Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Locally Acquired Eastern Equine Encephalitis Virus Disease, Arkansas, USA

Download as pdf or txt
Download as pdf or txt
You are on page 1of 2

LETTERS

Locally Acquired Eastern CSF examination on PSOD 4 showed 1,170 leukocytes/


mm3 (74% neutrophils), 137 erythrocytes/mm3, 204 mg/dL
Equine Encephalitis Virus protein, 66 mg/dL glucose, and a negative Gram stain. CSF
Disease, Arkansas, USA bacterial cultures, CSF herpes simplex virus PCR, and CSF
enterovirus reverse transcription PCR tests were negative.
Repeat CT scan of the brain on PSOD 6 showed frontal
Jeremy Garlick, T. Jacob Lee, Patrick Shepherd,
and temporal lobe edema. Physicians initiated measures to
W. Matthew Linam, Daniel M. Pastula,
monitor and control elevated intracranial pressure, includ-
Susan Weinstein, Stephen M. Schexnayder
ing placement of an external ventricular drain, hyperosmo-
Author affiliations: University of Arkansas for Medical Sciences, lar therapy with mannitol and 3% sodium chloride, cooling
Little Rock, Arkansas, USA (J. Garlick, T.J. Lee, P. Shepherd, to 34°C, chemical paralysis, and a pentobarbital-induced
W.M. Linam, S.M. Schexnayder); Centers for Disease Control coma. Pressors were subsequently added to maintain ce-
and Prevention, Fort Collins, Colorado, USA (D.M. Pastula); rebral perfusion pressures >60 mm Hg (i.e., minimum for
University of Colorado School of Medicine, Aurora, Colorado, adequate brain perfusion). Despite these measures, elevat-
USA (D.M. Pastula); Arkansas Department of Health, Little Rock ed intracranial pressure (from low 20s mm Hg to mid-30s
(S. Weinstein) mm Hg) continued for 2 weeks. On PSOD 19, the patient’s
intracranial pressure increased to 71 mm Hg. A repeat CT
DOI: http://dx.doi.org/10.3201/eid2212.160844
scan of the brain showed widespread cerebral edema, uncal
To the Editor: Eastern equine encephalitis virus herniation, intraparenchymal hemorrhages, and obstruc-
(EEEV) is an arbovirus (family Togaviridae, genus Alpha- tive hydrocephalus. Given clinical worsening, the family
virus) transmitted to humans primarily from Aedes, Coquil- elected to withdraw care and the patient died.
lettidia, and Culex mosquitoes. EEEV is maintained in a Serologic testing from PSOD day 4 for immunoglobu-
transmission cycle between Culiseta melanura mosquitoes lin (Ig) M and G antibodies against St. Louis encephalitis,
and birds in freshwater hardwood swamps (1). Affected hu- West Nile, and California serogroup viruses was negative.
mans and horses are considered to be dead-end hosts; that A commercial EEEV IgM antibody immunofluorescence
is, they usually do not develop sufficient levels of viremia assay (IFA) performed on CSF collected on PSOD 4 was
to infect mosquitoes. Although human EEEV disease is positive (titer 8). Confirmatory testing was performed at
rare, it has a case-fatality rate of >30% and >50% of survi- the Centers for Disease Control and Prevention’s Arboviral
vors may have permanent neurologic sequelae (2–5). Cases Diseases Branch (Fort Collins, CO, USA). Serum collect-
occur sporadically each year, primarily along the eastern ed on PSOD 12 tested positive for EEEV IgM antibodies
and Gulf coasts of North America, but no cases have been by microsphere immunoassay and for EEEV neutralizing
previously reported in Arkansas (1). We report a locally ac- antibodies by plaque reduction neutralization testing (titer
quired case of human EEEV disease in Arkansas. >20,480) (6). Additional CSF collected on PSOD 12 also
In October 2013, a male teenager from southwestern tested positive for EEEV IgM antibodies by microsphere
Arkansas sought care at a local hospital after 3 days of immunoassay and for EEEV neutralizing antibodies by
headache and 3 new-onset focal seizures. He had a history plaque reduction neutralization testing (titer 32).
of recent multiple mosquito bites and no history of recent Although human EEEV disease cases had been re-
travel. Initial laboratory studies on postsymptom onset day ported in neighboring Louisiana, Mississippi, and Texas,
(PSOD) 3 showed normal peripheral leukocyte count, elec- no cases had previously been reported in Arkansas (1).
trolytes, and liver function tests. Cerebrospinal fluid (CSF) However, EEEV was identified in horses in Arkansas be-
exam showed 5 leukocytes/mm3 (reference 0–5), 7 erythro- fore 2013 and in the patient’s county of residence in 2013,
cytes/mm3 (reference 0), 55 mg/dL glucose (reference 45– indicating that the virus was already present in the area
80), and 36 mg/dL protein (reference 15–40). Noncontrast (7). Several freshwater swamps, which are known to be
computed tomography (CT) of the head was normal. He important ecologic environments in the EEEV transmis-
was transferred to a regional academic pediatric hospital sion cycle, were within a 6-mile radius of the patient’s
on PSOD 3. residence (8). This case shows that human EEEV disease
On PSOD 4, the patient became increasingly lethargic, can occur in areas where EEEV is circulating in the envi-
febrile (39.2°C), tachycardic, and hypotensive. He received ronment, highlighting the need for continued surveillance
intravenous fluids and broad-spectrum antimicrobial drugs for EEEV and other arboviruses. Furthermore, the lack of
(e.g., vancomycin, ceftriaxone, acyclovir, and doxycy- a specific antiviral therapy for EEEV disease indicates the
cline). Magnetic resonance imaging of the brain on PSOD importance of mosquito-bite prevention strategies (e.g.,
4 revealed left frontal lobe edema and multiple T2 signal using insect repellent and wearing long-sleeved shirts and
abnormalities in the basal ganglia and midbrain. Repeat pants outdoors).

