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Home , Clostridium, Corynebacterium, Neisseria gonorrhoeae, Pseudomonas aeruginosa, Shigella flexneri, Shigella sonnei

Martin J. O'Malley Anthony G. Brown Governor Lt. Governor

A Publication of the Maryland Department of Health and Mental Hygiene Joshua M. Sharfstein, M.D. Secretary

The Laboratories Administration—Maryland’s State Public Health Laboratory

also been reported Laboratory in 2010.1 Other less common tick-borne Diagnosis of in the United States Tick-borne include tick-borne relapsing (TBRF) and Diseases Rickettsia phillipi, proposed. Health care providers Ticks can harbor should consider and test for these more than one in patients with -causing compatible syndromes. A history Figure 1: Vectors for ; the blacklegged tick, Ixodes agent and diagnosis scapularis. From left, an adult female, an adult male, a nymph, of a tick bite is not and a larva. Photo credit: CDC PHIL can be difficult necessarily a prerequisite for the inclusion of these part of the human body. In most cases, diseases in the differential diagnosis Tick-borne illnesses are caused by a the tick must be attached for 36-48 hours for patients with compatible illness. variety of , including rickettsia or more before the Lyme disease , viruses, and protozoa. Since bacterium can be transmitted. ticks can harbor more than one disease- Lyme Disease Characteristic of early localized disease causing agent, patients can be infected is the presence of a skin (Figure 2.) with more than one at the same Lyme disease is caused by a spirochete migrans (EM) is a skin lesion time, compounding the difficulty in Borrelia burgdorferi. The vector that (Continued on page 2) diagnosis and treatment. The incidence carries B. burgdorferi in the U.S. Mid- varies by geographic location and atlantic, Northeast, and North Central causative agent. The most common tick- states is the blacklegged tick (also known borne disease in Maryland and also in as the deer tick) Ixodes scapularis USA is Lyme disease (LD), but cases of (Figure 1.) Rocky Mountain (RMSF), October 2011 Babesiosis, (human The tick goes through three life stages. granulocytic anaplasmosis HGA or The larva hatch from eggs and molt into HGE), and (human the nymph stage, which develops into Volume 15, Number 10 monocytic ehrlichiosis or HME) have the adult stage. Ticks can attach to any Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Page 1 PRODUCTION MANAGER

Georgia Corso

EDITORIAL BOARD Figure 2: Lyme Disease Erythema Migran (EM) Photo credit: CDC PHIL Prince Kassim, Ph.D. Fizza Majid, Ph.D. (Continued from page 1) Robert Myers, Ph.D. Laboratory Diagnosis of Diagnosis of early-stage localized Lyme Maria Paz Carlos, DVM, Ph.D. Tick Borne Diseases disease can be made on the basis of EM alone without any additional laboratory Jafar Razeq, Ph.D. with a bull’s-eye pattern that develops at confirmatory testing.2 Early/late stage Jim Svrjcek, B.A. the site of the tick bite; it is usually disseminated disease requires laboratory present 7 to14 days after the tick bite confirmation. Laboratory confirmation Chengru Zhu, Ph.D. and should be around 5 cm diameter for requires demonstration of antibodies to a firm Lyme disease diagnosis.2 B. burgdorferi in serum or CSF. A two- test approach using a sensitive LABORATORIES ADMINISTRATION Disseminated disease that may affect the immunoassay (EIA) or immunofluores- musculoskeletal, cardiac, or nervous cence antibody test followed by Western system can follow EM within days or Blot (WB) is highly recommended. Director weeks, and is considered early-stage Follow-up testing of a positive or disseminated disease. Lyme carditis may equivocal EIA with a WB test is Robert Myers, Ph.D. overlap temporally with neurologic recommended by the Centers for Lyme disease (late-stage disseminated Disease Control and Prevention and the disease.) (Continued on page 3) TECHNICAL QUESTIONS Figure 3: Two-tiered serology testing for Lyme disease as recommended by the CDC. 4 National Center for Emerging and Zoonotic Infectious Diseases, Division of Vector Borne Diseases, Bacterial Diseases Branch. Questions concerning technical content of this newsletter Second Test may be referred to First Test Second Test Dr. Robert Myers at 410-767-6100 Enzyme Positive or Signs or IgM and IgG Immunoassay (EIA) Equivocal Result symptoms ≤ Western Blot 30 days The Critical Link is published monthly OR Immunofluores- by the staff of the Negative Result cence Assay (IFA) Laboratories Administration Signs or IgG Western Blot ONLY Department of Health & Mental Hygiene symptoms > 30 days 201 W. Preston Street Consider alternative diagnosis Baltimore, Maryland 21201 OR (Phone 410-767-6909) If patient has signs/symptoms consistent with Lyme disease for ≤ 30 days, consider obtaining a convalescent serum

Page 2 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Figures 5 and 6: Dermacentor andersoni, or wood tick, above and Der- macentor variabilis, or dog tick, below. The RMSF distribution in the U.S. by different tick . Yellow indicates the approximate distri- bution area. Photo credit: CDC PHIL

Figure 4: Blacklegged ticks can feed from mammals, , rep- tiles, and amphibians. The ticks need to have a new at each stage of their life, as shown above. Graphic credit: http://www.cdc.gov/ lyme/transmission/blacklegged.html

