Steven M. Standaert

Infections with Ehrlichia chaffeensis and Ehrlichia ewingii in Persons Coinfected with Human Immunodeficiency Virus

The clinical course and laboratory evaluation of 21 patients coinfected with human immunodeficiency virus (HIV) and Ehrlichia chaffeensis or Ehrlichia ewingii are reviewed and summarized, including 13 cases of ehrlichiosis caused by E. chaffeensis, 4 caused by E. ewingii, and 4 caused by either E. chaffeensis or E. ewingii. Twenty patients were male, and the median CD4(+) T lymphocyte count was 137 cells/microL. Exposures to infecting ticks were linked to recreational pursuits, occupations, and peridomestic activities. For 8 patients, a diagnosis of ehrlichiosis was not considered until > or =4 days after presentation. Severe manifestations occurred more frequently among patients infected with E. chaffeensis than they did among patients infected with E. ewingii, and all 6 deaths were caused by E. chaffeensis. Ehrlichiosis may be a life-threatening illness in HIV-infected persons, and the influence of multiple factors, including recent changes in the epidemiology and medical management of HIV infection, may increase the frequency with which ehrlichioses occur in this patient cohort.

Ehrlichiosis in a Golf-Oriented Retirement Community

BACKGROUND Ehrlichiosis due to Ehrlichia chaffeensis usually occurs sporadically or in small clusters, with an annual incidence estimated at 3 to 5 cases per 100,000 population in areas of endemic disease. The putative principal vector is the Lone Star tick (Amblyomma americanum). We investigated an outbreak of ehrlichiosis that occurred in June 1993 among members of a golf-oriented retirement community (community A) in Tennessee. The community is densely wooded and borders a wildlife-management area where deer are numerous. METHODS We conducted a case-control study, using medical-history reviews, serologic testing, and testing with the polymerase chain reaction for E. chaffeensis infection. We also surveyed a sample of 10 percent of the households in community A and in another golf-oriented community (community B) more than 20 miles (32 km) from the wildlife-management area. Survey participants completed a questionnaire and provided specimens for serologic testing. In both communities, searches for ticks were undertaken. RESULTS Eleven cases of symptomatic ehrlichiosis were identified in the case-control study, 10 of which were in community A (attack rate, 330 per 100,000). Of 311 surveyed residents of community A, 12.5 percent had serologic evidence of past E. chaffeensis infection, as compared with 3.3 percent of 92 in community B (relative risk in community A as compared with community B, 3.9; 95 percent confidence interval, 1.2 to 12.2). The risk of infection was associated with tick bites, exposure to wildlife, golfing, and among golfers, retrieving lost golf balls from the rough. Persons who never used insect repellent were more likely to have had infection than persons who did. In community A, thousands of Lone Star ticks were found; in community B, only three ticks were found. CONCLUSIONS The high rate of E. chaffeensis infection in community A resulted from its proximity to a wildlife reserve. When outdoor recreational activities are common and concentrations of ticks are high, outbreaks of arthropod-borne zoonoses can be anticipated.

Primary Isolation of Ehrlichia chaffeensis from Patients with Febrile Illnesses: Clinical and Molecular Characteristics

Ehrlichia chaffeensis was sought among patients with a history of tick exposure and fever, and the accuracy of other diagnostic tests was compared with that of primary isolation. Among the 38 patients enrolled, E. chaffeensis was isolated from the blood of 7 (18%) and from cerebrospinal fluid specimens of 2 of these 7. All 7 patients also were positive by polymerase chain reaction (PCR) of blood, and 6 patients developed diagnostic titers of antibody to E. chaffeensis. The isolates were characterized by molecular analysis of the 16S rRNA gene, the 120-kDa protein gene, and the variable-length PCR target (VLPT) of E. chaffeensis. On the basis of the 120-kDa and VLPT genotypes, the cerebrospinal fluid and blood isolates from the same patients were identical. This study demonstrates that both PCR and culture of blood for E. chaffeensis have high diagnostic yields. More frequent isolation of E. chaffeensis from patients with infection should further our understanding of the pathogenesis of this infection.

NOSOCOMIAL TRANSMISSION OF SALMONELLA GASTROENTERITIS TO LAUNDRY WORKERS IN A NURSING HOME

BACKGROUND Outbreaks of salmonella gastroenteritis in nursing homes are common. Person-to-person transmission to nursing home personnel occurs occasionally, but infection of laundry staff as a result of handling soiled linen rarely has been reported. OBJECTIVE To examine the nosocomial transmission of infection to laundry staff during an outbreak of salmonellosis in a nursing home. SETTING A 250-bed nursing home in a rural Tennessee county. METHODS Residents and staff of the nursing home were interviewed and cultures of stool samples examined for enteric pathogens. RESULTS Stool cultures from 32 residents and 8 employees were positive for Salmonella hadar. Infection among the residents was food-borne, but infection among employees likely represented secondary transmission, as none of the employees ate food prepared in the kitchen and their onset of symptoms occurred seven to 10 days after that of ill residents. Three laundry personnel who had no contact with residents were infected. Most of the ill residents (81%) were incontinent, which led to an increase in both the degree of fecal soiling and the amount of soiled linen received by the laundry during the outbreak. Laundry personnel regularly ate in the laundry room, did not wear protective clothing, and did not wear gloves consistently while handling soiled laundry. CONCLUSIONS This investigation implicates linen soiled with feces as the source of nosocomial S hadar infection in laundry workers and underscores the importance of using appropriate precautions when handling linen.

Ehrlichiosis — In Pursuit of an Emerging Infection

Ehrlichia are obligate intracellular coccobacilli resembling rickettsia that have historically been associated with diseases of animals. The etiologic agent of the hemorrhagic illness canine ehrlic...