Nonendemic State Research Articles

P302 Disseminated histoplasmosis: Rare entity in immunocompromised individuals in India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMInvasive mycoses kill more than one million people every year. The disease burden of mycoses has increased over the last 20 years and the importance of fungal disease is expected to keep increasing in the years to come. One of these mycoses, histoplasmosis, a disease caused by species of dimorphic genera, Histoplasma and is endemic in the USA, Asia, and Africa with sporadic cases reported from India. In the United States alone, 3.4 cases/100 000 people occur yearly. In India, prevalence of histoplasmosis is seen in the eastern part of the country and few cases are reported from north India. Here, we present four cases of classic progressive disseminated histoplasmosis from non-endemic central and northern parts of India.Cases I and II: Two cases, firstly a 51-year-old male resident of Delhi, came with complaints of fever, generalized weakness and weight loss for the past 6 months, and another a 55-year-old in an apparently immunocompetent female from a non-endemic state in central India. The disease was diagnosed by bone marrow aspirate incidentally.Cases III and IV: A 25-year-old female and a 29-year-old HIV-infected female, with chief complaints of multiple skins colored swellings on her face, neck, chest, and back and also on both limbs. Physical examination revealed multiple skin-colored papules and nodules coalescing to form large plaques on the face, neck, upper back, and chest which had overlying yellowish-brown crusting (Fig.1). Her entire face was involved with depression of the nasal bridge and madarosis. Multiple discrete 0.1-0.5 mm papules and nodules on bilateral upper and lower limbs. Patient was started on the treatment of cutaneous histoplasmosis with injection of liposomal amphotericin-B 100 mg intravenous (around 3 mg/kg/day) after pre-medication for 10 days. For both cases, capsule itraconazole 200 mg BD started for 4 days. Patient responded well to the treatment and follow-up showed improvement in the condition of the patient.ResultsIn all the cases, fine needle aspirate cytology of the lesions showed plenty of inflammatory cells and macrophages in pathological microscopic examination. Microscopic examination of skin tissue revealed that macrophages comprising of yeast forms of Histoplasma have pericellular halo around them. Moreover, on long incubation of biopsy sample on SDA media plate at 27˚C, white/buff colonies with yellow-tan on the back were observed. Furthermore, microscopic examination of grown fungal culture showed mycelial septate hyphae bearing round to pear-shaped, smooth-walled broadly elliptical microconidia, or tuberculate macroconidia. In all the cases, clinical suspicion, histopathological and mycological findings (microscopy, culture and post-culture sequencing) led to a confirmatory diagnosis of progressive disseminated Histoplasmosis by H. capsulatum var. capsulatum was made.ConclusionIn all, 3 of these cases are of progressive disseminated histoplasmosis in apparently immunocompetent patients from the non-endemic states of north India. On the contrary, one of the cases was HIV positive with mucocutaneous lesions. Disseminated histoplasmosis in immunocompetent individuals is not a rare entity, in India. High clinical suspicion and awareness regarding the pathogen are required. From the point of good patient care, an accurate diagnosis, and timely management in cases of histoplasmosis are warranted.

Tick-Borne Disease Risk and Exposure among Vulnerable Populations in Perceived Non-Endemic Regions

Migrant and seasonal workers in the United States, among others in rural agricultural communities, may be at an elevated risk for tick-borne diseases (TBDs). This research included a survey of over 250 such workers, both women and men, in 13 locations across five eco-systems in Texas, which is generally perceived as a non-endemic state. Employing a modified Horowitz Multiple Systemic Infectious Disease Syndrome Questionnaire, a range of data was collected regarding living conditions, such as sleeping outside, along with queries about tick exposure, tick bite encounters, illnesses, and prior TBD diagnoses. Findings revealed that 67% of the respondents who scored highest on symptom severity suggestive of a TBD reported sleeping outdoors (compared to 29% of the lowest scoring), with 78% of the likely-to-highly-likely group also recalling tick-bite encounters (compared to 20% of the lowest scoring). Approximately 28% of those who reported severe symptoms also indicated previous Lyme disease diagnoses. This research serves as an initial investigation into the living conditions associated with increased risk of TBDs among vulnerable populations. It underscores the need for further assessments of TBD risk relative to vulnerable populations even in perceived non-endemic regions and highlights the paucity of actionable data as a critical public health issue.

