Correspondence

Ehrlichia Infection as a Cause of Severe Respiratory Distress

N Engl J Med 1996; 334:273January 25, 1996

Article

To the Editor:

Human ehrlichiosis is increasingly being recognized as a cause of a diverse spectrum of illness in geographic regions where the tick vectors are found. The New York State Department of Health recently alerted physicians about human granulocytic ehrlichiosis in Westchester County, in the lower Hudson River valley, and on Long Island.1 This region has a high incidence of Lyme disease associated with the Ixodes scapularis tick vector. It has a high population density and an environment in which humans are likely to acquire zoonotic diseases through outdoor activities. Since 1994, the Wadsworth Center has analyzed for hantavirus infection 62 serum samples from patients with fever and acute respiratory distress syndrome. Only one of these samples, from a patient who died of acute respiratory distress syndrome in April 1995, was positive for hantavirus. We retested the hantavirus-negative serum samples for evidence of infection with either Ehrlichia equi or E. chaffeensis.

Of the 61 serum samples tested, 7 (11 percent) were positive for antibodies to E. equi (associated with human granulocytic ehrlichiosis), E. chaffeensis (associated with human monocytic ehrlichiosis), or both at titers suggestive of infection at an undetermined time (reciprocal antibody titers, >80). All the patients were severely ill and had clinical presentations that could be compatible with the case definition of ehrlichiosis recommended by the Centers for Disease Control and Prevention.

Acute respiratory distress syndrome may have a diverse spectrum of causes, but often the illness progresses so fast that only empirical therapy with broad-spectrum antibiotics can be implemented. Human ehrlichiosis responds quickly to treatment with tetracyclines if the patient is not already near death. The finding that 7 of 61 patients had signs and symptoms compatible with ehrlichiosis suggests that it is prudent to consider infection with ehrlichia in patients presenting with rapidly progressive respiratory distress, to order prompt laboratory tests for ehrlichia involving serologic analysis and the polymerase chain reaction (if available), and to implement therapy with tetracyclines if not otherwise contraindicated. Acute respiratory distress syndrome has a high mortality rate (reportedly 50 to 60 percent2), so the decrease in the rate that might be realized by identifying cases due to ehrlichiosis would be an important clinical benefit.

Susan Wong, Ph.D.
Leo J. Grady, Ph.D.
Wadsworth Center, New York State Department of Health, Albany, NY 12201-0509

2 References

1. 1

   Human granulocytic ehrlichiosis -- New York, 1995MMWR Morb Mortal Wkly Rep 1995;44:593-595
   Medline

2. 2

   Donowitz GR, Mandell GL. Acute pneumonia. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 4th ed. Vol. 1. New York: Churchill Livingstone, 1995:629.
   

Citing Articles (11)

Citing Articles

1. 1

   Neena Qasba, Amirhoushang A. Shamshirsaz, Henry M. Feder, Winston A. Campbell, James F. Egan, Alireza A. Shamshirsaz. (2011) A Case Report of Human Granulocytic Anaplasmosis (Ehrlichiosis) in Pregnancy and a Literature Review of Tick-Borne Diseases in the United States During Pregnancy. Obstetrical & Gynecological Survey 66:12, 788-796
   CrossRef

2. 2

   A. Dhand, R. B. Nadelman, M. Aguero-Rosenfeld, F. A. Haddad, D. P. Stokes, H. W. Horowitz. (2007) Human Granulocytic Anaplasmosis During Pregnancy: Case Series and Literature Review. Clinical Infectious Diseases 45:5, 589-593
   CrossRef

3. 3

   Anna Grzeszczuk, Nicole C. Barat, Johan S. Bakken, J. Stephen Dumler. 2007. Anaplasmosis in Humans. , 223-236.
   CrossRef

4. 4

   Jason A. Carlyon, Erol Fikrig. (2003) Invasion and survival strategies of Anaplasma phagocytophilum. Cellular Microbiology 5:11, 743-754
   CrossRef

5. 5

   J. R. Blanco, J. A. Oteo. (2002) Human granulocytic ehrlichiosis in Europe. Clinical Microbiology and Infection 8:12, 763-772
   CrossRef

6. 6

   Ann E. Smith Sehdev, Paul S. Sehdev, Ruth Jacobs, J. Stephen Dumler. (2002) Human Monocytic Ehrlichiosis Presenting as Acute Appendicitis During Pregnancy. Clinical Infectious Diseases 35:9, e99-e102
   CrossRef

7. 7

   Mary E. Martin, Karen Caspersen, J. Stephen Dumler. (2001) Immunopathology and Ehrlichial Propagation Are Regulated by Interferon-γ and Interleukin-10 in a Murine Model of Human Granulocytic Ehrlichiosis. The American Journal of Pathology 158:5, 1881-1888
   CrossRef

8. 8

   Sigurður Skarpheðinsson, Per Søgaar. (2001) Seroprevalence of Human Granulocytic Ehrlichiosis in High-risk Groups in Denmark. Scandinavian Journal of Infectious Diseases 33:3, 206-210
   CrossRef

9. 9

   Timothy R. Peters, Kathryn M. Edwards, Steven M. Standaert. (2000) SEVERE EHRLICHIOSIS IN AN ADOLESCENT TAKING TRIMETHOPRIM-SULFAMETHOXAZOLE. The Pediatric Infectious Disease Journal 19:2, 170
   CrossRef

10. 10

    Michelle L. Plier, Karen M. Young, Jeffrey E. Barlough, John E. Madigan, J. Stephen Dumler. (1999) Equine Granulocytic Ehrlichiosis: A Case Report with DNA Analysis and Species Comparison. Veterinary Clinical Pathology 28:4, 127-130
    CrossRef

11. 11

    J. Stephen Dumler, MD, Johan S. Bakken, MD. (1998) HUMAN EHRLICHIOSES: Newly Recognized Infections Transmitted by Ticks. Annual Review of Medicine 49:1, 201-213
    CrossRef