Correspondence

Severe fever with were positive for A phagocytophilum.3 Animal Parasitology of Ministry of Agriculture, Some patients with SFTS have been Shanghai Veterinary Research Institute, Chinese thrombocytopenia Academy of Agricultural Sciences, Shanghai, China misdiagnosed with quite common (JLZ). syndrome in China diseases, including common fever, 1 Liu Q, He B, Huang SY, et al. Severe fever with gastrointestinal disease, and thrombocytopenia syndrome, an emerging In their Review of severe fever respiratory disease (table). These data tick-borne zoonosis. Lancet Infect Dis 2014; 14: 763–72. with thrombocytopenia syndrome strongly suggest that most cases of 2 Yu XJ, Liang MF, Zhang SY, et al. Fever with (SFTS), Quan Liu and colleagues human granulocytic anaplasmosis thrombocytopenia associated with a novel bunyavirus in China. New Engl J Med 2011; reported that almost 2500 cases reported in China might actually be 364: 1523–32. of SFTS have been diagnosed with misdiagnosis cases of SFTS. Although 3 Xu BL, Liu LC, Huang XY, et al. Metagenomic an average mortality of 7·3%.1 this situation has been improving analysis of fever thrombocytopenia and leukopenia syndrome (FTLS) in Henan However, they did not mention in hospitals where doctors have the Province, China: discovery of a new the frequent misdiagnosis of knowledge and correct diagnostic bunyavirus. PLoS Pathog 2011; 7: 1–10. SFTS, especially surprising because tests to distinguish SFTS from other 4 Ding F, Zhang W, Wang L, et al. Epidemiologic features of severe fever with it constituted a major problem diseases, misdiagnosis is probably thrombocytopenia syndrome in China, before recognition of the disease still common in endemic regions, 2011–2012. Clin Infect Dis 2013; 56: 1682–83. in 2009. Several diseases, including even despite the discovery of the leptospirosis, haemorrhagic fever aetiological agent of SFTS.4 We hope with renal syndrome, and human that this situation will benefi t from Brucellar aortitis and granulocytic anaplasmosis, share the development of new diagnostic brucellar spondylitis many clinical features with SFTS.2 methods for the SFTS virus, the SFTS is often misdiagnosed as re-education of physicians, and We agree with most of the interesting these diseases (table), especially eff ective guidelines from the central contents of the Grand Round by human granulocytic anaplasmosis, government. Jesica Herrick and colleagues,1 al- which is also a tick-borne disease, We declare no competing interests. We have though we fi nd that the problem of caused by the intracellular bac- received grants from the National Science brucellar aortitis and its potential terium Anaplasma phagocytophilum. Foundation of China (31272305) and National coexistence with brucellar spondylitis Basic Research Program (973 project, Serology-confi rmed infections 2010CB530000). We thank Prof Geoff Hide was insufficiently addressed. The with A phagocytophilum were very (University of Salford, UK) for the critical investigators found 34 cases of rare in patients from endemic comments. brucellar arteritis and only 23 cases regions of China thought to have Yi-Ting Xie, De-Hua Lai, of brucellar aortis described in the human granulocytic anaplasmosis. Guang-Yuan Liu, Jin-Lin Zhou, scientifi c literature, in patients with a Furthermore, A phagocytophilum *Zhao-Rong Lun mean age of 42·9 years. has not been isolated in China from [email protected] We have previously analysed2 patients with suspected human State Key Laboratory of Biocontrol, Key Laboratory the epidemiological and clinical granulocytic anaplasmosis. Xu and of Gene Engineering of the Ministry of Education, characteristics of 46 cases of brucellar colleagues assessed 285 samples School of Life Sciences and Key Laboratory for aortic involvement. In 18 of these Tropical Disease Control of the Ministry of from patients with suspected Education, Zhongshan School of Medicine, cases, the complication involved human granulocytic anaplasmosis, Sun Yat-Sen University, Guangzhou 510275, China the ascending thoracic aorta; 16 of collected between 2007 and 2010 (YTX, DHL, ZRL); Department of Parasitology, these cases were related to brucellar State Key Laboratory of Veterinary Etiological in Henan province. They found that Biology, Lanzhou Veterinary Research Institute, endocarditis. In the remaining 238 (83·5%) were positive for SFTS Chinese Academy of Agricultural Sciences, 30 cases, the complication involved virus RNA, whereas only 24 (8·4%) Lanzhou, China (GYL, ZRL); and Key Laboratory of either the descending thoracic aorta or the abdominal aorta; in 13 of Confi rmed cases Misdiagnosed cases these cases, the complication was related to spondylitis of the lumbar HGA HFRS Common Gastrointestinal Respiratory Unknown fever disease disease diseases spine. The mean age of the patients 2006–11 489 266 0 11 6 3 13 was 54·2 years, the median age 2011–13 2047 24 9 0 0 0 17 of the patients 59·0 years (range Total 2536 290 9 11 6 3 30 23–80 years), and 41 (89%) of the 46 cases were in male patients. See appendix for references. HGA=human granulocytic anaplasmosis. HFRS=haemorrhagic fever with renal See Online for appendix syndrome. The mean age of the patients with abdominal or descending Table: Confi rmed and misdiagnosed cases of severe fever with thrombocytopenia syndrome in China thoracic involvement (65·5 years)

