Ehrlichiosis is a
tick-borne
bacterial infection, caused by bacteria of the family
Anaplasmataceae
The Ehrlichiaceae are a family of bacteria, included in the order Rickettsiales
The Rickettsiales, informally called rickettsias, are an order of small Alphaproteobacteria. They are obligate intracellular parasites, and some are notable path ...
, genera ''
Ehrlichia'' and ''
Anaplasma
''Anaplasma'' is a genus of bacteria of the alphaproteobacterial order Rickettsiales, family Anaplasmataceae.
''Anaplasma'' species reside in host blood cells and lead to the disease anaplasmosis. The disease most commonly occurs in areas wher ...
''. These
obligate intracellular bacteria
Bacteria (; singular: bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were am ...
infect and kill
white blood cell
White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...
s.
The average reported annual incidence is on the order of 2.3 cases per million people.
Types
Six (see note below) species have been shown to cause human infection:
* ''
Anaplasma phagocytophilum'' causes
human granulocytic anaplasmosis. ''A. phagocytophilum'' is endemic to New England and the north-central and Pacific regions of the United States.
* ''
Ehrlichia ewingii'' causes
human ewingii ehrlichiosis. ''E. ewingii'' primarily infects deer and dogs (see
Ehrlichiosis (canine)).
''E. ewingii'' is most common in the south-central and southeastern states.
* ''
Ehrlichia chaffeensis'' causes
human monocytic ehrlichiosis. ''E. chaffeensis'' is most common in the south-central and southeastern states.
* ''
Ehrlichia canis''
* ''
Neorickettsia sennetsu''
*''
Ehrlichia muris eauclairensis''
The latter three infections are not well studied. Ehrlichia muris eauclairensis was recently discovered and has low reporting numbers due to the fact that it is relatively new and because its symptoms are very similar to the symptoms caused by other Ehrlichia bacteria.
In 2008, human infection by a
Panola Mountain
Panola Mountain is a granite monadnock near Stockbridge, Georgia, Stockbridge on the boundary between Henry County, Georgia, Henry County and Rockdale County, Georgia. The peak is above sea level, rising above the South River (Ocmulgee River), ...
(in Georgia, USA) ''Ehrlichia'' species was reported. On August 3, 2011, infection by a yet-unnamed bacterium in the genus ''Ehrlichia'' was reported, carried by
deer ticks and causing
flu-like
Influenza-like illness (ILI), also known as flu-like syndrome or flu-like symptoms, is a medical diagnosis of possible influenza or other illness causing a set of common symptoms. These include fever, shivering, chills, malaise, dry cough, loss ...
symptoms in at least 25 people in
Minnesota
Minnesota () is a state in the upper midwestern region of the United States. It is the 12th largest U.S. state in area and the 22nd most populous, with over 5.75 million residents. Minnesota is home to western prairies, now given over t ...
and
Wisconsin
Wisconsin () is a state in the upper Midwestern United States. Wisconsin is the 25th-largest state by total area and the 20th-most populous. It is bordered by Minnesota to the west, Iowa to the southwest, Illinois to the south, Lake M ...
. Until then, human ehrlichiosis was thought to be very rare or absent in both states.
The new species, which is genetically very similar to an ''Ehrlichia'' species found in
Eastern Europe
Eastern Europe is a subregion of the European continent. As a largely ambiguous term, it has a wide range of geopolitical, geographical, ethnic, cultural, and socio-economic connotations. The vast majority of the region is covered by Russia, whi ...
and
Japan
Japan ( ja, 日本, or , and formally , ''Nihonkoku'') is an island country in East Asia. It is situated in the northwest Pacific Ocean, and is bordered on the west by the Sea of Japan, while extending from the Sea of Okhotsk in the n ...
called ''E. muris'', was identified at a
Mayo Clinic
The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staf ...
Health System hospital in
Eau Claire.
''Ehrlichia'' species are transported between cells through the host-cell
filopodia
Filopodia (singular filopodium) are slender cytoplasmic projections that extend beyond the leading edge of lamellipodia in migrating cells. Within the lamellipodium, actin ribs are known as ''microspikes'', and when they extend beyond the lame ...
during the initial stages of infection; whereas, in the final stages of infection, the pathogen ruptures the host cell membrane.
Signs and symptoms
Specific symptoms include fever, chills, severe headaches, muscle aches, nausea, vomiting, diarrhea, loss of appetite, confusion, and a splotchy or pinpoint rash. More severe symptoms include brain or nervous system damage, respiratory failure, uncontrollable bleeding, organ failure, and death. Ehrlichiosis can also blunt the immune system by suppressing production of
TNF-alpha, which may lead to opportunistic infections such as
candidiasis.
