Compatible Illness Research Articles

A Q fever cluster among workers at an abattoir in south-western Sydney, Australia, 2015.

BackgroundIn September 2015, the Public Health Unit of the South Western Sydney Local Health District was notified of two possible Q fever cases. Case investigation identified that both cases were employed at an abattoir, and both cases advised that co-workers had experienced similar symptoms. Public Health Unit staff also recalled interviewing in late 2014 at least one other Q fever case who worked at the same abattoir. This prompted an outbreak investigation.MethodsThe investigation incorporated active case finding, microbiological analysis, field investigation and a risk factor survey. Included cases were laboratory definitive or suspected cases occurring from October 2014 to October 2015, residing or working in south-western Sydney. A suspected case had clinically compatible illness, high-risk exposure and was epidemiologically linked to another confirmed case. A confirmed case included laboratory detection of C. burnetti.ResultsEight cases met the case definition with seven confirmed (including a deceased case) and one suspected. The eight cases were all males who had been employed at an abattoir in south-western Sydney during their incubation period; symptom onset dates ranged from November 2014 to September 2015. Field investigation identified multiple potential risk factors at the abattoir, and the majority (75%) of employees were not vaccinated against Q fever despite this high-risk setting.ConclusionThis cluster of Q fever in a single abattoir confirms the significance of this zoonotic disease as an occupational hazard among persons working in high-risk environments. Implementation of Q fever vaccination programmes should eliminate Q fever in high-risk occupational settings.

Characteristics of Children Aged

Zika virus is an emerging mosquito-borne flavivirus that typically causes an asymptomatic infection or mild illness, although infection during pregnancy is a cause of microcephaly and other serious brain abnormalities. Guillain-Barré syndrome and other neurologic complications can occur in adults after Zika virus infection. However, there are few published reports describing postnatally acquired Zika virus disease among children. During January 2015-July 2016, a total of 158 cases of confirmed or probable postnatally acquired Zika virus disease among children aged <18 years were reported to CDC from U.S. states. The median age was 14 years (range = 1 month-17 years), and 88 (56%) were female. Two (1%) patients were hospitalized; none developed Guillain-Barré syndrome, and none died. All reported cases were travel-associated. Overall, 129 (82%) children had rash, 87 (55%) had fever, 45 (29%) had conjunctivitis, and 44 (28%) had arthralgia. Health care providers should consider a diagnosis of Zika virus disease in children who have an epidemiologic risk factor and clinically compatible illness, and should report cases to their state or local health department.

Hospital-based enhanced surveillance for West Nile virus neuroinvasive disease.

Accurate data on the incidence of West Nile virus (WNV) disease are important for directing public health education and control activities. The objective of this project was to assess the underdiagnosis of WNV neuroinvasive disease through laboratory testing of patients with suspected viral meningitis or encephalitis at selected hospitals serving WNV-endemic regions in three states. Of the 279 patients with cerebrospinal fluid (CSF) specimens tested for WNV immunoglobulin M (IgM) antibodies, 258 (92%) were negative, 19 (7%) were positive, and two (1%) had equivocal results. Overall, 63% (12/19) of patients with WNV IgM-positive CSF had WNV IgM testing ordered by their attending physician. Seven (37%) cases would not have been identified as probable WNV infections without the further testing conducted through this project. These findings indicate that over a third of WNV infections in patients with clinically compatible neurological illness might be undiagnosed due to either lack of testing or inappropriate testing, leading to substantial underestimates of WNV neuroinvasive disease burden. Efforts should be made to educate healthcare providers and laboratorians about the local epidemiology of arboviral diseases and the optimal tests to be used in different clinical situations.