Seroprevalence and detection of Trypanosoma cruzi in dogs living in a non-endemic area for Chagas disease in the legal Amazon region, Brazil.

Trypanosoma cruzi, the etiological agent for Chagas disease, is widely distributed in the Americas. Its hosts are humans and wild and domestic mammals, and its vectors are triatomine insects. Studies have indicated that domestic dogs are sentinel animals in the epidemiology of Chagas disease in endemic regions, including states in the Legal Amazon region of Brazil. In São Luís, the capital of Maranhão, a non-endemic state, the existence of a domestic cycle involving domestic rats has been proven, along with a wild cycle maintained by didelphids. However, no studies on T. cruzi infection in domestic animals in this locality have been conducted. The aim of this study was to investigate occurrence of T. cruzi in dogs living in the Itaqui Bacanga district of São Luís, Maranhão, by means of serological and molecular tests. Blood samples were obtained from 330 dogs and structured epidemiological questionnaires were applied to their keepers. These samples were used in the indirect immunofluorescent antibody test (IFAT), enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR). Fisher's exact test was used for statistical calculations with the aim of identifying risk factors. Out of the 330 animals, 105 (31.8%) were reactive in IFAT, 46 (13.0%) in ELISA and 20 (6.0%) in both serological tests. The results were not significant (p>0.05) when submitted to statistical analysis for the studied variables. From PCR, 58 samples (17.5%) were found to be positive and, of these, one (0.3%) showed similarity to T. cruzi after sequencing. These data demonstrate that dogs were exposed to and infected by T. cruzi. Thus, they can be considered sentinel animals for Chagas disease in the locality studied, which signals that there is a need for epidemiological surveillance actions.

Active search strategies, clinicoimmunobiological determinants and training for implementation research confirm hidden endemic leprosy in inner São Paulo, Brazil.

This study evaluates implementation strategies for leprosy diagnosis based on responses to a Leprosy Suspicion Questionnaire (LSQ), and analyzes immunoepidemiological aspects and follow-up of individuals living in a presumptively nonendemic area in Brazil. Quasi-experimental study based on LSQ throughout Jardinópolis town by community health agents, theoretical-practical trainings for primary care teams, dermatoneurological examination, anti-PGL-I serology, RLEP-PCR, and spatial epidemiology. A Leprosy Group (LG, n = 64) and Non-Leprosy Group (NLG, n = 415) were established. Overall, 3,241 LSQs were distributed; 1,054 (32.5%) LSQ were positive for signs/symptoms (LSQ+). Among LSQ+ respondents, Q2-Tingling (pricking)? (11.8%); Q4-Spots on the skin? (11.7%); Q7-Pain in the nerves? (11.6%); Q1-Numbness in your hands and/or feet? (10.7%) and Q8-Swelling of hands and feet? (8.5%) were most frequently reported symptoms. We evaluated 479 (14.8%) individuals and diagnosed 64 new cases, a general new case detection rate (NCDR) of 13.4%; 60 were among 300 LSQ+ (NCDR-20%), while 4 were among 179 LSQ negative (NCDR-2.23%). In LG, Q7(65%), Q2(60%), Q1(45%), Q4(40%) and Q8(25%) were most frequent. All 2x2 crossings of these 5 questions showed a relative risk for leprosy ranging from 3 to 5.8 compared with NLG. All patients were multibacillary and presented hypochromatic macules with loss of sensation. LG anti-PGL-I titers were higher than NLG, while 8.9% were positive for RLEP-PCR. The leprosy cases and anti-PGL-I spatial mappings demonstrated the disease spread across the town. Implementation actions, primarily LSQ administration focused on neurological symptoms, indicate hidden endemic leprosy in a nonendemic Brazilian state.

Characteristics of transfusion-transmitted Babesia microti, American Red Cross 2010-2017.

