Ehrlichia chaffeensis in Child, Venezuela by mpp15079

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       Ehrlichia                          sufficiency. Serologic tests were nega-       illness. Leukocyte count was within
                                          tive for Epstein-Barr and hepatitis B        reference range thereafter; throm-
    chaffeensis in                        and positive for cytomegalovirus and         bocytopenia was present until day 7
   Child, Venezuela                       hepatitis A viruses. Blood and stool         (99,000/mm3). ALT was elevated from
                                          cultures were negative. Blood samples        day 3 and peaked (481 IU) on day 7.
     To the Editor: Human mono-           were taken 4 and 35 days after illness       AST levels increased on day 5 and
cytic ehrlichiosis is a tick-borne in-    onset; buffy-coat smears were stained        peaked (215 IU) on day 7. Both values
fectious disease caused by Ehrlichia      with Dip Quick (Jorgensen Laborato-          decreased progressively to reference
chaffeensis (1). Serologic studies have   ries, Inc., Loveland, CO, USA), and          levels (after 25 days for ALT and 46
indicated E. chaffeensis infection in     immunologic and PCR tests were               days for AST). Lactic dehydrogenase
Latin American countries: Venezuela       performed. Immunoglobulin (Ig) M             was elevated for 9 days while eryth-
(2), Mexico (3), Argentina (4), Chile     against dengue virus was present at          rocyte count, sedimentation rate, and
(5), and Brazil (6). However, no mo-      days 4 and 35 of illness; IgG against        serum glucose, amylase, urea, creati-
lecular evidence for E. chaffeensis has   dengue was absent on day 4 and pres-         nine, bilirubin, calcium, sodium, and
been reported.                            ent on day 35. PCR and viral isolation       potassium remained within reference
     In December 2001, a 9-year-old       tests for dengue virus were negative.        limits. The patient was released after
boy was admitted to a hospital in         Serologic tests for E. chaffeensis (in-      8 days of hospitalization.
Carabobo, Venezuela, after 3 days         direct immunofluorescence) were also               The buffy-coat smear performed
of fever (39°C–41°C), malaise, an-        negative on day 4 and positive (256)         4 days after illness onset showed ba-
orexia, headache, abdominal pain,         on day 35. Detection of Ehrlichia spe-       sophilic intracytoplasmic inclusions
and cutaneous tick-bite lesions. Dur-     cies–specific DNA was performed by            inside vacuoles of lymphocytes and
ing the 6 weeks before admission, the     using nested PCR as described (7).           monocytes, with typical features of
patient had been exposed to ticks in           Starting on the first day of hospi-      morulae reported for human monocyt-
a rural area (Cojedes, Venezuela). At     talization, the patient was treated with     ic ehrlichiosis (Figure). Nested PCR
the time of physical examination, the     doxycycline (14 days) and chloram-           analysis was positive for E. chaffeen-
patient appeared acutely ill with fe-     phenicol (8 days). After 24 hours, mal-      sis, and sequencing of the amplified
ver (41°C), dehydration, somnolence,      aise, headache, facial edema, and con-       DNA fully confirmed the 16S rRNA
conjunctivitis, facial edema, cervical    junctivitis improved. After 48 hours,        targeted sequence.
adenomegaly, soft depressible abdo-       fever and rash were gone. After 3 days,           This report provides molecular ev-
men painful to palpation, and hepa-       his appetite improved; progressively         idence of E. chaffeensis infection in a
tomegaly. Cardiopulmonary exami-          over time, cervical adenomegaly and          patient with acute disease in Venezuela.
nation found regular cardiac sounds       cutaneous lesions improved. Abdomi-          A previous case of human monocytic
with systolic tricuspid murmur and        nal pain persisted for 7 days after treat-   ehrlichiosis in a 17-month-old girl in
abnormal bilateral respiratory sounds     ment. Nausea and vomiting started 2          Venezuela has been demonstrated sero-
(rhonchi). Skin examination showed        days after admittance; on day 7, vomit       logically (2). E. canis in an asymptom-
multiple tick bites and an erythema-      was of coffee-ground consistency. All        atic patient in Venezuela has been dem-
tous maculopapular rash. Appropriate      remaining symptoms abated thereafter.        onstrated by PCR and culture isolation
informed consent was obtained.            The patient had diarrhea during days 3–      (8) and was recently demonstrated in
     Blood values were as follows:        6 after admittance; hepatomegaly dis-        symptomatic patients (9). Excluding
leukocytes 6,280 cells/mm3 (84%           appeared after 4 days. Ultrasonographic      the esophageal lesions (Mallory-Weiss
neutrophils, 13% lymphocytes, 2%          images of the abdomen indicated acute        syndrome), our case is compatible with
monocytes, 1% eosinophils), platelets     cholecystitis and hepatosplenomegaly;        cases reported previously (10). The
130,000/μL, hemoglobin 12.5 g/dL,         endoscopic examination of the upper          clinical manifestations of ehrlichiosis
glucose 102 mg/dL, blood urea 28.3        digestive tract showed hyperplasia, hy-      are similar to those of dengue fever and
mg/dL, creatinine 0.9 mg/dL, aspar-       peremia, and linear and pseudomem-           mononucleosis, both common diseases
tate aminotransferase (AST) 20.4 U/L,     branous lacerations in the middle and        in Venezuela. The positive anti-dengue
alanine aminotransferase (ALT) 54.4       distal thirds of the esophagus (Mal-         IgM and the seroconversion of the IgG
U/L, erythrocyte sedimentation rate       lory-Weiss syndrome) and moderate            together with the negative PCR and
(Katz index) 15 mm/h, prothrombin         erythema of the stomach. Test results        isolation results suggest a recent, inac-
time ratio 1.02, partial thromboplastin   for Helicobacter pylori and Giardia          tive infection with dengue virus.
time –2.8 s. Radiographs of the thorax    lamblia were negative.                            According to our findings, eh-
showed bilateral infiltrate. Echocar-           Laboratory results showed leu-          rlichiosis should be a differential di-
diogram showed minor tricuspid in-        kopenia and monocytosis on day 5 of          agnosis for febrile patients who have