First reported outbreak of locally acquired hepatitis E virus infection in Australia

To determine the source and extent of a locally acquired hepatitis E virus (HEV) infection outbreak. A cluster of notified cases of HEV infection linked to a single restaurant (X) was identified in May 2014. People with laboratory-confirmed HEV infection in New South Wales between January 2013 and December 2014 were interviewed about potential risk factors for HEV infection. Co-diners at restaurant X and patients with suspected but unexplained viral hepatitis were retrospectively tested. Foods eaten by the infected persons were compared with those of seronegative co-diners. HEV RNA detected in sera from infected persons was sequenced and genotyped. Implicated foods were traced back to their sources. Potential sources of infection, including overseas travel and foods eaten, and origin of implicated food products. In 55 serologically confirmed cases of HEV infection, 24 people had not travelled overseas during their incubation periods. Of the 24, 17 reported having eaten at restaurant X, 15 of whom could be interviewed. All reported consuming pork liver pâté, compared with only four of seven uninfected co-diners (P <0.05). The other seven people with locally acquired infections each reported consuming a pork product during their incubation periods. HEV RNA was detected in 16 of the 24 cases; all were of genotype 3. Sequencing indicated greater than 99% homology among restaurant X isolates. HEV RNA was isolated from pork sausages from a batch implicated in one of the locally acquired infections not linked with restaurant X. The pork livers used for pâté preparation by restaurant X were traced to a single Australian farm. This is the first reported HEV outbreak in Australia. HEV should be considered in patients presenting with a compatible illness, even without a history of overseas travel. Pork products should be thoroughly cooked before consumption.

Treatment of Tropical and Travel Related Rickettsioses

Infections with organisms of the genera Rickettsia and Orientia are undifferentiated in regard to their manifesting signs and symptoms. Hence, a high degree of suspicion is required when a patient has a compatible illness coupled with exposure to potential vectors. Confirmatory diagnosis is usually retrospective, as it is obtained through serologic methods to determine seroconversion or a fourfold increase in antibody titers from acute to convalescent phase sera. Since many of these infections are associated with considerable morbidity and mortality, empiric treatment is imperative when illness is suspected. Antibiotics in the tetracycline class are highly active in vitro and have an excellent track record in the treatment of these diseases. Of the antibiotics in this class, doxycycline is the drug of choice, as it has excellent bioavailability, ease of twice daily dosing, and more favorable gastrointestinal tolerability. The usual duration of treatment is 7 days. In the most severe rickettsiosis, Rocky Mountain spotted fever, use of the usual alternative, chloramphenicol, is associated with a higher case fatality rate. Therefore, doxycycline is recommended in children <8 years of age—short courses do not cause appreciable staining of developing permanent teeth. Chloramphenicol is not available in its oral form in the USA, and the parenteral formulation is becoming difficult to acquire. In countries where available, it should be used with careful consideration of the risk-benefit ratio when weighed against the pathogenicity of the suspected agent. For infection with less pathogenic spotted fever group and typhus group rickettsiae (e.g., R. conorii and R. typhi), fluoroquinolones are an alternative. The agent that causes scrub typhus, Orientia tsutsugamushi, is intrinsically resistant to fluoroquinolones. Azithromycin can be used for scrub typhus in areas where there is reported failure of doxycycline or when a safer agent is required (i.e., pregnancy).

Sustained Transmission of Pertussis in Vaccinated, 1–5-Year-Old Children in a Preschool, Florida, USA

Abstract In September 2013, local county health officials in Tallahassee, Florida, USA, were notified of a laboratory-confirmed pertussis case in a 1-year-old preschool attendee. During a 5-month period, 26 (22%) students 1–5 years of age, 2 staff from the same preschool, and 11 family members met the national case definition for pertussis. Four persons during this outbreak were hospitalized for clinical management of pertussis symptoms. Only 5 students, including 2 students with pertussis, had not received the complete series of vaccinations for pertussis. Attack rates in 1 classroom for all students who received the complete series of vaccinations for pertussis approached 50%. This outbreak raises concerns about vaccine effectiveness in this preschool age group and reinforces the idea that recent pertussis vaccination should not dissuade physicians from diagnosing, testing, or treating persons with compatible illness for pertussis.

Clinical characteristics of 35 non-pregnant patients with Listeria monocytogenes sepsis

