Julie R. Harris

Evaluation of a Newly Developed Lateral Flow Immunoassay for the Diagnosis of Cryptococcosis

This study, evaluating the performance of a novel cryptococcal lateral flow immunoassay, shows that the assay performs as well as available diagnostic methods is economical, rapid, and easy to perform; and as such can be a point of care test in resource limited settings.

Necrotizing Cutaneous Mucormycosis after a Tornado in Joplin, Missouri, in 2011

BACKGROUND Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri. METHODS We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case-control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively. RESULTS A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1-D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains. CONCLUSIONS We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.

Cryptococcus gattii in the United States: Clinical Aspects of Infection With an Emerging Pathogen

BACKGROUND Cryptococcus gattii (Cg) has caused increasing infections in the US Pacific Northwest (PNW) since 2004. We describe this outbreak and compare clinical aspects of infection in the United States among patients infected with different Cg genotypes. METHODS Beginning in 2005, PNW state health departments conducted retrospective and prospective passive surveillance for Cg infections, including patient interviews and chart reviews; clinical isolates were genotyped at the US Centers for Disease Control and Prevention (CDC). We examined symptom frequency and underlying conditions in US patients with Cg infection and modeled factors associated with death. RESULTS From 1 December 2004 to July 2011, 96 Cg infections were reported to the CDC. Eighty-three were in patients in or travelers to the PNW, 78 of which were genotypes VGIIa, VGIIb, or VGIIc (outbreak strains). Eighteen patients in and outside the PNW had other molecular type Cg infections (nonoutbreak strains). Patients with outbreak strain infections were more likely than those with nonoutbreak-strain infections to have preexisting conditions (86% vs 31%, respectively; P < .0001) and respiratory symptoms (75% vs 36%, respectively; P = .03) and less likely to have central nervous system (CNS) symptoms (37% vs 90%, respectively; P = .008). Preexisting conditions were associated with increased pneumonia risk and decreased risk of meningitis and CNS symptoms. Nineteen (33%) of 57 patients died. Past-year oral steroid use increased odds of death in multivariate analysis (P = .05). CONCLUSIONS Clinical differences may exist between outbreak-strain (VGIIa, VGIIb, and VGIIc) and nonoutbreak-strain Cg infections in the United States. Clinicians should have a low threshold for testing for Cg, particularly among patients with recent travel to the PNW.

Fungal Infections Associated with Contaminated Methylprednisolone Injections

BACKGROUND Fungal infections are rare complications of injections for treatment of chronic pain. In September 2012, we initiated an investigation into fungal infections associated with injections of preservative-free methylprednisolone acetate that was purchased from a single compounding pharmacy. METHODS Three lots of methylprednisolone acetate were recalled by the pharmacy; examination of unopened vials later revealed fungus. Notification of all persons potentially exposed to implicated methylprednisolone acetate was conducted by federal, state, and local public health officials and by staff at clinical facilities that administered the drug. We collected clinical data on standardized case-report forms, and we tested for the presence of fungi in isolates and specimens by examining cultures and performing polymerase-chain-reaction assays and histopathological and immunohistochemical testing. RESULTS By October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of July 1, 2013, there were 749 reported cases of infection in 20 states, with 61 deaths (8%). Laboratory evidence of Exserohilum rostratum was present in specimens from 153 case patients (20%). Additional data were available for 728 case patients (97%); 229 of these patients (31%) had meningitis with no other documented infection. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 15 to 97), and the median incubation period (the number of days from the last injection to the date of the first diagnosis) was 47 days (range, 0 to 249); 40 patients (5%) had a stroke. CONCLUSIONS Analysis of data from a large, multistate outbreak of fungal infections showed substantial morbidity and mortality. The infections were associated with injection of a contaminated glucocorticoid medication from a single compounding pharmacy. Rapid public health actions included prompt recall of the implicated product, notification of exposed persons, and early outreach to clinicians.

Whole Genome Sequence Analysis of Cryptococcus gattii from the Pacific Northwest Reveals Unexpected Diversity

A recent emergence of Cryptococcus gattii in the Pacific Northwest involves strains that fall into three primarily clonal molecular subtypes: VGIIa, VGIIb and VGIIc. Multilocus sequence typing (MLST) and variable number tandem repeat analysis appear to identify little diversity within these molecular subtypes. Given the apparent expansion of these subtypes into new geographic areas and their ability to cause disease in immunocompetent individuals, differentiation of isolates belonging to these subtypes could be very important from a public health perspective. We used whole genome sequence typing (WGST) to perform fine-scale phylogenetic analysis on 20 C. gattii isolates, 18 of which are from the VGII molecular type largely responsible for the Pacific Northwest emergence. Analysis both including and excluding (289,586 SNPs and 56,845 SNPs, respectively) molecular types VGI and VGIII isolates resulted in phylogenetic reconstructions consistent, for the most part, with MLST analysis but with far greater resolution among isolates. The WGST analysis presented here resulted in identification of over 100 SNPs among eight VGIIc isolates as well as unique genotypes for each of the VGIIa, VGIIb and VGIIc isolates. Similar levels of genetic diversity were found within each of the molecular subtype isolates, despite the fact that the VGIIb clade is thought to have emerged much earlier. The analysis presented here is the first multi-genome WGST study to focus on the C. gattii molecular subtypes involved in the Pacific Northwest emergence and describes the tools that will further our understanding of this emerging pathogen.

