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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
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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
evidence of nine new cases. Braz J Infect
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-
520 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 3, March 2008
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