To better understand the clinical characteristics and predisposing factors in non-pregnant patients with Listeria monocytogenes (Listeria) sepsis. Clinical data were collected at Peking Union Medical College Hospital between January 2002 and December 2014. A case with non-pregnant Listeria sepsis is defined as a non-pregnant person with clinically compatible illness and from whom Listeria was isolated from his/her blood culture. We define an underlying condition if a patient has been diagnosed of and/or has been treated for a concurrent baseline disease within 1 month prior to the onset of Listeria sepsis. A total of 35 patients were enrolled. The age of all patients was (49.1 ± 17.0) years. The male to female ratio was 2: 3. Most patients were combined with at least 1 underlying condition (33, 94.3%), including 42.9% patients with an autoimmune disease, 34.3% with malignancies. The majority (91.4%) represented an acute onset (<1 week) with median time of 3 days. Clinical manifestations included fever (34/35, 97.1%), central nervous system (CNS) symptoms (17/35, 48.6%), gastrointestinal tract symptoms (13/35, 37.1%). Fourteen patients had undergone lumber puncture and cerebral spinal fluid (CSF) tests, which revealed abnormalities comparable of Listeria meningitis. Listeria was isolated from CSF in 11 of 14 patients (78.6%). There were 34 patients receiving empiric antibiotics including 54.3% cephalosporins which are resistant to Listeria. Twenty five (71.4%) patients were switched to the target antimicrobials according to positive blood culture. Of the 35 patients with Listeria sepsis, 21 (60.0%) recovered or were cured, however the rest (40.0%) had dismal outcome. Six patients died in hospital, 8 critical patients were discharged and died after transferring to local hospitals. Listeria sepsis is commonly associated with non-pregnant patients with compromised immune function. Clinical presentations include acute fever, CNS symptoms and gastrointestinal symptoms etc. Empiric antibiotics covering Listeria should be considered when sepsis is suspected among susceptible hosts.

Coccidioidomycosis among Workers Constructing Solar Power Farms, California, USA, 2011-2014.

Coccidioidomycosis is associated with soil-disruptive work in Coccidioides-endemic areas of the southwestern United States. Among 3,572 workers constructing 2 solar power-generating facilities in San Luis Obispo County, California, USA, we identified 44 patients with symptom onset during October 2011-April 2014 (attack rate 1.2 cases/100 workers). Of these 44 patients, 20 resided in California outside San Luis Obispo County and 10 resided in another state; 9 were hospitalized (median 3 days), 34 missed work (median 22 days), and 2 had disseminated disease. Of the 25 patients who frequently performed soil-disruptive work, 6 reported frequent use of respiratory protection. As solar farm construction in Coccidioides-endemic areas increases, additional workers will probably be exposed and infected unless awareness is emphasized and effective exposure reduction measures implemented, including limiting dust generation and providing respiratory protection. Medical providers, including those in non-Coccidioides-endemic areas, should suspect coccidioidomycosis in workers with compatible illness and report cases to their local health department.

Investigation of the First Case of Dengue Virus Infection Acquired in Western Australia in Seven Decades: Evidence of Importation of Infected Mosquitoes?

In October 2013, a locally-acquired case of dengue virus (DENV) infection was reported in Western Australia (WA) where local dengue transmission has not occurred for over 70 years. Laboratory testing confirmed recent DENV infection and the case demonstrated a clinically compatible illness. The infection was most likely acquired in the Pilbara region in the northwest of WA. Follow up investigations did not detect any other locally-acquired dengue cases or any known dengue vector species in the local region, despite intensive adult and larval mosquito surveillance, both immediately after the case was notified in October 2013 and after the start of the wet season in January 2014. The mechanism of infection with DENV in this case cannot be confirmed. However, it most likely followed a bite from a single infected mosquito vector that was transiently introduced into the Pilbara region but failed to establish a local breeding population. This case highlights the public health importance of maintaining surveillance efforts to ensure that any incursions of dengue vectors into WA are promptly identified and do not become established, particularly given the large numbers of viraemic dengue fever cases imported into WA by travellers returning from dengue-endemic regions.

Poor Positive Predictive Value of Lyme Disease Serologic Testing in an Area of Low Disease Incidence.