Babesia microti, a red blood cell (RBC) parasite transmitted naturally to vertebrate hosts by ixodid ticks, is endemic to the northeastern and upper midwestern United States, with the geographic range of infected ticks expanding. B. microti is a blood safety issue with >200 transfusion-transmissions reported. The American Red Cross's Hemovigilance program investigated hospital-reported transfusion-transmitted babesiosis (TTB) cases. Follow-up samples from involved donors were tested for B. microti antibodies and parasite DNA, the latter by real-time polymerase chain reaction (PCR). Test-positive donors were permanently deferred from future donations. B. microti-positive donors were implicated in 77 of 143 suspect TTB cases investigated from 2010 through 2017. In four cases, two positive donors were identified for a total of 81 positive donors. In three cases, a RBC unit was split and components transfused multiple times to the same pediatric recipient. RBCs were the transmitting product in all cases. At follow-up, all involved donors were antibody positive; 25 donors were also PCR positive. Positive donations were collected throughout the year, peaking in the summer. Most donors (78) were resident of, or traveled to (2), an endemic state. One donor resided in a non-endemic state without relevant travel history. One fatality listed babesia as a contributing factor. No implicated donation was screened by an investigational protocol. Babesiosis remains a blood safety issue. Prior to FDA-licensed screening test availability and final FDA Guidance, blood collectors in endemic states investigationally tested none, a portion, or all collections. Future expanded testing will reduce the frequency of TTB cases.

Borrelia burgdorferi in small mammal reservoirs in Kentucky, a traditionally non-endemic state for Lyme disease.

The incidence of tick-borne zoonoses such as Lyme disease has steadily increased in the southeastern United States. Southeastern states accounted for 1500 of over 28,000 confirmed cases of Lyme disease reported in the United States during 2015. Borrelia burgdorferi, the etiologic agent of Lyme disease, is maintained in small mammal reservoirs and vectored to new hosts by ixodid ticks. This study examined ecological relationships of the B. burgdorferi/vector/reservoir system in order to understand the dynamics of Lyme disease risk in Kentucky. Small mammals were captured using live traps from November 2014 to October 2015. Ticks were removed and blood and tissue collected from small mammals were screened for B. burgdorferi DNA by PCR with primers specific to the OspA gene. Prevalence of B. burgdorferi (21.8%) in Kentucky small mammals was comparable to the lowest recorded prevalence in regions where Lyme disease is endemic. Moreover, infestation of small mammals by Ixodes scapularis, the primary vector of B. burgdorferi, was rare, while Dermacentor variabilis comprised the majority of ticks collected. These findings provide ecological insight into the relative paucity of Lyme disease in Kentucky.

Seroprevalence and Risk Factors Associated With Corynebacterium pseudotuberculosis Detectable Antibodies in Equids in Alabama

A cross-sectional serological survey was carried out to screen the equine population of the nonendemic state of Alabama for the presence of detectable antibody titers against Corynebacterium pseudotuberculosis. A second objective was to determine the association of detectable titers with risk factors such as exposure to ruminants or previous travel to endemic states. A total of 342 equine serum samples from 40 Alabama counties were analyzed using the synergistic hemolysis inhibition test (SHI). The prevalence of detectable antibody titers (≥1:8) was 52.5% (95% confidence interval [CI], 47%–57.9%). Titers ≥1:128 were detected in 2.63% (95% CI, 1.2%–4.9%), and titers ≥1:512 were detected in 0.3% (95% CI, 0%–1.6%) of the sampled population. In the final generalized linear model, age (P < .001), breed (P = .023), and contact with cattle (P = .05) were associated with increasing SHI titers. Contact with goats was associated in the initial but not in the final analysis (P = .19). Previous travel was not associated with increasing SHI titer (P = .97). The results demonstrated a high prevalence of low detectable titers and low prevalence of titers ≥ 1:128 in a nonendemic population. Further evaluation of SHI cutoff titers and accuracy is warranted to reduce the risk of a false positive diagnosis.

Exploratory spatial analysis of Lyme disease in Texas -what can we learn from the reported cases?

