonotic agents.

Lack of interference by zoster vaccine with the immune response to yellow fever vaccine.

Concerns exist about the serologic response to yellow fever (YF) vaccine when given within 28 days of another live virus vaccine. We report the case of a healthy adult who received 17D YF vaccine 21 days following administration of another live viral vaccine, and developed a protective level of immunity against YF virus.

The burden of imported malaria in Gauteng Province.

OBJECTIVES: To describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. DESIGN: We conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. OUTCOME MEASURES: Malaria frequency, severity, and treatment. Results. We identified 1 701 malaria cases; 1 548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals; 1 149 (68%) patients were male. Median age was 27 years (range 1 month - 89 years). Most (84%) infections were acquired in Mozambique. Disease severity did not differ by age or sex. Patients who were South African-born were more likely to have severe disease (OR=1.43 (1.08 - 1.91)), as were patients who experienced a delay >48 hours between onset of symptoms and diagnosis or treatment (OR=1.98 (1.48 - 2.65)). While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. CONCLUSIONS: The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. Providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.

Primary pneumonic plague contracted from a mountain lion carcass.

BACKGROUND: Primary pneumonic plague is a rare but often fatal form of Yersinia pestis infection that results from direct inhalation of bacteria and is potentially transmissible from person to person. We describe a case of primary pneumonic plague in a wildlife biologist who was found deceased in his residence 1 week after conducting a necropsy on a mountain lion. METHODS: To determine cause of death, a postmortem examination was conducted, and friends and colleagues were interviewed. Physical evidence was reviewed, including specimens from the mountain lion and the biologist's medical chart, camera, and computer. Human and animal tissues were submitted for testing. Persons in close contact (within 2 meters) to the biologist after he had developed symptoms were identified and offered chemoprophylaxis. RESULTS: The biologist conducted the necropsy in his garage without the use of personal protective equipment. Three days later, he developed fever and hemoptysis and died approximately 6 days after exposure. Gross examination showed consolidation and hemorrhagic fluid in the lungs; no buboes were noted. Plague was diagnosed presumptively by polymerase chain reaction and confirmed by culture. Tissues from the mountain lion tested positive for Y. pestis, and isolates from the biologist and mountain lion were indistinguishable by pulsed-field gel electrophoresis. Among 49 contacts who received chemoprophylaxis, none developed symptoms consistent with plague. CONCLUSIONS: The biologist likely acquired pneumonic plague through inhalation of aerosols generated during postmortem examination of an infected mountain lion. Enhanced awareness of zoonotic diseases and appropriate use of personal protective equipment are needed for biologists and others who handle wildlife.