(Continued from page 2) results, so physicians should be headache, abdominal pain, vomiting, Laboratory Diagnosis of informed of all patient medications prior and muscle pain. A rash may also Tick Borne Diseases to testing. The polymerase chain develop, but is often absent in the first reaction (PCR) test detects the DNA of few days. However in some patients, Association of State and Territorial the bacteria that causes Lyme disease. It may never develop. RMSF can be a Public Health Laboratory Directors.3 is sometimes used for patients who have severe or even fatal illness if not treated Lyme IgM Western blot should not be neurological symptoms or Lyme in the first few days of symptoms. The used to diagnose any condition less than arthritis. The PCR test is performed on initial diagnosis is made based on one month in duration due to the high spinal fluid collected from a lumbar clinical signs and symptoms, as well as rate of false positives. puncture (spinal tap) or synovial fluid and medical history, and can later be (collected from an affected joint.) For confirmed serologically with a four-fold The interpretation of WB antibody most patients, standard antibody rise in titer by immunofluorescent assays is based on the number of tests are preferred. antibody (IFA.) Antibody titers of 1:64 positive bands: two of three bands (23, are considered evidence of current or 39, 41kDa) for IgM indicate positivity past infections. A four-fold increase of and five out of ten bands (18, 23, 28, 30, Rocky Mountain Spotted titers at a three week interval 39, 41, 45, 58, 66, or 93 kDa) for IgG Fever (RMSF) demonstrates an active .4 No positivity. The WB is to be used only microbiological or immunological tests following initial EIA testing, and are sensitive enough to exclude the positive results confirm B. burgdorferi RMSF is a potentially fatal human diagnosis of RMSF within the time infection. Other spirochete diseases, illness caused by . It frame of emergency evaluation and such as and , can is transmitted to humans by the bite of management. The decision to administer cause false positive results, as well as an infected dog tick, Demacentor should be based on history, other disease conditions such as HIV variabilis, or wood tick, Dermacentor physical examination, and clinical infection, mononucleosis, and a variety andersoni (Figures 5 and 6) or a brown suspicion, not confirmatory tests. of other autoimmune diseases. dog tick, Rhipicephalus sanguineus. Typical symptoms include fever, Antibiotics can interfere with the test (Continued on page 4)

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Page 3 In contrast, HME is caused by (Figure 10) which infects monocytes. HME is transmitted to humans by the lone star tick, Figure 9: The lone star tick, Ambylomma americanum is found in south- Ambylomma eastern U.S. Photo credit: CDC PHIL americanum

Photo Courtesy of CDC (Figure 9.) HGA and HME have the Figure 7: Human granulocytic ehrlichiosis same clinical manifestations. Therefore, A positive immunofluorescence assay (HGE.) Photo credit: CDC PHIL the term ehrlichiosis is used for both (titer great than or equal to 1:64) types of infections. The total duration of suggests current or previous infection. In illness for HME and HGA is unknown. general, the higher the titer, the more No chronic cases have been reported at likely the patient has an active infection. (Continued from page 3) this time. Four-fold rises in titer also indicate Laboratory Diagnosis of active infection. The diagnosis of HME Tick Borne Diseases Infectious forms are injected during tick or HGA rests on either a single elevated bites and the enters the immunoglobulin G (IgG) antibody (IFA) vascular system where it infects titer or the demonstration of a four-fold Ehrlichiosis monocytes. It is sequestered in host- or greater increase between acute and membrane-limited parasitophorous convalescent IFA titers.5 Serology may vacuoles known as morulae. These can not be helpful in the acute phase of Ehrlichiosis is an infection caused by be readily observed on Giemsa- or illness, and molecular methods, PCR, obligate intracellular, gram-negative Wright's-stained smears of peripheral are recommended in conjunction with rickettsia that infects leukocytes. Human blood from infected persons. IFA. PCR testing should be done on granulocytic anaplasmosis (HGA), whole blood drawn during the first week formerly known as human granulocytic Most cases of ehrlichiosis are probably of symptoms and prior to ehrlichiosis (HGE) is caused by subclinical or mild, but the infection can treatment. Identification of morulae in Anaplasma phagocytophilum, which be severe and life-threatening; there is a leukocytes or culture can also be used to infect granulocytes (Figure 7.) 2% to 3% mortality rate. Fever, fatigue, document infection.5 malaise, headache, and other "flu-like" HGA is transmitted by deer ticks (Ixodes symptoms occur most commonly. Figure 8.) The deer mouse is the Central nervous system involvement can reservoir and, overall, the epidemiology result in and coma. Leukopenia, is very much like that of Lyme disease , and elevated hepatic and babesiosis. transaminases are frequent laboratory findings.

Diagnosis is based on detection of a four-fold rise in antibody levels by IFA. Blood specimens should be Figure 10: Human monocytic Erlichiosis drawn at (HME) caused by Ehrlichia chaffeensis and Figure 8: Ixodes scapularis, also called the blacklegged tick or deer tick, least two transmitted by the lone star tick. transmits Human granulocytic anaplasmosis (HGA). Green indicates it's approximate geographic distribution in the U.S. Photo credit: CDC PHIL weeks apart.

Page 4 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Babesiosis The services and Babesiosis is caused by an intra Tularemia occurs throughout the U.S. facilities of the erythrocytic protozoon in the Tularemia is caused by the bacterium Maryland Babesia. Babesia microti is responsible . The disease can for the vast majority of human cases in be transmitted through several routes, Department of the United States.6 Babesia microti including: Health and Mental shares a tick vector with the causative Hygiene (DHMH) agents of Lyme disease and HGA, the 1. Tick and deer fly bites; are operated on a deer tick (Ixodes). The majority of 2. Skin contact with infected ; patients with babesiosis have a mild 3. Ingestion of contaminated water; non-discriminatory illness or are asymptomatic, but some 4. Inhalation of contaminated dusts or basis. This policy develop a severe illness that may result aerosols by laboratory exposure; or prohibits discrimina- in death. Patient symptoms may include 5. As a result of bioterrorism. tion on the basis of fever, chills, extreme fatigue, and severe age; ancestry; color; anemia. Symptoms are easily confused Symptoms vary depending upon the with those of Lyme disease. route of infection. Although tularemia creed; marital can be life-threatening, most infections status; mental or can be treated successfully with physical disability; antibiotics. national origin;