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was significantly higher than that Ebola: lessons learned and fear associated with Ebola virus of patients with ascending aortic from HIV and disease. involvement (42·5 years, p=0·0006). Third, all exposed people should This difference could be explained tuberculosis epidemics be screened for Ebola virus infection. by the high prevalence of abdominal Successful tuberculosis control aortic comorbidity in elderly people.2 Amidst concerns of Ebola virus disease programmes have included contact We recommend that patients becoming a pandemic, the global tracing of infected people and testing older than 50 years, who have medical community has mounted a exposed people. Although 87% of blood cultures positive for Brucella crucial response. As the director of west Africans with the disease had spp in addition to fever and back, the US Centers for Disease Control a fever according to a report,5 13% abdominal, or chest pain, undergo an and Prevention has said, “we have to are missed in screening algorithms extensive diagnostic test for brucellar work now so this is not the world’s relying on the presence of fever, aortic involvement and aneurysm next AIDS.”1 Although diff erent from which is not acceptable. Anybody, formation. Similarly, patients HIV/AIDS, we could apply lessons including a health worker, who is with aortic mycotic aneurysms or learned from the HIV and tuberculosis exposed to patients infected with the with pseudo-aneurysms should be epidemics to address the Ebola crisis. virus, should be tested for infection assessed for brucellosis on the basis This experience suggests four near- irrespective of the presence of of medical history (in particular, term objectives. symptoms. The availability of a rapid epidemiological characteristics), First, as with HIV, a rapid, point- Ebola test will help these eff orts, clinical signs, and symptoms as well of-care test is imperative to quickly and it could also be used to screen as by culture, serology, or molecular identify people who are infected international travellers at airports. tests, if available. Patients with with Ebola virus to reduce trans- Fourth, the protection of health- brucellar thoracic aortic involvement mission. Whereas fi rst-generation, care workers must be paramount. should undergo further screening to lab oratory-based HIV tests were Infection control practices, including exclude concomitant endocarditis, essential to confi rm disease, rapid use of personal protective equipment and patients with brucellar HIV tests enabled the widespread and isolation practices, were abdominal aortic involvement screening of asymptomatic people developed largely in tuberculosis should undergo further screening in resource-limited settings.2 As control programmes. Poor infection- to exclude concomitant spondylitis with fi rst-generation HIV tests, control practices lead to increased or abdominal or pelvic abscesses. A present diagnostic Ebola tests are transmission to health workers and converse procedure should be applied too expensive, time-consuming, and patients. As with successful tuber- in patients with endocarditis or equipment-dependent. Two com- culosis control programmes in devel- spondylitis. Anti-brucellar antibiotic panies, Senova and Corgenix, are oped countries, health workers therapy should be initiated as soon as developing rapid, fi nger-prick, whole- treating patients infected with Ebola possible, followed by an appropriate blood tests, and their eff orts should virus need full training in the use of surgical approach.2 receive strong international support.3 and access to personal protective We declare no competing interests. Second, the stigma and fear of Ebola equipment before encountering virus disease must be addressed. HIV patients, and need the capacity to *Antonio Cascio, Chiara Iaria taught us that stigma and fear drive isolate infected patients. [email protected] people away from both testing and Confronting the HIV and tuberculosis Department of Human Pathology, University of medical attention, which thereby epidemics has needed a massive, Messina, Messina 98125, Italy (AC); Infectious Diseases Unit, Azienda Ospedaliera Piemonte- perpetuates transmission. An access- coordinated response—the same will Papardo, Messina, Italy (CI); and Associazione ible test does not automatically be needed for Ebola virus disease. Italiana per la Lotta contro le Malattie Infettive translate into people tested—54% of However, our collective experience (Italian Association for the Control of Infectious Diseases), University of Messina, Messina 98125, HIV-infected people worldwide are still with HIV and tuberculosis has shown Italy (AC, CI) unaware of their status.4 If perceived that such a response is possible. 1 Herrick JA, Lederman RJ, Sullivan B, Powers fears outweigh perceived benefi ts, the I am supported by the Harvard Global Health JH, Palmore TN. Brucella arteritis: clinical erection of treatment centres might Institute, the Fogarty International Clinical Research manifestations, treatment, and prognosis. not benefi t the people who need Scholars and Fellows Program at Vanderbilt Lancet Infect Dis 2014; 14: 520–26. University (R24 TW007988), the Infectious Disease 2 Cascio A, De Caridi G, Lentini S, et al. care. For HIV, stigma and fear have Society of America Education and Research Involvement of the aorta in brucellosis: the been addressed through information Foundation and National Foundation for Infectious forgotten, life-threatening complication. A Diseases, The Program in AIDS Clinical Research systematic review. Vector Borne Zoonotic Dis campaigns, peer education, and access 2012; 12: 827–40. Training Grant (T32 AI007433), the National to therapy—the same is likely to be Institute of Allergy and Infectious Disease of the necessary to eradicate the stigma National Institutes of Health (K23 AI108293), the

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