2216 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 22, No. 12, December 2016
LETTERS

For those who develop EEEV disease, supportive care Address for correspondence: Stephen M. Schexnayder, University of
is currently the only treatment option. Elevated intracranial Arkansas for Medical Sciences, College of Medicine, Section of Critical
pressure should be watched for, monitored, and aggres- Care Medicine, Arkansas Children’s Hospital, 1 Children’s Way, S-4415,
sively managed. Hyperosmolar therapy, external ventricu- Little Rock, AR 72202, USA; email: SchexnayderSM@uams.edu
lar drain placement, cooling, sedation, and paralysis have
been used in the management of elevated intracranial pres-
sure for other conditions and have been used with varying
degrees of success in treating EEEV disease (9,10). Fur-
ther research regarding the management of EEEV disease Tick-Borne Relapsing Fever,
is needed. Southern Spain, 2004–2015
Acknowledgments
We thank Marc Fischer and the Arbovirus Diagnostics Luis Castilla-Guerra,1 Jorge Marín-Martín,1
Laboratory of the CDC, Charles Glasier, and other Arkansas Miguel Angel Colmenero-Camacho
clinicians and public health officials who were involved in the Author affiliations: Hospital Universitario Virgen Macarena,
care of this patient and in investigation of this case. Seville, Spain (L. Castilla-Guerra, M.A. Colmenero-Camacho);
Universidad de Sevilla, Seville (L. Castilla-Guerra,
The findings and conclusions in this report are those of the
M.A. Colmenero-Camacho); Hospital de la Merced, Seville
authors and do not necessarily represent the official position of
(J. Marín-Martín)
the Centers for Disease Control and Prevention or the Arkansas
Department of Health. DOI: http://dx.doi.org/10.3201/eid2212.160870