Presumptive diagnosis is made based on race; religious a history of exposure to a tick-endemic affiliation, belief, or region and clinical signs and symptoms. opinion; sex; or Serological testing can aid in sexual orientation establishing a definitive diagnosis. The and plies to the organism is often not present in large Figure 11 and 12: Intraerythrocytic B. mi- provisions of croti, showing the Maltese cross, tetrade numbers in blood or and is form without pigment. Photo credit: CDC PHIL therefore difficult to cultivate. It is employment and important to inform the laboratory staff granting of if tularemia is suspected as a differential advantages, diagnostic possibility, because the organism can grow on normal culture privileges and media. Culture isolation of the organism accommodations. should only be performed under a Bio-Safety Level 3 facility. A four-fold The Department, increase in the titer or a single titer of in compliance with 1:160 or more is the common threshold, although this varies with the laboratory. the Americans The methods of testing vary from with Disabilities Diagnosis of this infection with antibody detection by latex agglutination Act, ensures that traditional methods is often difficult or enzyme-linked immunosorbent assay qualified because in both early acute and (ELISA) testing to a range of PCR individuals with persistent disease, is often products that directly measure DNA from the .7 disabilities are given slight and organisms are often difficult to visualize on peripheral blood smears. an opportunity to Antibody testing is useful for Testing Results participate in and confirmation of babesiosis, but is not in the Laboratories benefit from DHMH widely available and also may be services, programs, negative in the early phase of illness. Administration The definitive laboratory diagnosis of benefits, and babesiosis rests on the demonstration From 2007 to 2011, the Laboratories employment of Babesia microti characteristic Administration has analyzed 3,050 opportunities. intraerythrocytic inclusions in Giemsa samples for Lyme, 720 samples for stained thin blood films (Figures 11 Ehrlichiosis, and 461 samples for and 12). (Continued on page 6)

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Page 5 (Continued from page 5) serodiagnosis for tick-borne diseases. other health-care and public health professionals. Laboratory Diagnosis of For information on laboratory tests MMWR Recomm Rep. Mar 31 2006; 55(RR-4):1- 27. www.ncbi.nlm.nih.gov/pubmed/16572105 Tick Borne Diseases available for tick-borne diseases, contact the Microbial Serology section at 3 CDC. Recommendations for test performance RMSF. In 2010 alone, 25 cases of 410-767-6159 and check our website and interpretation from the Second National Anaplasmosis (HGA), 19 cases of http://dhmh.maryland.gov/labs/. Conference on Serologic Diagnosis of Lyme Disease. MMWR 1995; 44:590-1.

Babesiosis, 17 cases of HME Ehrlichiosis, 1,617 cases of Lyme This article written by Dr. Leena Trivedi 4 CDC website www.cdc.gov/lyme/healthcare/ disease, and 48 cases of RMSF were clinician_twotier.html reported in Maryland.1 Health care References 5 CDC website Ehrlichiosis. www.cdc.gov/ providers should consider appropriate ehrlichiosis 1 laboratory testing for diagnosis of tick- Datasource Maryland: borne diseases. The selection of http://ideha.dhmh.maryland.gov/pdf/ 6 CDC website www.cdc.gov/parasites/babesiosis/ counts_rates/2010Summary_PrintCriteria_Counts_ laboratory diagnostic test strategies gen_info/index.html FINAL.pdf should also take into account the 7 Matero P, Hemmila H, Tomaso H, et al. Rapid 2 geographic location of the patient and Chapman AS, Bakken JS, Folk SM, Paddock CD, field detection assays for anthracis, the type of specimen. The Division of Bloch KC, Krusell A. Diagnosis and management Brucella spp., Francisella tularensis and Yersinia of tickborne rickettsial diseases: Rocky Mountain Virology and Immunology of the pestis. Clin Microbiol Infect. Jan 2011; 17(1): spotted fever, ehrlichioses, and anaplasmosis-- 34-43. Laboratories Administration provides United States: a practical guide for physicians and

CAMPYLOBACTER JEJUNI CAMPYLOBACTER SPECIES PRESENT. M 3 1 ALLEGANY SENT TO CDC FOR IDENTIFICATION. M 29 1 ALLEGANY F 70 1 BALTIMORE F 1 1 ALLEGANY , O157:H7 F 60 1 ALLEGANY F 30 1 BALTIMORE CITY F 22 1 ANNE ARUNDEL F 8 1 BALTIMORE CITY F 26 1 ANNE ARUNDEL F 8 1 FREDERICK

M 45 1 ANNE ARUNDEL F 2 1 WASHINGTON F 77 1 ANNE ARUNDEL SALMONELLA F 64 1 BALTIMORE U 2 1 ANNE ARUNDEL U 59 1 BALTIMORE F 5 1 BALTIMORE F 49 1 BALTIMORE F 86 1 BALTIMORE F 28 1 BALTIMORE F 41 1 BALTIMORE M 37 1 BALTIMORE U 3 1 BALTIMORE M 20 1 BALTIMORE F 53 1 BALTIMORE M 7 1 BALTIMORE M 68 1 BALTIMORE M 53 1 BALTIMORE M 22 1 BALTIMORE Reported by the M 42 1 BALTIMORE U 20 1 BALTIMORE CITY Reported by the M 22 1 BALTIMORE M 5 1 BALTIMORE CITY Laboratories Administration F 71 2 BALTIMORE CITY U 20 1 BALTIMORE CITY F 41 1 BALTIMORE CITY M 35 1 FREDERICK covering results from the month of F 25 1 CHARLES F 26 1 HARFORD M 57 1 HARFORD F 16 1 MONTGOMERY F 4 1 HARFORD F 79 1 OUT OF STATE AUGUSTAUGUST 20112011 F 35 1 HARFORD M 17 1 OUT OF STATE F 17 1 OUT OF STATE F 53 1 OUT OF STATE F 15 1 OUT OF STATE F 49 1 OUT OF STATE F 55 1 OUT OF STATE F 20 1 OUT OF STATE ENTERIC M 19 1 OUT OF STATE U 68 1 OUT OF STATE F 26 1 OUT OF STATE F 3 1 OUT OF STATE GENUS SEROVAR U 64 1 OUT OF STATE F 53 1 WASHINGTON SEX AGE # JURISDICTION U 53 1 OUT OF STATE SALMONELLA SER. 4,12:I:- F 42 1 OUT OF STATE U 81 1 CARROLL CAMPYLOBACTER M 60 1 OUT OF STATE U 81 1 CARROLL F 46 1 ALLEGANY M 49 1 OUT OF STATE SALMONELLA SER. 4,5,12:I:- M 3 1 BALTIMORE M 42 1 OUT OF STATE F 48 1 BALTIMORE CITY M 0 1 BALTIMORE F 55 1 TALBOT U 72 1 CARROLL F 32 1 OUT OF STATE F 49 1 TALBOT F 1 1 OUT OF STATE M 11 1 OUT OF STATE