Most of the signs and symptoms of ehrlichiosis can likely be ascribed to the immune dysregulation that it causes. A "
toxic shock-like" syndrome is seen in some severe cases of ehrlichiosis. Some cases can present with
purpura
Purpura () is a condition of red or purple discolored spots on the skin that do not blanch on applying pressure. The spots are caused by bleeding underneath the skin secondary to platelet disorders, vascular disorders, coagulation disorders, ...
and in one such case, the organisms were present in such overwhelming numbers that in 1991, Dr. Aileen Marty of the
AFIP
The Armed Forces Institute of Pathology (AFIP) (1862 – September 15, 2011) was a U.S. government institution concerned with diagnostic consultation, education, and research in the medical specialty of pathology.
Overview
It was founded in 1 ...
was able to demonstrate the bacteria in human tissues using standard stains, and later proved that the organisms were indeed ''Ehrlichia'' using immunoperoxidase stains.
Experiments in mouse models further support this hypothesis, as mice lacking TNF-alpha I/II receptors are resistant to liver injury caused by ''Ehrlichia'' infection.
About 3% of human monocytic ehrlichiosis cases result in death; however, these deaths occur "most commonly in immunosuppressed individuals who develop
respiratory distress syndrome,
hepatitis
Hepatitis is inflammation of the liver tissue. Some people or animals with hepatitis have no symptoms, whereas others develop yellow discoloration of the skin and whites of the eyes ( jaundice), poor appetite, vomiting, tiredness, abdominal ...
, or opportunistic
nosocomial infections."
Prevention
No human vaccine is available for ehrlichiosis. Tick control is the main preventive measure against the disease. However, in late 2012, a breakthrough in the prevention of canine monocytic ehrlichiosis was announced when a vaccine was accidentally discovered by Prof. Shimon Harrus, Dean of the
Hebrew University of Jerusalem
The Hebrew University of Jerusalem (HUJI; he, הַאוּנִיבֶרְסִיטָה הַעִבְרִית בִּירוּשָׁלַיִם) is a public research university based in Jerusalem, Israel. Co-founded by Albert Einstein and Dr. Chaim Weiz ...
's Koret School of Veterinary Medicine.
Measures of tick bite prevention include staying out of tall grassy areas that ticks tend to live in, treating clothes and gear that a tick could jump on, using EPA approved bug repellent, tick checks for all humans, animals, and gear that potentially came into contact with a tick, and showering soon after being in an area that ticks might also be in.
Treatment
Doxycycline
Doxycycline is a broad-spectrum tetracycline class antibiotic used in the treatment of infections caused by bacteria and certain parasites. It is used to treat bacterial pneumonia, acne, chlamydia infections, Lyme disease, cholera, typhus ...
and
minocycline are the medications of choice. For people allergic to
antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention ...
s of the
tetracycline
Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including acne, cholera, brucellosis, plague, malaria, and syphilis.
Common side effects in ...
class,
rifampin is an alternative.
Early clinical experience suggested that
chloramphenicol
Chloramphenicol is an antibiotic useful for the treatment of a number of bacterial infections. This includes use as an eye ointment to treat conjunctivitis. By mouth or by injection into a vein, it is used to treat meningitis, plague, chole ...
may also be effective, but'' in vitro'' susceptibility testing revealed resistance.
Epidemiology
Ehrlichiosis is a nationally notifiable disease in the United States. Cases have been reported in every month of the year, but most cases are reported during April–September.
[Dahlgren FS, Heitman KN, Drexler NA, Massung RF, Behravesh CB]
"Human granulocytic anaplasmosis in the United States from 2008 to 2012: a summary of national surveillance data"
Am J Trop Med Hyg 2015;93:66–72. [Nichols KH, Dahlgren FS, Drexler NA, Massung RF, Behravesh CB. Increasing incidence of ehrlichiosis in the United States: a summary of national surveillance of ''Ehrlichia chaffeensis'' and ''Ehrlichia ewingii'' infections in the United States, 2008–2012. Am J Trop Med Hyg 2016;94:52–60.] These months are also the peak months for tick activity in the United States.
The majority of cases of Ehrlichiosis tend to be in the United States. The states affected most include "the southeastern and south-central United States, from the East Coast extending westward to Texas."
Since the first case of Ehrlichiosis was reported in 2000, cases reported to the CDC have increased, for example, in 2000, 200 cases were reported and in 2019, 2,093 cases were reported. Fortunately, the "proportion of ehrlichiosis patients that died as a result of infection" has gone down since 2000.
From 2008 to 2012, the average yearly incidence of ehrlichiosis was 3.2 cases per million persons. This is more than twice the estimated incidence for 2000–2007.
The incidence rate increases with age, with the ages of 60–69 years being the highest age-specific years. Children less than 10 years and adults aged 70 years and older have the highest case-fatality rates.
A documented higher risk of death exists among persons who are immunosuppressed.
See also
*
''Ehrlichia'' Wisconsin HM543746
References
External links
* Aayushi Pratap
Dog ticks may get more of a taste for human blood as the climate changes On: ScienceNews. November 30, 2020.
{{Gram-negative bacterial diseases
Bacterium-related cutaneous conditions
Tick-borne diseases