To the Editor: Surveillance data indicate that tick-


References borne diseases are substantial and increasing global public
1. US Centers for Disease Control and Prevention. Eastern equine health problems (1). Various pathogens, including viruses,
encephalitis. Updated 2016 Apr 5 [cited 2016 May 22].
http://www.cdc.gov/EasternEquineEncephalitis.
bacteria, protozoa, and helminthes, are transmitted from
2. Feemster RF. Equine encephalitis in Massachusetts. N Engl J Med. ticks to vertebrates (2). Tick-borne relapsing fever (TBRF)
1957;257:701–4 http://dx.doi.org/10.1056/NEJM195710102571504 is a zoonosis that is enzootic in many countries (3). This
3. Przelomski MM, O’Rourke E, Grady GF, Berardi VP, Markley HG. illness is caused by >10 Borrelia species and is transmit-
Eastern equine encephalitis in Massachusetts: a report of 16 cases,
1970–1984. Neurology. 1988;38:736–9. http://dx.doi.org/10.1212/
ted to humans through the bite of soft ticks of the genus
WNL.38.5.736 Ornithodoros (3).
4. Letson GW, Bailey RE, Pearson J, Tsai TF. Eastern equine Currently, TBRF is endemic in various foci around
encephalitis (EEE): a description of the 1989 outbreak, recent the world. However, few TBRF cases are reported in the
epidemiologic trends, and the association of rainfall with EEE
occurrence. Am J Trop Med Hyg. 1993;49:677–85.
United States, and in most western European countries,
5. Reimann CA, Hayes EB, DiGuiseppi C, Hoffman R, Lehman JA, such as Spain, TBRF occurs sporadically, usually after
Lindsey NP, et al. Epidemiology of neuroinvasive arboviral opportunistic infections in persons exposed to ticks (3,4).
disease in the United States, 1999–2007. Am J Trop Med Hyg. Many authors consider TBRF to be underrecognized and
2008;79:974–9.
6. Basile AJ, Horiuchi K, Panella AJ, Laven J, Kosoy O, Lanciotti RS,
underreported (5). Although molecular tools such as PCR
et al. Multiplex microsphere immunoassays for the detection of can dramatically improve diagnosis of this illness, methods
IgM and IgG to arboviral diseases. PLoS One. 2013;8:e75670. used to diagnose TBRF have changed little since the dis-
http://dx.doi.org/10.1371/journal.pone.0075670 covery of the spirochete.
7. US Department of Agriculture. 2013 Summary of eastern equine
encephalitis cases in the United States—January 1, 2013–
To evaluate the prevalence and clinical features of
December 31, 2013. 2014 May [cited 2016 May 22]. TBRF in a rural area of southern Spain, we retrospective-
https://www.aphis.usda.gov/animal_health/downloads/animal_ ly reviewed clinical data for all patients ≥14 years of age
diseases/2013_EEE_FINAL.pdf who sought care for TBRF during January 2004–December
8. Komar N, Spielman A. Emergence of eastern encephalitis
in Massachusetts. Ann N Y Acad Sci. 1994;740:157–68.
2015 at Hospital de la Merced, a county hospital in Seville,
http://dx.doi.org/10.1111/j.1749-6632.1994.tb19866.x Spain. We defined a case of TBRF as detection of spiro-
9. Wendell LC, Potter NS, Roth JL, Salloway SP, Thompson BB. chetes on thin- or thick-blood smears or in cerebrospinal
Successful management of severe neuroinvasive eastern fluid (CSF) samples by using conventional microscopy af-
equine encephalitis. Neurocrit Care. 2013;19:111–5.
http://dx.doi.org/10.1007/s12028-013-9822-5
ter Giemsa or Wright staining (Figure).
10. Nakagawa K, Chang CW, Koenig MA, Yu M, Tokumaru S. Of 75 patients, 42 (56%) were male and 33 (44%) were
Treatment of refractory intracranial hypertension with 23.4% female. Mean age was 33 (range 14–72) years. Nine (12%)
saline in children with severe traumatic brain injury. J Clin Anesth.
2012;24:318–23. http://dx.doi.org/10.1016/j.jclinane.2011.10.011 1
These authors contributed equally to this article.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 22, No. 12, December 2016 2217

You might also like