Page 6 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 U 6 1 WASHINGTON F 7 1 OUT OF STATE M 7 1 OUT OF STATE M 58 1 WICOMICO F 30 1 OUT OF STATE M 1 1 OUT OF STATE SALMONELLA SER. ABERDEEN F 21 1 OUT OF STATE M 0 1 OUT OF STATE F 0 1 OUT OF STATE M 54 1 OUT OF STATE M 0 1 OUT OF STATE SALMONELLA SER. BAREILLY F 0 1 WICOMICO F 35 1 PRINCE GEORGE'S F 32 1 BALTIMORE M 0 1 WICOMICO F 52 1 PRINCE GEORGE'S SALMONELLA SER. ENTERITIDIS F 30 30 WORCESTER F 46 1 TALBOT F 68 1 ANNE ARUNDEL SALMONELLA SER. MUENCHEN F 35 1 TALBOT M 58 1 ANNE ARUNDEL F 19 1 MONTGOMERY F 2 1 WICOMICO F 62 1 ANNE ARUNDEL SALMONELLA SER. NEWPORT SALMONELLA SER. UNTYPEABLE M 48 1 BALTIMORE M 46 1 ANNE ARUNDEL M 57 1 CHARLES F 24 1 BALTIMORE F 59 1 BALTIMORE FLEXNERI M 24 1 BALTIMORE F 4 1 BALTIMORE M 84 1 BALTIMORE CITY F 60 1 BALTIMORE M 53 1 BALTIMORE M 34 1 BALTIMORE CITY M 4 1 BALTIMORE U 2 1 BALTIMORE CITY M 67 1 PRINCE GEORGE'S F 37 1 BALTIMORE F 55 1 KENT F 68 1 BALTIMORE M 55 1 KENT F 48 1 BALTIMORE F 61 1 BALTIMORE CITY F 43 1 OUT OF STATE U 51 1 BALTIMORE CITY M 58 1 BALTIMORE CITY F 20 1 OUT OF STATE F 8 1 MONTGOMERY F 31 1 BALTIMORE CITY F 4 1 OUT OF STATE U 7 1 MONTGOMERY U 84 1 BALTIMORE CITY M 24 1 OUT OF STATE U 18 1 MONTGOMERY F 53 2 BALTIMORE CITY F 66 1 OUT OF STATE M 5 1 MONTGOMERY F 38 1 BALTIMORE CITY F 35 1 OUT OF STATE M 12 1 OUT OF STATE M 32 1 BALTIMORE CITY F 22 1 OUT OF STATE F 10 1 PRINCE GEORGE'S F 25 1 BALTIMORE CITY M 0 1 OUT OF STATE F 61 1 OUT OF STATE M 75 1 BALTIMORE CITY F 47 1 WICOMICO M 10 1 OUT OF STATE U 48 1 BALTIMORE CITY M 80 1 WICOMICO VULNIFICUS M 52 1 BALTIMORE CITY M 47 1 WICOMICO F 15 1 CALVERT U 0 1 BALTIMORE CITY F 33 1 WICOMICO F 28 1 CECIL M 45 1 WICOMICO TOTAL 254 M 53 1 FREDERICK M 5 1 WICOMICO M 58 1 FREDERICK M 71 1 WICOMICO F 41 1 HARFORD SALMONELLA SER. NORWICH ISOLATES - MISCELLANEOUS M 60 1 HARFORD F 0 2 ANNE ARUNDEL F 85 1 MONTGOMERY F 1 1 OUT OF STATE GENUS SPECIES M 52 1 MONTGOMERY F 0 1 OUT OF STATE SOURCE # JURISDICTION F 2 1 OUT OF STATE SALMONELLA SER. ORANIENBURG SORDELLII F 2 1 OUT OF STATE M 11 1 BALTIMORE BLOOD 1 BALTIMORE CITY F 50 1 OUT OF STATE SALMONELLA SER. PARATYPHI A ACCOLENS F 1 1 OUT OF STATE M 2 3 BALTIMORE CITY BLOOD 1 BALTIMORE CITY F 0 1 OUT OF STATE SALMONELLA SER. PARATYPHI B FAECALIS M 3 1 OUT OF STATE F 67 3 BALTIMORE BLOOD 1 BALTIMORE CITY M 48 1 OUT OF STATE F 27 1 OUT OF STATE 1 PRINCE GEORGE'S F 64 1 OUT OF STATE F 35 1 PRINCE GEORGE'S ESCHERICHIA COLI F 82 1 OUT OF STATE SALMONELLA SER. SAINTPAUL BLOOD 2 BALTIMORE CITY F 56 1 OUT OF STATE F 64 1 OUT OF STATE ESCHERICHIA SPECIES F 25 1 OUT OF STATE M 13 1 OUT OF STATE BLOOD 1 BALTIMORE CITY F 37 1 OUT OF STATE M 39 1 PRINCE GEORGE'S M 23 1 OUT OF STATE SALMONELLA SER. THOMPSON VAGINAL 5 PRINCE GEORGE'S M 12 1 UNKNOWN M 48 1 OUT OF STATE GRAM-NEGATIVE BACILLUS F 72 1 UNKNOWN M 59 1 WICOMICO URINE 1 HOWARD F 37 1 WASHINGTON SALMONELLA SER. TYPHIMURIUM F 11 1 WASHINGTON F 48 1 ANNE ARUNDEL BLOOD 1 BALTIMORE CITY F 39 1 WASHINGTON U 39 1 BALTIMORE LACTOBACILLUS SPECIES URINE 1 ANNE ARUNDEL F 36 1 WASHINGTON F 1 1 BALTIMORE URINE 1 HARFORD F 82 1 WICOMICO U 22 1 BALTIMORE SALMONELLA SER. HEIDELBERG F 2 1 BALTIMORE CITY 1 CARROLL M 20 1 OUT OF STATE M 43 1 CALVERT AERUGINOSA SALMONELLA SER. JAVIANA M 71 1 CARROLL BLOOD 1 BALTIMORE CITY F 3 1 ANNE ARUNDEL U 1 1 FREDERICK WOUND 1 CARROLL F 35 1 ANNE ARUNDEL F 0 2 FREDERICK F 33 1 ANNE ARUNDEL M 11 1 FREDERICK BLOOD 1 BALTIMORE CITY F 47 1 BALTIMORE M 34 1 MONTGOMERY AUREUS F 46 1 BALTIMORE CITY M 1 1 MONTGOMERY BLOOD 2 BALTIMORE CITY F 32 1 OUT OF STATE F 1 1 OUT OF STATE CSF 2 BALTIMORE CITY M 4 1 OUT OF STATE M 13 2 OUT OF STATE PENIS 1 BALTIMORE CITY