Recent Multistate Outbreaks of Human Salmonella Infections Acquired from Turtles: A Continuing Public Health Challenge

The federal ban in the United States on the sale of turtles with shell lengths <4 inches that was established in 1975 has reduced the number of turtle-associated human Salmonella infections during subsequent years, especially among children. Although numerous sporadic turtle-associated Salmonella infections in humans have been reported since the ban went into effect, outbreaks were not reported until recently. Since 2006, 3 multistate outbreaks of turtle-associated Salmonella infections have been documented in the United States. This review examines the history of turtle-associated human Salmonella infections in the United States and discusses reasons why an increase in turtle-associated salmonellosis may be occurring and how challenges in enforcement of the ban affect disease control. Additional steps should be considered by the public health community, state governments, and enforcement agencies to prevent turtle-associated Salmonella infections in humans.

Field evaluation of Crystal VC® Rapid Dipstick test for cholera during a cholera outbreak in Guinea‐Bissau

Objectives  To evaluate performance characteristics and ease of use of the new commercially available Crystal VC® Rapid Dipstick (VC) test (Span Diagnostics, India) for Vibrio cholerae O1 and O139.

Multistate outbreak of Salmonella infections associated with small turtle exposure, 2007-2008.

OBJECTIVE: Turtle-associated salmonellosis was increasingly recognized in the United States during the 1960s, leading to a federal ban in 1975 on the sale of turtles <4 inches in carapace length (small turtles). Although sporadic reports of turtle-associated Salmonella are frequent, outbreaks are rare. In September 2007, several patients with Salmonella enterica serotype Paratyphi B var Java infections reported recent turtle exposure. We conducted an investigation to determine the source and extent of the infections. PATIENTS AND METHODS: Patients with Salmonella Paratyphi B var Java infections with a specific pulsed-field gel electrophoresis pattern (outbreak strain) and illness onset between May 2007 and January 2008, were compared with healthy controls. Reptile exposure and awareness of a Salmonella-reptile link were assessed. Turtle size and purchase information were collected. RESULTS: We identified 107 patients with outbreak-strain infections. The median patient age was 7 years; 33% were hospitalized. Forty-seven (60%) of 78 patients interviewed reported exposure to turtles during the week before illness; 41 (87%) were small turtles, and 16 (34%) were purchased in a retail pet store. In the case-control study, 72% of 25 patients reported turtle exposure during the week before illness compared with 4% of 45 controls (matched odds ratio [mOR]: 40.9 [95% confidence interval (CI): 6.9–unbounded]). Seven (32%) of 22 patients versus 11 (28%) of 39 controls reported knowledge of a link between reptile exposure and Salmonella infection (mOR: 1.3 [95% CI: 0.4–4.6]). CONCLUSIONS: We observed a strong association between turtle exposure and Salmonella infections in this outbreak. Small turtles continue to be sold and pose a health risk, especially to children; many people remain unaware of the link between Salmonella infection and reptile contact.

Cryptococcus gattii Infections in Multiple States Outside the US Pacific Northwest

Clonal VGII subtypes (outbreak strains) of Cryptococcus gattii have caused an outbreak in the US Pacific Northwest since 2004. Outbreak-associated infections occur equally in male and female patients (median age 56 years) and usually cause pulmonary disease in persons with underlying medical conditions. Since 2009, a total of 25 C. gattii infections, 23 (92%) caused by non–outbreak strain C. gattii, have been reported from 8 non–Pacific Northwest states. Sixteen (64%) patients were previously healthy, and 21 (84%) were male; median age was 43 years (range 15–83 years). Ten patients who provided information reported no past-year travel to areas where C. gattii is known to be endemic. Nineteen (76%) patients had central nervous system infections; 6 (24%) died. C. gattii infection in persons without exposure to known disease-endemic areas suggests possible endemicity in the United States outside the outbreak-affected region; these infections appear to differ in clinical and demographic characteristics from outbreak-associated C. gattii. Clinicians outside the outbreak-affected areas should be aware of locally acquired C. gattii infection and its varied signs and symptoms.

Cryptococcus gattii in the United States: Genotypic Diversity of Human and Veterinary Isolates

Background Cryptococcus gattii infections are being reported in the United States (US) with increasing frequency. Initially, US reports were primarily associated with an ongoing C . gattii outbreak in the Pacific Northwest (PNW) states of Washington and Oregon, starting in 2004. However, reports of C . gattii infections in patients from other US states have been increasing since 2009. Whether this is due to increasing frequency of disease, greater recognition within the clinical community, or both is currently unknown. Methodology/Principal Findings During 2005–2013, a total of 273 C . gattii isolates from human and veterinary sources in 16 US states were collected. Of these, 214 (78%) were from the Pacific Northwest (PNW) and comprised primarily the clonal C . gattii genotypes VGIIa (64%), VGIIc (21%) and VGIIb (9%). The 59 isolates from outside the PNW were predominantly molecular types VGIII (44%) and VGI (41%). Genotyping using multilocus sequence typing revealed small clusters, including a cluster of VGI isolates from the southeastern US, and an unrelated cluster of VGI isolates and a large cluster of VGIII isolates from California. Most of the isolates were mating type MATα, including all of the VGII isolates, but one VGI and three VGIII isolates were mating type MATa . Conclusions/Significance We provide the most comprehensive report to date of genotypic diversity of US C . gattii isolates both inside and outside of the PNW. C . gattii may have multiple endemic regions in the US, including a previously-unrecognized endemic region in the southeast. Regional clusters exist both in California and the Southeastern US. VGII strains associated with the PNW outbreak do not appear to have spread substantially beyond the PNW.