Lyme disease is diagnosed by 2-tiered serologic testing in patients with a compatible clinical illness, but the significance of positive test results in low-prevalence regions has not been investigated. We reviewed the medical records of patients who tested positive for Lyme disease with standardized 2-tiered serologic testing between 2005 and 2010 at a single hospital system in a region with little endemic Lyme disease. Based on clinical findings, we calculated the positive predictive value of Lyme disease serology. Next, we reviewed the outcome of serologic testing in patients with select clinical syndromes compatible with disseminated Lyme disease (arthritis, cranial neuropathy, or meningitis). During the 6-year study period 4723 patients were tested for Lyme disease, but only 76 (1.6%) had positive results by established laboratory criteria. Among 70 seropositive patients whose medical records were available for review, 12 (17%; 95% confidence interval, 9%-28%) were found to have Lyme disease (6 with documented travel to endemic regions). During the same time period, 297 patients with a clinical illness compatible with disseminated Lyme disease underwent 2-tiered serologic testing. Six of them (2%; 95% confidence interval, 0.7%-4.3%) were seropositive, 3 with documented travel and 1 who had an alternative diagnosis that explained the clinical findings. In this low-prevalence cohort, fewer than 20% of positive Lyme disease tests are obtained from patients with clinically likely Lyme disease. Positive Lyme disease test results may have little diagnostic value in this setting.

Control of norovirus outbreak on a pediatric oncology unit

Patients undergoing treatment for cancer with chemotherapy and hematopoietic stem cell recipients are at risk for severe morbidity caused by norovirus (NV). We describe a NV outbreak on the Memorial Sloan Kettering Cancer Center's pediatric oncology unit. Stool testing for diagnosis of NV was performed by real-time polymerase chain reaction (PCR). Twelve NV cases occurred; 7 were hospital acquired. Twenty-five health care workers reported NV compatible illness. Patient-to-patient transmission occurred once. The practices of the Centers for Disease Control and Prevention were supplemented with electronic surveillance, surrogate screening for NV, and heightened cleaning. Two additional cases occurred after implementation of interventions. Long-term shedding was detected in 2 patients. We describe interventions for controlling NV on a pediatric oncology unit. High-risk chronic shedders pose ongoing transmission risks. PCR is a valuable diagnostic tool but may be overly sensitive. Surrogate markers to assess NV burden in stool and studies on NV screening are needed to develop guidelines for high-risk chronic shedders.

Abstract O.08: Rashless Kawasaki Disease (KD): Colorado’s Experience

Objective: Published studies describe Incomplete KD, but rashless KD has not been well characterized. We describe a 10 year experience with rashless KD patients, diagnosed based on the presence of a compatible illness and coronary artery lesions (CALs). Methods: We prospectively collected cases of rashless KD with CALs diagnosed at Children’s Hospital Colorado from 7/1/2004-6/30/2014. Patient charts were reviewed for demographic, clinical, laboratory, and diagnostic information. Results: 11 patients were identified (median age 3.7 yrs), representing 10.3% (11/107) of all KD patients with CALs diagnosed during the same time period. Diagnosis was made on median day of illness (DOI) 8 (range 4-17 days), and patients had a median of 4 (range 2-7) healthcare contacts prior to diagnosis. All patients (100%) had the presence or history of conjunctival injection and 8/11 (72.7%) had oral changes. Five patients had only 2 major clinical features in addition to fever; 1 patient had one. All patients had very elevated inflammatory markers. Infectious Disease consultants suspected KD and recommended treatment prior to echocardiogram (ECHO) results in 8/11 (72.7%), recommended treatment if ECHO abnormal in 2/11 (18.1%), and in 1/11 (9.2%) KD was thought to be unlikely, but the diagnosis was made by ECHO. Conclusions: 10.3% of KD patients with CALs at our institution presented without a rash. As rash is often considered a defining characteristic of KD, some children with rashless KD are likely not being identified and treated. Providers should consider the diagnosis of KD in patients with unexplained fever, conjunctivitis, and elevated inflammatory markers.

What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention.

West Africa is currently in the midst of the largest Ebola outbreak in history. Although there have been no Ebola virus disease cases identified in the United States, two U.S. health care workers with Ebola virus disease were medically evacuated from Liberia to the United States in early August 2014. The Centers for Disease Control and Prevention has been working closely with other U.S. government agencies and international and nongovernmental partners for several months to respond to this global crisis. Limited evidence suggests that pregnant women are at increased risk for severe illness and death when infected with Ebola virus, but there is no evidence to suggest that pregnant women are more susceptible to Ebola virus disease. In addition, pregnant women with Ebola virus disease appear to be at an increased risk for spontaneous abortion and pregnancy-associated hemorrhage. Neonates born to mothers with Ebola virus disease have not survived. Although it is very unlikely that obstetrician-gynecologists (ob-gyns) in the United States will diagnose or treat a patient with Ebola virus disease, it is important that all health care providers are prepared to evaluate and care for these patients. Specifically, U.S. health care providers, including ob-gyns, should ask patients about recent travel and should know the signs and symptoms of Ebola virus disease and what to do if assessing a patient with compatible illness. This article provides general background information on Ebola and specifically addresses what is known about Ebola virus disease in pregnancy and the implications for practicing ob-gyns in the United States.