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Page 7 WOUND 1 CARROLL M 16 BALTIMORE ABSCESSUS WOUND 1 CARROLL U 2 BALTIMORE F 81 1 OUT OF STATE VAGINAL 1 PRINCE GEORGE'S F 11 BALTIMORE CITY MYCOBACTERIUM AVIUM COMPLEX WOUND 1 PRINCE GEORGE'S M 22 BALTIMORE CITY F 78 1 ANNE ARUNDEL SPUTUM 1 WASHINGTON U 3 BALTIMORE CITY F 35 1 BALTIMORE STAPHYLOCOCCUS EPIDERMIDIS F 5 CALVERT F 38 1 BALTIMORE BLOOD 1 BALTIMORE CITY M 6 CALVERT F 88 1 BALTIMORE STAPHYLOCOCCUS, F 1 CAROLINE F 90 1 BALTIMORE NEGATIVE F 3 CARROLL M 58 1 BALTIMORE CSF 1 BALTIMORE CITY M 2 CARROLL F 21 1 BALTIMORE CITY WOUND 1 CARROLL F 1 CECIL F 41 1 BALTIMORE CITY M 4 CECIL F 50 1 BALTIMORE CITY BETA HEMOLYTIC GROUP A F 7 CHARLES F 61 1 BALTIMORE CITY THROAT 1 ALLEGANY M 5 CHARLES F 82 1 BALTIMORE CITY STREPTOCOCCUS F 1 DORCHESTER M 70 2 BALTIMORE CITY BETA HEMOLYTIC GROUP B F 9 FREDERICK F 69 1 CALVERT VAGINAL 2 ANNE ARUNDEL M 3 FREDERICK M 62 2 CALVERT VAGINAL 2 PRINCE GEORGE'S U 1 FREDERICK F 86 2 FREDERICK VAGINAL 4 PRINCE GEORGE'S F 1 GARRETT F 71 1 PRINCE GEORGE'S STREPTOCOCCUS INTERMEDIUS M 1 GARRETT M 31 2 PRINCE GEORGE'S BLOOD 1 BALTIMORE CITY F 9 HARFORD F 46 1 TALBOT M 3 HARFORD M 35 1 WASHINGTON BLOOD 1 BALTIMORE CITY F 2 HOWARD F 80 1 WICOMICO M 4 HOWARD M 60 2 WICOMICO BLOOD 2 BALTIMORE CITY F 3 KENT M 72 1 WICOMICO TWO OR MORE ORGANISMS M 1 KENT NO FURTHER WORK-UP IS INDICATED F 16 MONTGOMERY F 57 1 CALVERT BLOOD 1 BALTIMORE CITY M 2 MONTGOMERY MYCOBACTERIUM CSF 1 BALTIMORE CITY F 56 PRINCE GEORGE'S FORTUITUM COMPLEX 1 BALTIMORE CITY M 56 PRINCE GEORGE'S F 47 1 BALTIMORE F 6 QUEEN ANNE'S F 21 1 BALTIMORE CITY TOTAL 49 F 4 SAINT MARY'S F 24 2 MONTGOMERY M 3 SAINT MARY'S F 76 1 MONTGOMERY F 4 SOMERSET F 85 1 OUT OF STATE F 3 TALBOT MYCOBACTERIUM GORDONAE SEXUALLY TRANSMITTED DISEASES M 1 TALBOT M 20 1 ANNE ARUNDEL F 5 WASHINGTON F 71 1 BALTIMORE GENUS SPECIES M 5 WASHINGTON F 41 1 BALTIMORE CITY SEX # JURISDICTION F 14 WICOMICO M 67 1 BALTIMORE CITY M 10 WICOMICO F 83 1 FREDERICK SYPHILIS SEROLOGY F 4 WORCESTER M 48 1 FREDERICK F 1 ANNE ARUNDEL M 2 WORCESTER M 41 1 OUT OF STATE M 3 ANNE ARUNDEL M 25 5 PRINCE GEORGE'S M 32 1 PRINCE GEORGE'S F 3 BALTIMORE TOTAL 386 M 80 3 PRINCE GEORGE'S M 5 BALTIMORE M 72 1 WICOMICO F 14 BALTIMORE CITY GONORRHOEAE MYCOBACTERIUM KANSASII M 13 BALTIMORE CITY F 2 DORCHESTER F 45 1 BALTIMORE CITY M 1 DORCHESTER M 1 DORCHESTER F 3 MONTGOMERY M 1 HOWARD F 41 1 CALVERT M 17 MONTGOMERY M 1 MONTGOMERY M 70 1 CALVERT F 5 PRINCE GEORGE'S F 3 PRINCE GEORGE'S MYCOBACTERIUM SCROFULACEUM M 34 PRINCE GEORGE'S M 13 PRINCE GEORGE'S M 60 1 BALTIMORE U 1 PRINCE GEORGE'S F 1 WICOMICO MYCOBACTERIUM M 1 SAINT MARY'S M 1 WICOMICO M 45 1 BALTIMORE M 2 WASHINGTON M 75 1 BALTIMORE F 1 WICOMICO TOTAL 23 M 1 WICOMICO M 31 1 BALTIMORE CITY M 1 WORCESTER M 59 1 BALTIMORE CITY M 61 1 BALTIMORE CITY