                          Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 3, March 2008                      519
LETTERS


                                                                                                    7.   Dawson JE, Biggie KL, Warner CK,
                                                                                                         Cookson K, Jenkins S, Levine JF, et al.
                                                                                                         Polymerase chain reaction evidence of
                                                                                                         Ehrlichia chaffeensis, an etiologic agent of
                                                                                                         human ehrlichiosis, in dogs from southeast
                                                                                                         Virginia. Am J Vet Res. 1996;57:1175–9.
                                                                                                    8.   Perez M, Rikihisa Y, Wen B. Ehrlichia ca-
                                                                                                         nis–like agent isolated from a man in Ven-
                                                                                                         ezuela: antigenic and genetic characteriza-
                                                                                                         tion. J Clin Microbiol. 1996;34:2133–9.
                                                                                                    9.   Perez M, Bodor M, Zhang C, Xiong Q,
                                                                                                         Rikihisa Y. Human infection with Eh-
                                                                                                         rlichia canis accompanied by clinical
                                                                                                         signs in Venezuela. Ann N Y Acad Sci.
                                                                                                         2006;1078:110–7.
                                                                                                   10.   Schutze GE, Buckingham SC, Marshall
                                                                                                         GS, Woods CR, Jackson MA, Patterson
                                                                                                         LE, et al. Human monocytic ehrlichio-
                                                                                                         sis in children. Pediatr Infect Dis J.
                                                                                                         2007;26:475–9.