Babesiosis surveillance, new jersey, USA, 2006-2011.

Babesiosis surveillance, new jersey, USA, 2006-2011.

Yersinia pestis infection in dogs: 62 cases (2003-2011).

To describe the epidemiology, clinical signs, and treatment practices in dogs with Yersinia pestis infection in New Mexico. Retrospective case series. 62 dogs with plague in New Mexico. Confirmed case animals had isolation of Yersinia pestis from a clinical specimen, a positive direct fluorescent antibody test result, or a minimum 4-fold change between acute and convalescent serum antibody titers with clinically compatible illness. Retrospective review of cases of laboratory-confirmed plague from 2003 to 2011 was performed with a standardized chart abstraction form. Epidemiologic, clinical, and treatment data were evaluated. 62 confirmed cases of canine plague were identified from 2003 to 2011. Most cases (85%) were confirmed by serologic titers alone or in conjunction with other testing methods. Clinical signs included fever (100%), lethargy (97%), anorexia (77%), lymphadenopathy (23%), vomiting (13%), diarrhea (8%), and abscesses (2%). Most case animals (73%) were treated with multiple antimicrobials. Sixty (97%) case animals survived; of the 2 nonsurvivors, one was euthanized and another died. Potential sources of exposure to Y pestis included hunting, rodent or rabbit exposure, and residence in rural areas. Results indicated that dogs with exposure to Y pestis can develop moderate to severe illness or die as a result of infection. Veterinarians practicing in and examining animals from the western United States need to be familiar with the epidemiology of plague and query owners about potential plague exposures when consistent clinical signs are present. Veterinarians are often the first to recognize signs of plague among sentinel populations and have the opportunity to intervene and prevent zoonotic disease transmission.

Outbreak of Shiga toxin-producing Escherichia coli (STEC) O157:H7 associated with romaine lettuce consumption, 2011.

BackgroundShiga toxin-producing Escherichia coli (STEC) O157:H7 is the causal agent for more than 96,000 cases of diarrheal illness and 3,200 infection-attributable hospitalizations annually in the United States.Materials and MethodsWe defined a confirmed case as a compatible illness in a person with the outbreak strain during 10/07/2011-11/30/2011. Investigation included hypothesis generation, a case-control study utilizing geographically-matched controls, and a case series investigation. Environmental inspections and tracebacks were conducted.ResultsWe identified 58 cases in 10 states; 67% were hospitalized and 6.4% developed hemolytic uremic syndrome. Any romaine consumption was significantly associated with illness (matched Odds Ratio (mOR) = 10.0, 95% Confidence Interval (CI) = 2.1–97.0). Grocery Store Chain A salad bar was significantly associated with illness (mOR = 18.9, 95% CI = 4.5–176.8). Two separate traceback investigations for romaine lettuce converged on Farm A. Case series results indicate that cases (64.9%) were more likely than the FoodNet population (47%) to eat romaine lettuce (p-value = 0.013); 61.3% of cases reported consuming romaine lettuce from the Grocery Store Chain A salad bar.ConclusionsThis multistate outbreak of STEC O157:H7 infections was associated with consumption of romaine lettuce. Traceback analysis determined that a single common lot of romaine lettuce harvested from Farm A was used to supply Grocery Store Chain A and a university campus linked to a case with the outbreak strain. An investigation at Farm A did not identify the source of contamination. Improved ability to trace produce from the growing fields to the point of consumption will allow more timely prevention and control measures to be implemented.

