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Abstract Pultorak, Elizabeth Lauren ABSTRACT PULTORAK, ELIZABETH LAUREN. The Epidemiology of Lyme Disease and Bartonellosis in Humans and Animals. (Under the direction of Edward B. Breitschwerdt). The expansion of vector borne diseases in humans, a variety of mammalian hosts, and arthropod vectors draws attention to the need for enhanced diagnostic techniques for documenting infection in hosts, effective vector control, and treatment of individuals with associated diseases. Through improved diagnosis of vector-borne disease in both humans and animals, epidemiological studies to elucidate clinical associations or spatio-temporal relationships can be assessed. Veterinarians, through the use of the C6 peptide in the SNAP DX test kit, may be able to evaluate the changing epidemiology of borreliosis through their canine population. We developed a survey to evaluate the practices and perceptions of veterinarians in North Carolina regarding borreliosis in dogs across different geographic regions of the state. We found that veterinarians’ perception of the risk of borreliosis in North Carolina was consistent with recent scientific reports pertaining to geographic expansion of borreliosis in the state. Veterinarians should promote routine screening of dogs for Borrelia burgdorferi exposure as a simple, inexpensive form of surveillance in this transitional geographic region. We next conducted two separate studies to evaluate Bartonella spp. bacteremia or presence of antibodies against B. henselae, B. koehlerae, or B. vinsonii subsp. berkhoffii in 296 patients examined by a rheumatologist and 192 patients with animal exposure (100%) and recent animal bites and scratches (88.0%). Among 296 patients examined by a rheumatologist, prevalence of antibodies (185 [62%]) and Bartonella spp. bacteremia (122 [41.1%]) was high. In the population exposed to animal bites and scratches, we documented Bartonella spp. seroreactivity or bacteremia in 49.5% (n=95) and 23.9% (n=46) of the patients, respectively. In both studies, serology, in conjunction with blood, serum, and BAPGM enrichment culture PCR, facilitated the diagnosis of Bartonella spp. bacteremia. Patients in both studies frequently reported symptoms including fatigue, sleeplessness, joint pain, and muscle pain. However, neither study can establish a causal link between Bartonella spp. infection and these symptoms in our populations. In our rheumatology population, B. henselae bacteremia was significantly associated with prior referral to a neurologist, most often for blurred vision, subcortical neurologic deficits, or numbness in the extremities, whereas B. koehlerae bacteremia was associated with examination by an infectious disease physician. The contribution of Bartonella spp. infection to these symptoms should be systematically investigated. Due to low levels of bacteremia in nonreservoir-adapted hosts, which result in diagnostically low levels of circulating bacteria in the bloodstream at a given point in time, Bartonella detection at a single time point may result in false negatives. Therefore, we next sought to determine if the testing of specimens collected serially over a 1-week period significantly improved PCR documentation of Bartonella bacteremia in human patients compared to the testing of specimens from a single time point. Detection was improved when patients were tested three times within a one week period (OR = 3.4 [1.2-9.8]; p = 0.02). Obtaining three sequential blood samples during a one-week period should be considered as a diagnostic approach when bartonellosis is suspected. Finally, based upon the established oncogenic properties of Bartonella, we hypothesized that Bartonella spp. can be molecularly detected in canine cutaneous histiocytoma (CCH) and can be localized within skin neoplasms using indirect immunofluorescence (IIF). There were no significant differences in the prevalence of Bartonella spp. between our CCH group and controls (p=0.63), and Bartonella was identified in only 2/4 (50.0%) CCH tissues using IIF. Bartonella spp. are unlikely to cause CCH. Though Bartonella can be visualized in CCH using IIF, cellular localization of Bartonella within the skin has reduced sensitivity due to low organism load, a limitation well-supported by previous attempts by our laboratory to localize the bacterium in various tissues and lesions. © Copyright 2014 by Elizabeth Lauren Pultorak All Rights Reserved The Epidemiology of Lyme Disease and Bartonellosis in Humans and Animals by Elizabeth Lauren Pultorak A dissertation submitted to the Graduate Faculty of North Carolina State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy Comparative Biomedical Science Raleigh, North Carolina 2014 APPROVED BY: _______________________________ ______________________________ Edward B. Breitschwerdt Ricardo G. Maggi Committee Chair ________________________________ ______________________________ Adam Birkenheuer Matthew Breen DEDICATION To my sweet boy, little lady, and dear husband. ii BIOGRAPHY Elizabeth received her Bachelor of Science in Molecular and Cell Biology from the University of Illinois, Urbana-Champaign and her Master of Science in Epidemiology and Biostatistics from the University of Illinois, Chicago. iii ACKNOWLEDGMENTS I would like to thank my entire research committee team for their support and encouragement during my PhD. Thank you to Dr. Ed Breitschwerdt for taking a chance on a kid from the Midwest with zero benchwork expertise. Dr. Breitschwerdt allowed me to grow into my role as infectious disease epidemiologist and placed an exceptional amount of confidence in my abilities even when I did not feel as confident. I would also like to thank my other committee members, Dr. Adam Birkenheuer, Dr. Ricardo Maggi, and Dr. Matthew Breen, for their advice, encouragement, and technical expertise, and for pushing me to think a little bit harder when the going got lazy. Thank you to all current and former members of the Vector Borne Disease and Diagnostic Laboratory and the Intracellular Pathogens Research Laboratory, including Julie Bradley, Pat Faw, Jackie York, Brittany Thomas, Natalie Cherry, Barbara Qurollo, Barbara Hegarty, Mrudula Varanat, and Patricia Mascarelli. My sincerest gratitude goes out to my fellow labmate, Nandhakumar Balakrishnan, who taught me how to use a pipette and gave me many words of encouragement. Thank you to Dr. Maria Correa for helping me get started at NC State, the entire Breen lab, especially Katie Kennedy and Christina Williams, for their patience and understanding while I learned to not constantly panic during bench work, and Dr. Marna Erickson, for her hospitality and confocal expertise. Special thanks to all the people that helped make our office a little sunnier, including Neal Sontakke, Alaire Comyn, Chelsea Trull, Brian Cerrito, and Dana Riggins. I would also like to thank the Major lab at UNC Lineberger, who played no role in the actual success of my PhD, but sure did help make the journey a little more fun. I would also like to profoundly iv thank my dear husband, Matt Walker, PhD Extraordinaire, for his unwavering support and encouragement, never-ending pick-me-ups when things failed, and inspiration to finish. Thank you to my wonderful parents and brother who have taught me the art of ‘focus, organization, and discipline’ while remembering to have fun. Thank you to my beautiful dog, Egg, for all the tacos and slumber parties. Last, but certainly not least, to my mind-blowingly cool son, George Robert, who inspires me to be a better person each day. I love you all. v TABLE OF CONTENTS LIST OF TABLES .............................................................................................................. x LIST OF FIGURES .......................................................................................................... xii CHAPTER 1. EPIDEMIOLOGY OF LYME DISEASE AND BARTONELLOSIS IN HUMANS AND ANIMALS .............................................................................................. 1 Lyme Disease .................................................................................................................. 2 Introduction ..................................................................................................................................................... 2 Lifecycle ............................................................................................................................................................. 3 Vectors .............................................................................................................................................................................. 3 Hosts .................................................................................................................................................................................. 5 Molecular and Cellular Characteristics ................................................................................................. 6 Bacterial proteins ........................................................................................................................................................ 7 Lipoproteins ............................................................................................................................................................. 7 Outer surface proteins (Osps) .......................................................................................................................... 8 Animal Models ................................................................................................................................................
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