MYCOBACTERIOLOGY M 91 1 CALVERT TOTAL 106 M 41 1 MONTGOMERY

ISOLATE M 51 1 MONTGOMERY TRACHOMATIS SEX AGE # JURISDICTION F 44 1 OUT OF STATE F 1 ALLEGANY F 45 1 OUT OF STATE M 2 ALLEGANY ACID-FAST SEEN. M 36 1 OUT OF STATE F 27 ANNE ARUNDEL M 61 1 HOWARD M 38 1 OUT OF STATE M 11 ANNE ARUNDEL ACID-FAST BACILLUS M 44 1 OUT OF STATE U 1 ANNE ARUNDEL M 36 1 MONTGOMERY M 56 1 OUT OF STATE F 27 BALTIMORE AEROBIC ACTINOMYCETE M 39 1 PRINCE GEORGE'S M 82 1 WASHINGTON

Page 8 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 MYCOBACTERIUM PARASITOLOGY WATER TUBERCULOSIS COMPLEX M 43 1 ANNE ARUNDEL GENUS/SPECIES # TESTED # NON-COMPLIANT F 29 1 BALTIMORE # JURISDICTION COMMUNITY 1 0 F 39 1 BALTIMORE M 28 1 BALTIMORE CITY BLASTOCYSTIS HOMINIS NON-COMMUNITY 393 104 M 31 1 BALTIMORE CITY 1 MONTGOMERY M 34 2 BALTIMORE CITY 1 PRINCE GEORGE'S M 43 1 BALTIMORE CITY 1 MONTGOMERY TOTAL 394 104 M 91 1 CALVERT 1 PRINCE GEORGE'S M 61 4 HOWARD 3 MONTGOMERY M 81 4 HOWARD 2 HOWARD F 98 4 MONTGOMERY 1 MONTGOMERY M 51 1 MONTGOMERY 2 PRINCE GEORGE'S F 19 1 OUT OF STATE 1 MONTGOMERY FOOD PROTECTION F 37 1 OUT OF STATE 1 FREDERICK F 44 1 OUT OF STATE 1 MONTGOMERY TOTALS M 58 1 OUT OF STATE 2 PRINCE GEORGE'S M 28 1 PRINCE GEORGE'S CHILOMASTIX MESNILI FOOD M 39 2 PRINCE GEORGE'S 4 HOWARD SAMPLES TESTED* 41 NON-PHOTOCHROMOGENIC DIENTAMOEBA FRAGILIS NOTABLE PATHOGENS: MYCOBACTERIA 4 MONTGOMERY M 69 1 BALTIMORE 1 PRINCE GEORGE'S CAMPYLOBACTER SP. F 62 1 PRINCE GEORGE'S ENDOLIMAX NANA SPP. M 91 2 PRINCE GEORGE'S 1 MONTGOMERY SALMONELLA SPP. SCOTOCHROMOGENIC MYCOBACTERIA 1 HOWARD F 24 1 MONTGOMERY 4 PRINCE GEORGE'S EHEC/STEC 1 MONTGOMERY F 72 1 BALTIMORE CITY OTHER M 43 1 BALTIMORE CITY 1 PRINCE GEORGE'S F 62 1 CALVERT 3 MONTGOMERY 2 FREDERICK M 67 1 CARROLL CRABMEAT F 66 1 CECIL 2 MONTGOMERY M 73 1 CECIL 3 PRINCE GEORGE'S SAMPLES TESTED 13 1 PRINCE GEORGE'S EXCEEDING STANDARDS1 0 TOTAL 114 ENTAMOEBA COLI 1 MONTGOMERY NOTABLE PATHOGENS: 1 PRINCE GEORGE'S LISTERIA SPP. 4 FREDERICK 2 MONTGOMERY MYCOBACTERIUM 1 PRINCE GEORGE'S SHELLFISH 1 MONTGOMERY SUSCEPTIBILITY RESULTS SAMPLES TESTED 6 2 PRINCE GEORGE'S 12 ISOLATES IDENTIFIED 2 MONTGOMERY EXCEEDING STANDARDS2 0 ENTAMOEBA HARTMANNI

2 DRUG RESISTANT STRAINS FOUND 1 FREDERICK 2 PRINCE GEORGE'S SHELLFISH GROWING WATERS 1 MONTGOMERY # JURISDICTION DRUG(S) NUMBER OF SAMPLES 497 2 CARROLL 1 MONTGOMERY , ENTEROBIUS VERMICULARIS 1 KENT PYRAZINAMIDE, OTHER STREPTOMYCIN, 1 FREDERICK RIFAMPIN GIARDIA LAMBLIA 1 PRINCE GEORGE'S 2 MONTGOMERY 1 MONTGOMERY ISONIAZID, 1 PRINCE GEORGE'S *RETAIL MEAT TEST DATA NOT INCLUDED STREPTOMYCIN, 1 MONTGOMERY ETHIONAMIDE, HYMENOLEPIS NANA PARA AMINO 1 PRINCE GEORGE'S STANDARDS IODAMOEBA BÜTSCHLII 1 MONTGOMERY A TWO ISOLATES FROM THE SAME PATIENT 1CRABMEAT FRESH B PROBABLE FOR M. BOVIS 1 PRINCE GEORGE'S C MEETS CASE DEFINITION OF 1 MONTGOMERY ESCHERICHIA COLI AT < 36 MPN/100 GRAMS 2 BALTIMORE CITY MULTI-DRUG TUBERCULOSIS (MDRTB) STANDARD PLATE COUNT AT < 100 PLASMODIUM FALCIPARUM Mycobacterium tuberculosis complex 2 OUT OF STATE 2 MONTGOMERY consists of: 2SHELLFISH M. tuberculosis M. africanum 2 MONTGOMERY M. bovis M. microti FECAL COLIFORMS AT < 230 MPN/100 GRAMS M. bovis, BCG M. canettii TOTAL 84 STANDARD PLATE COUNT AT < 500,000 PER GRAM