Lymphocytic Choriomeningitis Virus Infections among American Indians

Lymphocytic Choriomeningitis Virus Infections among American Indians

Differences and Similarities between Culture-Confirmed Human Granulocytic Anaplasmosis and Early Lyme Disease

Lyme disease is transmitted by the bite of certain Ixodes ticks, which can also transmit Anaplasma phagocytophilum, the cause of human granulocytic anaplasmosis (HGA). Although culture can be used to identify patients infected with A. phagocytophilum and is the microbiologic gold standard, few studies have evaluated culture-confirmed patients with HGA. We conducted a prospective study in which blood culture was used to detect HGA infection in patients with a compatible clinical illness. Early Lyme disease was defined by the presence of erythema migrans. The epidemiologic, clinical, and laboratory features of 44 patients with culture-confirmed HGA were compared with those of a convenience sample of 62 patients with early Lyme disease. Coinfected patients were excluded. Patients with HGA had more symptoms (P = 0.003) and had a higher body temperature on presentation (P < 0.001) than patients with early Lyme disease. HGA patients were also more likely to have a headache, dizziness, myalgias, abdominal pain, anorexia, leukopenia, lymphopenia, thrombocytopenia, or elevated liver enzymes. A direct correlation between the number of symptoms and the duration of illness at time of presentation (rho = 0.389, P = 0.009) was observed for HGA patients but not for patients with Lyme disease. In conclusion, although there are overlapping features, culture-confirmed HGA is a more severe illness than early Lyme disease.

Clinician Assessment forCoxiella burnetiiInfection in Hospitalized Patients with Potentially Compatible Illnesses During Q Fever Outbreaks and Following a Health Alert, Montana, 2011

Coxiella burnetii is an endemic bacterial pathogen in the United States and the causative agent of Q fever. Two outbreaks of Q fever occurred in Montana during 2011, which led to the issuance of a health alert urging clinicians to test patients with Q fever-compatible illnesses for C. burnetii infection. We retrospectively evaluated the medical records of patients hospitalized for fever, pneumonia, chest pain, and viral infection of unknown etiologies during the two Q fever outbreaks and following the health alert. A total of 103 patients were included in the analysis. Clinicians assessed<1% of patients suffering illnesses compatible with Q fever for known risk factors or C. burnetii infection. Only 1 patient had Q fever excluded as a diagnosis. Clinicians should assess for Q fever risk factors and consider the diagnosis in patients hospitalized with Q fever-compatible illnesses when the etiology of illness is unknown. Work is warranted to evaluate the effectiveness of current healthcare alert practices for zoonotic diseases.

Differing burden and epidemiology of non-Typhi Salmonella bacteremia in rural and urban Kenya, 2006-2009.

BackgroundThe epidemiology of non-Typhi Salmonella (NTS) bacteremia in Africa will likely evolve as potential co-factors, such as HIV, malaria, and urbanization, also change.MethodsAs part of population-based surveillance among 55,000 persons in malaria-endemic, rural and malaria-nonendemic, urban Kenya from 2006–2009, blood cultures were obtained from patients presenting to referral clinics with fever ≥38.0°C or severe acute respiratory infection. Incidence rates were adjusted based on persons with compatible illnesses, but whose blood was not cultured.ResultsNTS accounted for 60/155 (39%) of blood culture isolates in the rural and 7/230 (3%) in the urban sites. The adjusted incidence in the rural site was 568/100,000 person-years, and the urban site was 51/100,000 person-years. In both sites, the incidence was highest in children <5 years old. The NTS-to-typhoid bacteremia ratio in the rural site was 4.6 and in the urban site was 0.05. S. Typhimurium represented >85% of blood NTS isolates in both sites, but only 21% (urban) and 64% (rural) of stool NTS isolates. Overall, 76% of S. Typhimurium blood isolates were multi-drug resistant, most of which had an identical profile in Pulse Field Gel Electrophoresis. In the rural site, the incidence of NTS bacteremia increased during the study period, concomitant with rising malaria prevalence (monthly correlation of malaria positive blood smears and NTS bacteremia cases, Spearman's correlation, p = 0.018 for children, p = 0.16 adults). In the rural site, 80% of adults with NTS bacteremia were HIV-infected. Six of 7 deaths within 90 days of NTS bacteremia had HIV/AIDS as the primary cause of death assigned on verbal autopsy.ConclusionsNTS caused the majority of bacteremias in rural Kenya, but typhoid predominated in urban Kenya, which most likely reflects differences in malaria endemicity. Control measures for malaria, as well as HIV, will likely decrease the burden of NTS bacteremia in Africa.