BackgroundLyme disease (LD) is a tick-borne zoonotic illness caused by the bacterium Borrelia burgdorferi. Texas is considered a non-endemic state for LD and the spatial distribution of the state’s reported LD cases is unknown.MethodsWe analyzed human LD cases reported to the Texas Department of State Health Services (TX-DSHS) between 2000 and 2011 using exploratory spatial analysis with the objective to investigate the spatial patterns of LD in Texas. Case data were aggregated at the county level, and census data were used as the population at risk. Empirical Bayesian smoothing was performed to stabilize the variance. Global Moran’s I was calculated to assess the presence and type of spatial autocorrelation. Local Indicator of Spatial Association (LISA) was used to determine the location of spatial clusters and outliers.Results and DiscussionThere was significant positive spatial autocorrelation of LD incidence in Texas with Moran’s I of 0.41 (p = 0.001). LISA revealed significant variation in the spatial distribution of human LD in Texas. First, we identified a high-risk cluster in Central Texas, in a region that is thought to be beyond the geographical range of the main vector, Ixodes scapularis. Second, the eastern part of Texas, which is thought to provide the most suitable habitat for I. scapularis, did not appear to be a high-risk area. Third, LD cases were reported from several counties in western Texas, a region considered unsuitable for the survival of Ixodes ticks.ConclusionsThese results emphasize the need for follow-up investigations to determine whether the identified spatial pattern is due to: clustering of misdiagnosed cases, clustering of patients with an out-of state travel history, or presence of a clustered unknown enzootic cycle of B. burgdorferi in Texas. This would enable an improved surveillance and reporting of LD in Texas.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2286-0) contains supplementary material, which is available to authorized users.

Filariasis presented as a spermatic cord nodule in a nonendemic hilly state of Uttarakhand: A case report of second case in the region

Filariasis presented as a spermatic cord nodule in a nonendemic hilly state of Uttarakhand: A case report of second case in the region

TRANSFUSION COMPLICATIONS: A fatal case of transfusion‐transmitted babesiosis in the State of Delaware

BACKGROUND: Most cases of human babesiosis in North America are caused by Babesia microti, which is endemic in the northeastern and upper midwestern United States. Although the disease is usually transmitted by a tick bite, there has been an increase in the number of transfusion‐transmitted cases reported. We describe a fatal case of transfusion‐transmitted babesiosis in a nonendemic state, Delaware.CASE REPORT: The patient was a 43‐year‐old Caucasian woman with history of transfusion‐dependent Diamond‐Blackfan syndrome, hepatitis C, and splenectomy. She was admitted initially for presumptive pneumonia. The next day, a routine examination of the peripheral blood smears revealed numerous intraerythrocytic ring forms, consistent with Babesia. The parasitemia was approximately 5% to 6%. The diagnosis was confirmed by positive polymerase chain reaction (PCR) for B. microti DNA and high titer of antibody to B. microti (1:2048). Despite aggressive therapy including clindamycin and quinine antibiotics, the patient expired 3 days after admission. Subsequently, 13 blood donors were tested for B. microti. All tested donors were negative by PCR. However, one donor living in New Jersey had a significant elevated B. microti antibody titer (1:1024).CONCLUSIONS: We believe that this is the first reported case of transfusion‐transmitted babesiosis in Delaware, a nonendemic state. Our case illustrates that clinicians should consider babesiosis in the differential diagnosis of immunocompromised patients who have fever and recent transfusion history, even in areas where babesiosis is not endemic. It also demonstrates the need for better preventive strategies including more sensitive, specific, and rapid blood donor screening tests to prevent transfusion‐transmitted babesiosis.

First report of filariasis in a non-endemic hill state of India

First report of filariasis in a non-endemic hill state of India

High prevalence anti-Trypanosoma cruzi antibodies, among blood donors in the State of Puebla, a non-endemic area of Mexico.

Blood transfusion is the second most common transmission route of Chagas disease in many Latin American countries. In Mexico, the prevalence of Chagas disease and impact of transfusion of Trypanosoma cruzi-contaminated blood is not clear. We determined the seropositivity to T. cruzi in a representative random sample, of 2,140 blood donors (1,423 men and 647 women, aged 19-65 years), from a non-endemic state of almost 5 millions of inhabitants by the indirect hemagglutination (IHA) and enzyme linked immunosorbent assay (ELISA) tests using one autochthonous antigen from T. cruzi parasites, which were genetically characterized like TBAR/ME/1997/RyC-V1 (T. cruzi I) isolated from a Triatoma barberi specimen collected in the same locality. The seropositivity was up to 8.5% and 9% with IHA and ELISA tests, respectively, and up to 7.7% using both tests in common. We found high seroprevalence in a non-endemic area of Mexico, comparable to endemic countries where the disease occurs, e.g. Brazil (0.7%), Bolivia (13.7%) and Argentina (3.5%). The highest values observed in samples from urban areas, associated to continuous rural emigration and the absence of control in blood donors, suggest unsuspected high risk of transmission of T. cruzi, higher than those reported for infections by blood e.g. hepatitis (0.1%) and AIDS (0.1%) in the same region.