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Description of Eschar-Associated Rickettsial Diseases Using Passive Surveillance Data — United States, 2010–2016

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Description of Eschar-Associated Rickettsial Diseases Using Passive Surveillance Data — United States, 2010–2016 Morbidity and Mortality Weekly Report Description of Eschar-Associated Rickettsial Diseases Using Passive Surveillance Data — United States, 2010–2016 Naomi Drexler, MPH1; Kristen Nichols Heitman, MPH1; Cara Cherry, DVM1 Rickettsial eschars are necrotic lesions that occur at the site systems, and includes clinical details, diagnostic criteria, and of tick or mite bites and represent locations of primary inocula- patient outcomes. Since 2010, the CDC supplemental case tion of spotted fever group Rickettsia and Orientia species. In report form* has requested information on eschars. the United States, eschars are hallmarks of less severe spotted For this report, supplementary surveillance data collected fever diseases, including those caused by endemic agents such as by state and local health departments for illness with onset Rickettsia parkeri (1) and Rickettsia species 364D (2), as well as during 2010–2016 that were received and entered by CDC several imported agents, including Rickettsia africae, Rickettsia as of November 13, 2018, were summarized. TBRDs are not conorii, and Orientia tsutsugamushi. Eschars generally do not reportable conditions in Alaska and Hawaii, so no data from occur with Rocky Mountain spotted fever (RMSF), a poten- these states were included in this report. Case classifications tially deadly disease caused by Rickettsia rickettsii and have not were made according to the Council of State and Territorial been associated with Ehrlichia or Anaplasma species. The pres- Epidemiologists definitions (6,7). Confirmed cases were clini- ence of eschars can help differentiate less severe spotted fever cally compatible and had confirmatory diagnostic evidence rickettsioses from RMSF and clarify the potential contributions obtained by seroconversion (fourfold change) in anti-Ehrlichia, of each within surveillance data. The lone star tick (Amblyomma -Anaplasma, or -Rickettsia immunoglobulin (Ig)G antibody americanum), the Gulf Coast tick (Amblyomma maculatum), titers by indirect immunofluorescence antibody assay or tested and the Pacific Coast tick (Dermacentor occidentalis) are the positive by polymerase chain reaction (PCR), immunohisto- three most common species of tick vectors that spread eschar- chemistry, or culture. Probable cases were clinically compatible associated pathogens in the United States (1–4). Lone star and and included supportive laboratory evidence from serologic Gulf Coast ticks are vectors of R. parkeri, and Pacific Coast assays (including IgG- or IgM-positive antibodies reactive ticks are vectors of Rickettsia species 364D. In commonly avail- to Ehrlichia, Anaplasma, or Rickettsia species using immuno- able serologic assays, spotted fever group Rickettsia antigens fluorescence antibody assay or other serologic methods) or cross-react, which presents a challenge when differentiating reported the presence of morulae (intracellular inclusion bod- RMSF from other spotted fever rickettsioses. Incidence of ies in leukocytes) (7). Data were analyzed using SAS software spotted fever rickettsiosis continues to rise, with few cases (version 9.4; SAS Institute). providing species-specific laboratory evidence; therefore, the A rickettsial eschar begins as a small, painless papule that proportion of spotted fever rickettsioses caused by R. rickettsii appears within a few days after the bite of an infected vector. remains unclear (5). This analysis serves as the first summary The papule grows, becomes vesicular or pustular, and ulcerates of eschar-associated rickettsial disease surveillance data in the forming a brown-to-black crust surrounded by a red annular United States. During 2010–2016, the presence or absence of halo (Figure 1). During 2010–2016, a total of 44,099 cases eschars was reported in <20% of tickborne rickettsial disease of TBRD with supplemental case report forms were reported (TBRD) cases. Eschar-associated illnesses represented a small to CDC, including 484 (1.1%) reported as eschar-associated percentage (1.1%) of TBRD cases. Among the 484 reported TBRD; however, most case reports (35,749, 81.1%) were miss- eschar-associated cases, 97 (20%) were classified as ehrlichio- ing information on eschars altogether. Among reported eschar- sis or anaplasmosis. Further research is needed to determine associated cases, 387 (80.0%) were classified as spotted fever whether eschars associated with ehrlichiosis or anaplasmosis rickettsioses, 64 (13.2%) as Ehrlichia chaffeensis ehrlichiosis, 30 reflect a reporting error, a new finding, or the result of coin- (6.2%) as Anaplasma phagocytophilum anaplasmosis, one (0.2%) fection with another eschar-associated rickettsial pathogen. as Ehrlichia ewingii ehrlichiosis, and two (0.4%) as undeter- Notifiable rickettsial diseases are reported to CDC through mined ehrlichiosis/anaplasmosis. Notation of suspected spotted the National Notifiable Diseases Surveillance System, which fever species is not required but was listed for 16 (4.1%) cases, also collects basic demographic information. Supplementary * The TBRD case report form used for this review can be found at https://www. information is recorded through submission of TBRD supple- cdc.gov/ticks/pdf/2010_TBRD_case_report.pdf; however, a case definition mental case report forms, or extractions from state surveillance change for spotted fever rickettsiosis will go into effect January 1, 2020, and a new case report form is forthcoming. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / January 3, 2020 / Vol. 68 / Nos. 51 & 52 1179 Morbidity and Mortality Weekly Report FIGURE 1. Rickettsial disease eschar from a patient with Rickettsia TABLE. Demographic characteristics and outcome indicators for parkeri rickettsiosis tickborne rickettsial disease cases by eschar status— United States case report forms, 2010–2016 No. (%) Missing Eschar No eschar information Chi- reported reported about eschars squared Characteristic (n = 484) (n = 7,866) (n = 35,749) p-value* Case classification p<0.001 Confirmed 42 (8.7) 1,093 (13.9) 11,145 (31.2) Probable 442 (91.3) 6,773 (86.1) 24,604 (68.8) Sex p<0.001 Male 290 (59.9) 5,037 (64.0) 21,887 (61.2) Female 189 (39.0) 2,780 (35.3) 13,166 (36.8) Unknown 5 (1.0) 49 (0.6) 696 (2.0) Race p<0.001 White 331 (68.4) 5,896 (75.0) 23,923 (66.9) Black 10 (2.1) 143 (1.8) 670 (1.9) Photo/CDC American Indian/ 8 (1.7) 40 (0.5) 776 (2.2) Alaska Native Asian/Pacific 2 (0.4) 37 (0.5) 186 (0.5) including R. africae (11 cases), R. parkeri (two) and R. conorii Islander Not specified/ 133 (27.5) 1,750 (22.3) 10,194 (28.5) (one), Rickettsia species 364D (one), and Rickettsia akari (one). Unknown No eschar-associated cases were associated with R. rickettsii. Ethnicity p<0.001 Patients reporting eschar-associated illnesses were pre- Hispanic 10 (2.1) 203 (2.6) 677 (1.9) Non-Hispanic 402 (83.1) 6,267 (79.7) 21,668 (60.6) dominantly male (290, 59.9%), white (331, 68.4%), and Unknown 72 (14.9) 1,396 (17.8) 13,404 (37.5) non-Hispanic (402, 83.1%) (Table). Hospitalization (90, Age group (yrs) p<0.001 18.6%) and death (1, 0.2%) occurred among a smaller propor- <10 11 (2.3) 183 (2.5) 789 (3.1) tion of patients with eschar-associated illness than among those 10–19 14 (2.9) 387 (5.3) 1,350 (5.3) 20–29 37 (7.6) 546 (7.4) 1,705 (6.7) with illness not associated with eschar (2,120, 27.0% and 21, 30–39 45 (9.3) 827 (11.2) 2,408 (9.5) 0.3%), respectively. Race and sex distributions were similar 40–49 71 (14.7) 1,128 (15.3) 3,448 (13.5) 50–59 99 (20.5) 1,547 (21.0) 5,269 (20.6) among patients with and without eschars. All but seven jurisdic- 60–69 91 (18.8) 1,526 (20.7) 5,569 (21.9) tions in which TBRD are reportable submitted information on ≥70 79 (16.3) 1,220 (16.6) 4,960 (19.5) the presence and absence of eschars during this period. Most Unknown 37 (7.6) 502 (6.4) 10,261 (28.7) eschar-associated cases (74.6%, 361) were reported from the See table footnotes on the next page. South, compared with 60.3% (4,738) of cases not associated with eschar (Table). Most eschar-associated cases (462, 95.5%) proportions of spotted fever rickettsioses that are caused by less were reported from states where ticks that transmit eschar- pathogenic spotted fever group Rickettsia and those caused by associated pathogens were present (Figure 2). A large proportion R. rickettsii. In addition, rickettsial eschars serve as an important of all TBRD cases were missing travel history (30,455, 69.1%). clinical specimen; rickettsial DNA can be extracted from eschar Only 42 (8.7%) of 484 eschar-associated cases were con- lesions obtained by punch biopsies, by removing a portion of firmed, compared with 1,093 (13.9%) TBRD cases not the eschar scab, or by swabbing the ulcerated area (9). PCR associated with eschar (Table). Thirty-four (7.0%) reported testing of eschar swabs and scabs provides confirmatory testing eschar-associated cases were tested by PCR, one report without a more invasive biopsy, although the pathogen cannot described visualization of morulae, and 447 (92.0%) cases be cultured and immunohistochemistry cannot be performed met confirmed or supportive laboratory criteria using serologic on eschar swabs or scabs. To assist agencies that request rickett- evidence; techniques were not mutually exclusive. sial disease testing, CDC provides instructions for collection and submission of eschar swab and skin biopsy specimens.† Discussion Demographic characteristics of patients with eschar- The presence of an eschar can aid in the clinical and epi- associated TBRD were similar to those of patients for whom demiologic differentiation of less severe spotted fever rickett- eschars were not reported. Eschar-associated cases reported sioses (e.g., Pacific Coast tick fever [Rickettsia species 364D] during this period were less likely to be confirmed, and less and R.
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