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Page 9 VIRUS ISOLATION M 21 2 BALTIMORE CITY 153 29 BALTIMORE CITY M 22 1 BALTIMORE CITY 8 0 CALVERT ISOLATE M 24 3 BALTIMORE CITY 32 1 CARROLL SEX AGE # JURISDICTION M 25 1 BALTIMORE CITY 56 3 CECIL M 33 1 BALTIMORE CITY 2 0 CHARLES ADENOVIRUS M 57 1 BALTIMORE CITY 1 0 DORCHESTER M 21 1 WICOMICO F 22 1 CALVERT 20 2 FREDERICK 16 0 GARRETT F 20 1 CAROLINE VIRUS TYPE 1 40 1 HARFORD F 35 1 CECIL 9 1 HOWARD M 29 1 PRINCE GEORGE'S F 17 1 CHARLES M 30 1 BALTIMORE CITY 2 1 KENT F 24 1 CHARLES 152 2 MONTGOMERY INFLUENZA A VIRUS F 27 1 FREDERICK 109 6 PRINCE GEORGE'S M 9 1 MONTGOMERY F 20 1 MONTGOMERY 14 1 SAINT MARY'S RHINOVIRUS M 23 1 MONTGOMERY 3 0 TALBOT F 72 1 CALVERT M 27 1 MONTGOMERY 20 1 WASHINGTON M 87 1 CALVERT U 23 1 PRINCE GEORGE'S 8 0 WICOMICO F 18 1 PRINCE GEORGE'S TOTAL 5 F 21 2 PRINCE GEORGE'S SUBTOTAL F 37 1 PRINCE GEORGE'S 886 78 F 39 1 PRINCE GEORGE'S F 66 1 PRINCE GEORGE'S TOTALS VIRAL POLYMERASE M 26 1 PRINCE GEORGE'S 2,493 100 CHAIN REACTION (PCR) F 33 1 TALBOT M 23 1 WICOMICO ISOLATE SEX AGE # JURISDICTION TOTAL 72 RABIES

SOURCE # JURISDICTION TYPE 1

F 22 1 ANNE ARUNDEL BAT 1 ANNE ARUNDEL F 0 1 BALTIMORE CITY 1 BALTIMORE F 21 2 BALTIMORE CITY VIRAL 12 BALTIMORE CITY M 22 1 BALTIMORE CITY 1 CALVERT M 24 2 BALTIMORE CITY ORGANISM 2 CARROLL F 20 1 CHARLES # SPECIMENS 2 FREDERICK F 21 1 FREDERICK # POSITIVES 2 HARFORD F 23 1 HOWARD JURISDICTION 2 HOWARD F 24 1 PRINCE GEORGE'S 4 MONTGOMERY F 41 1 PRINCE GEORGE'S HEPATITIS A 1 0 BALTIMORE CITY 1 PRINCE GEORGE'S F 19 1 SAINT MARY'S CAT 1 ANNE ARUNDEL F 40 1 WASHINGTON SUBTOTAL 1 CARROLL HERPES SIMPLEX VIRUS 1 0 FOX 1 FREDERICK TYPE 1 AND TYPE 2 1 MONTGOMERY F 25 1 HARFORD 3 SAINT MARY'S HERPES SIMPLEX VIRUS TYPE 2 52 0 ALLEGANY RACCOON 1 BALTIMORE F 20 1 ANNE ARUNDEL 135 1 ANNE ARUNDEL 1 DORCHESTER F 21 1 ANNE ARUNDEL 30 2 BALTIMORE 1 HARFORD M 21 1 ANNE ARUNDEL 390 7 BALTIMORE CITY 1 HOWARD M 28 1 ANNE ARUNDEL 8 0 CALVERT 1 PRINCE GEORGE'S F 21 1 BALTIMORE 29 1 CARROLL 1 SOMERSET F 44 1 BALTIMORE 86 0 CECIL SKUNK 2 SAINT MARY'S M 26 1 BALTIMORE 2 0 CHARLES 1 TALBOT M 27 1 BALTIMORE 20 0 FREDERICK

U 19 1 BALTIMORE CITY 17 0 GARRETT TOTAL U 20 1 BALTIMORE CITY 24 0 HARFORD 24 0 HOWARD POSITIVES 44 U 22 1 BALTIMORE CITY 411 2 MONTGOMERY U 24 1 BALTIMORE CITY 270 9 PRINCE GEORGE'S TOTAL U 30 1 BALTIMORE CITY 2 0 QUEEN ANNE'S SPECIMENS 663 F 0 1 BALTIMORE CITY 13 0 SAINT MARY'S F 17 1 BALTIMORE CITY 3 0 TALBOT F 21 2 BALTIMORE CITY 38 0 WASHINGTON F 22 2 BALTIMORE CITY 52 0 WICOMICO CHLAMYDIOPHILIA PSITTACI F 24 1 BALTIMORE CITY (CHLAMYDIA) F 26 2 BALTIMORE CITY SUBTOTAL F 29 2 BALTIMORE CITY 1,606 22 REPORTED QUARTERLY F 30 1 BALTIMORE CITY NO REPORT THIS MONTH F 36 1 BALTIMORE CITY HEPATITIS C F 49 1 BALTIMORE CITY 56 4 ALLEGANY CD4 FLOW CYTOMETRY WORKLOAD F 50 1 BALTIMORE CITY 157 25 ANNE ARUNDEL 28 1 BALTIMORE M 0 1 BALTIMORE CITY REPORTED QUARTERLY NO REPORT THIS MONTH

Page 10 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 NEWBORN & CHILDHOOD SCREENING ENVIRONMENTAL CHEMISTRY

PRESUMPTIVE POSITIVES COMPLIANT # TESTED SAMPLE # NON- DISORDERS # TYPES PHENYLKETONURIA (PKU) 13 MAPLE SYRUP URINE DISEASE (MSUD) 5 HOMOCYSTINURIA 7 TYROSINEMIA 2 ASBESTOS ARGININEMIA 1 AIR 0 0 CITRULLINEMIA 1 BULK 5 12 GALACTOSEMIA 0 BIOTINIDASE DEFICIENCY 1 AIR QUALITY