                                                                                                   Address for correspondence: Francisco J. Triana-
                                                                                                   Alonso, BIOMED-UC, Final Calle Cecilio
                                                                                                   Acosta, Cantarrana, Las Delicias, Maracay,
Figure. Peripheral blood smears (buffy-coat preparation) showing variable-sized basophilic         Edo. Aragua, Venezuela; email: ftrianaalonso@
inclusions (arrows) in mononuclear cells from a 9-year-old boy with human monocytic
                                                                                                   yahoo.com
ehrlichiosis, Carabobo, Venezuela. Dip Quick (Jorgensen Laboratories, Inc., Loveland,
CO, USA) staining; magnification ×1,000.

thrombocytopenia, hepatomegaly, and           *University of Carabobo, Aragua, Venezu-
recent exposure to ticks. Although            ela; †Biomedical Research Institute, Mara-
Amblyomma americanum, the main                cay, Venezuela; and ‡Institute for Advanced
known vector of E. chaffeensis, has           Studies, Caracas, Venezuela
not been reported in Venezuela, Rhipi-                                                                       Resource
cephalus sanguineus and A. cajen-             References
nense are abundant in rural areas of                                                                     Allocation during
Venezuela; their ability to be vectors
                                               1.   Paddock CD, Childs JE. Ehrlichia
                                                    chaffeensis: a prototypical emerging patho-             an Influenza
should be investigated.
                                               2.
                                                    gen. Clin Microbiol Rev. 2003;16:37–64.
                                                    Arraga-Alvarado C, Montero-Ojeda M,
                                                                                                             Pandemic
                                                    Bernardoni A, Anderson BE, Parra O.
Acknowledgments                                                                                         To the Editor: Planning for pan-
                                                    Human ehrlichiosis: report of the 1st case
     We are grateful to Jacqueline Dawson           in Venezuela [in Spanish]. Invest Clin.        demic influenza is accepted as an es-
for providing the DH82 cell lines infected          1996;37:35–49.                                 sential healthcare service and has
with E. canis and E. chaffeensis. We also      3.   Gongora-Biachi RA, Zavala-Velasquez J,         included creation of national and in-
                                                    Castro-Sansores C, Gonzalez-Martinez P.
thank Guillermo Comach for performing                                                              ternational antiviral drug stockpiles
                                                    First case of human ehrlichiosis in Mexi-
serologic testing, isolation, and PCR tech-         co. Emerg Infect Dis. 1999;5:481.              and novel approaches to emergency
niques for dengue virus.                       4.   Ripoll CM, Remondegui CE, Ordonez G,           vaccine development (1). The ef-
                                                    Arazamendi R, Fusaro H, Hyman MJ, et           fectiveness of these strategies in a
     This work was supported by a grant             al. Evidence of rickettsial spotted fever
                                                                                                   pandemic may be substantial but is
(no. FCS 96-014) from the Council for               and ehrlichial infections in a subtropical
                                                    territory of Jujuy, Argentina. Am J Trop       unknown. More certain is that effec-
Scientific and Humanistic Development of
                                                    Med Hyg. 1999;61:350–4.                        tive management of severe and com-
the University of Carabobo.                    5.   López J, Rivera M, Concha JC, Gatica S,        plicated influenza will reduce deaths
                                                    Loeffeholz M, Barriga O. Serologic evi-
                                                                                                   and that demand will exceed available
                                                    dence for human ehrlichiosis in Chile. Rev
       María C. Martínez,*†                         Med Chil. 2003;131:67–70.                      treatment resources (2). Appropri-
       Clara N. Gutiérrez,*†                   6.   da Costa PS, Valle LM, Brigatte ME,            ate allocation of treatment resources
        Franklin Monger,*                           Greco DB. More about human monocy-             is therefore essential, perhaps more
                                                    totropic ehrlichiosis in Brazil: serological
Johanny Ruiz,† Akemys Watts,*                                                                      important than any specific treatment
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Victor M. Mijares,* María G. Rojas,‡                Dis. 2006;10:7–10.                             such as administering antiviral medi-
and Francisco J. Triana-Alonso†                                                                    cation to symptomatic patients. Re-

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