HYPOTHYROIDISM 55 PM 2.5 0 354 -DISEASE 13 RADIATION HEMOGLOBIN -BENIGN 452 CONGENITAL ADRENAL HYPERPLASIA (CAH) 7 AIR/CHARCOAL FILTERS 0 63 0 0 3 FATTY ACID OXIDATIONS 5 WIPES 0 62 ORGANIC ACIDEMIAS 21 ACYLCARNITINE - BORDERLINE 16 RAW WATER 0 8 ACYLCARNITINE - OTHERS 0 VEGETATION 0 0 MONTHLY TOTALS OTHER 0 0 # OF SPECIMENS SCREENED 13,372 DRINKING WATER NUMBER OF TESTS 865,062 % UNSATISFACTORY SPECIMENS 3.2 METALS 2011 YEAR-TO-DATE CONFIRMED CASES COMMUNITY 4 11 CONDITIONS # CONFIRMED NON-COMMUNITY 6 38 2-METHYLBUTYRUL-CoA DEHYDROGENASE DEFICIENCY (2MBCD) 1 PRIVATE WELLS 32 184 3-METHYLCROTONYL-CoA CARBOXYLASE DEFICIENCY (3-MCC) 2 MEDIUM CHAIN ACYL-CoA DEHYDROGENASE DEFICIENCY (MCAD) 2 PESTICIDES & PCBs SHORT CHAIN ACYL-CoA DEHYDROGENASE DEFICIENCY (SCAD) 7 COMMUNITY 3 199 VERY LONG-CHAIN ACY-Co-A DEHYDROGENASE DEFICIENCY (VLCAD) - CARRIER 5 NON-COMMUNITY 0 127 CARNITINE DEFICIENCY (MATERNAL) 1 PRIVATE WELLS 0 13 CARNITINE UPTAKE DEFICIENCY (CUD) 1 PROPIONIC ACIDEMIA (PA) 1 VOLATILE ORGANIC COMPOUNDS OTC DEFICIENCY 1 COMMUNITY 10 151 CITRULLINEMIA (CIT) 1 NON-COMMUNITY 1 141 TYROSINEMIA III 1 CLASSICAL PHENYLKETONURIA (PKU) 2 PRIVATE WELLS 0 38 HYPERPHENYLALANINEMIA 1 RADIATION HYPERMTHIONINEMIA 1 COMMUNITY 1 36 HYPOTHYROIDISM - PRIMARY 26 OTHER HYPOTHYROIDISM 5 NON-COMMUNITY 0 0 TBG DEFICIENCY 5 PRIVATE WELLS 2 8 CONGENITAL ADRENAL HYPERPLASIA-SALT WASTING 1 INORGANICS CONGENITAL ADRENAL HYPERPLASIA-SIMPLE VIRILIZATION 1 BIOTINIDASE DEFICIENCY - CARRIER 1 COMMUNITY 0 10 BIOTINIDASE DEFICIENCY - PARTIAL 2 NON-COMMUNITY 8 61 BIOTINIDASE DEFICIENCY 1 PRIVATE WELLS 4 112 PROBABLE BIOTINIDASE CARRIER 4 FOOD CHEMISTRY PROBABLE GN 3 SUSPECTED 0 0 CYSTIC FIBROSIS 7 TAMPERING GALACTOSEMIA - VARIANT -DG 1 GALACTOSEMIA - VARIANT -DN 1 MICROSCOPIC FILTH 0 18 GALACTOSEMIA_UNKNOWN VARIANT 1 LABELING 0 0 SICKLE CELL DISEASE -SS 25 SURVEILLANCE 0 36 SICKLE CELL DISEASE -SC 12 CHEMICAL SICKLE CELL DISEASE -SV 1 0 0 CONTAMINATION SICKLE CELL TRAIT - FAS 3

SICKLE CELL TRAIT - FV 2 SICKLE CELL TRAIT - FC 2 TOTAL 76 1,685

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10 Page 11 VIRAL LOAD SPECIMENS HIV ANTIBODY SCREENING SPECIMENS SPECIMENS POSITIVE POSITIVE POSITIVE POSITIVE TOTALS TOTALS 10 10 TOTAL % EIA % WB # EIA # EIA # WB <10 >10 3 4 —10 —10 SUBMITTER HIV-1 RNA COPIES/ML 3 5

4 5

CORRECTION FACILITY JUVENILE 139 0 0.00% 0 0.00% ALLEGANY 4 0 1 0 5 CORRECTIONAL INSTITUTIONS 261 1 0.38% 1 100.00%

CARROLL 1 0 0 0 1 FAMILY PLANNING 21 0 0.00% 0 0.00% (NON-GOVERNMENT)

FREDERICK 2 0 0 0 2 HEALTH CENTERS 342 19 5.56% 18 94.74% (NON-GOVERNMENT) HLTH DEPT, NON-STD, MONTGOMERY 57 5 12 3 77 339 0 0.00% 0 0.00% FAMILY PLAN

PRINCE GEORGE'S 131 10 12 9 162 HLTH DEPT, NON-STD, OB/GYN 26 0 0.00% 0 0.00% HLTH DEPT, NON-STD, OTHER 575 76 13.22% 72 94.74% SOMERSET 2 0 0 0 2 HLTH DEPT, STD CLINICS 1,286 19 1.48% 13 68.42% , OTHER 123 10 8.13% 8 80.00% WASHINGTON 5 0 1 0 6 HOSPITAL, PUBLIC 30 1 3.33% 1 100.00%

WICOMICO 1 1 0 0 2 LABORATORIES (NON-HOSPITAL) 266 1 0.38% 1 100.00% PEDIATRIC - CHILD HEALTH 11 0 0.00% 0 0.00% SUBTOTALS 203 16 26 12 257 PRIVATE STUDENT HEALTH CTRS 11 0 0.00% 0 0.00%

DEPT. OF PUBLIC STUDENT HEALTH CTRS 3 0 0 0 3 14 0 0.00% 0 0.00% CORRECTIONS UNKNOWN, NOT SPECIFIED 1 0 0.00% 0 0.00%

TOTALS 206 16 26 12 260

TOTALS 3,445 127 3.69% 114 89.76%

MAILING LABEL LABEL MAILING

Baltimore, Maryland 21201 21201 Maryland Baltimore,

201 West Preston Street Street Preston West 201

Department of Health & Mental Hygiene Hygiene Mental & Health of Department

J. Mehsen Joseph Public Health Laboratory Laboratory Health Public Joseph Mehsen J.

c/o Georgia Corso, Room L-15 L-15 Room Corso, Georgia c/o Critical Link Link Critical

Page 12 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • October 2011 • Vol. 15, No. 10