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Volume 20, Number 9—September 2014

Volume 20, Number 9—September 2014   PDF Version [PDF - 17.75 MB - 179 pages]


  • Molecular Epidemiology of Reemergent Rabies in Yunnan Province, Southwestern China PDF Version [PDF - 888 KB - 10 pages]
    H. Zhang et al.
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    This province is a focal point for spread of rabies between Southeast Asia and China.

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    Yunnan Province in China borders 3 countries (Vietnam, Laos, and Myanmar) in Southeast Asia. In the 1980s, a large-scale rabies epidemic occurred in this province, which subsided by the late 1990s. However, 3 human cases of rabies in 2000 indicated reemergence of the disease in 1 county. In 2012, rabies was detected in 77 counties; 663 persons died of rabies during this new epidemic. Fifty two rabies virus strains obtained during 2008–2012 were identified and analyzed phylogenetically by sequencing the nucleoprotein gene. Of the 4 clades identified, clades YN-A and YN-C were closely related to strains from neighboring provinces, and clade YN-B was closely related to strains from Southeast Asia, but formed a distinct branch. Rabies virus diversity might be attributed to dog movements among counties, provinces, and neighboring countries. These findings suggest that Yunnan Province is a focal point for spread of rabies between Southeast Asia and China.

  • Encephalitis Caused by Pathogens Transmitted through Organ Transplants, United States, 2002–2013 PDF Version [PDF - 532 KB - 9 pages]
    S. V. Basavaraju et al.
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    Donor-derived infectious encephalitis among transplant recipients is rare and may not be recognized by clinicians.

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    The cause of encephalitis among solid organ transplant recipients may be multifactorial; the disease can result from infectious or noninfectious etiologies. During 2002–2013, the US Centers for Disease Control and Prevention investigated several encephalitis clusters among transplant recipients. Cases were caused by infections from transplant-transmitted pathogens: West Nile virus, rabies virus, lymphocytic choriomeningitis virus, and Balamuthia mandrillaris amebae. In many of the clusters, identification of the cause was complicated by delayed diagnosis due to the rarity of the disease, geographic distance separating transplant recipients, and lack of prompt recognition and reporting systems. Establishment of surveillance systems to detect illness among organ recipients, including communication among transplant center physicians, organ procurement organizations, and public health authorities, may enable the rapid discovery and investigation of infectious encephalitis clusters. These transplant-transmitted pathogen clusters highlight the need for greater awareness among clinicians, pathologists, and public health workers, of emerging infectious agents causing encephalitis among organ recipients.

  • Medscape CME Activity
    Confirmed Bacillus anthracis Infection among Persons Who Inject Drugs, Scotland, 2009–2010 PDF Version [PDF - 736 KB - 12 pages]
    M. Booth et al.
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    Patients who died had an increased sequential organ failure assessment score and need for vasopressors.

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    In Scotland, the 2009 outbreak of Bacillus anthracis infection among persons who inject drugs resulted in a 28% death rate. To compare nonsurvivors and survivors, we obtained data on 11 nonsurvivors and 16 survivors. Time from B. anthracis exposure to symptoms or hospitalization and skin and limb findings at presentation did not differ between nonsurvivors and survivors. Proportionately more nonsurvivors had histories of excessive alcohol use (p = 0.05) and required vasopressors and/or mechanical ventilation (p<0.01 for each individually). Nonsurvivors also had higher sequential organ failure assessment scores (mean + SEM) (7.3 + 0.9 vs. 1.2 + 0.4, p<0.0001). Antibacterial drug administration, surgery, and anthrax polyclonal immune globulin treatments did not differ between nonsurvivors and survivors. Of the 14 patients who required vasopressors during hospitalization, 11 died. Sequential organ failure assessment score or vasopressor requirement during hospitalization might identify patients with injectional anthrax for whom limited adjunctive therapies might be beneficial.


  • Passive Surveillance for Azole-Resistant Aspergillus fumigatus, United States, 2011–2013 PDF Version [PDF - 414 KB - 6 pages]
    C. D. Pham et al.
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    A. fumigatus cyp51A–mediated resistance to azole drugs is rare in the United States.

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    Emergence of Aspergillus fumigatus strains containing mutations that lead to azole resistance has become a serious public health threat in many countries. Nucleotide polymorphisms leading to amino acid substitutions in the lanosterol demethylase gene (cyp51A) are associated with reduced susceptibility to azole drugs. The most widely recognized mutation is a lysine to histidine substitution at aa 98 (L98H) and a duplication of the untranscribed promoter region, together known as TR34/L98H. This mechanism of resistance has been reported in Europe, Asia, and the Middle East, and is associated with resistance to all azole drugs and subsequent treatment failures. To determine whether isolates with this mutation are spreading into the United States, we conducted a passive surveillance–based study of 1,026 clinical isolates of A. fumigatus from 22 US states during 2011–2013. No isolates harboring the TR34/L98H mutation were detected, and MICs of itraconazole were generally low.

  • Swine-to-Human Transmission of Influenza A(H3N2) Virus at Agricultural Fairs, Ohio, USA, 2012 PDF Version [PDF - 751 KB - 9 pages]
    A. S. Bowman et al.
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    Local health care providers should be alerted to the possibility of human infection with variant influenza A viruses, especially during fairs.

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    Agricultural fairs provide an opportunity for bidirectional transmission of influenza A viruses. We sought to determine influenza A virus activity among swine at fairs in the United States. As part of an ongoing active influenza A virus surveillance project, nasal swab samples were collected from exhibition swine at 40 selected Ohio agricultural fairs during 2012. Influenza A(H3N2) virus was isolated from swine at 10 of the fairs. According to a concurrent public health investigation, 7 of the 10 fairs were epidemiologically linked to confirmed human infections with influenza A(H3N2) variant virus. Comparison of genome sequences of the subtype H3N2 isolates recovered from humans and swine from each fair revealed nucleotide identities of >99.7%, confirming zoonotic transmission between swine and humans. All influenza A(H3N2) viruses isolated in this study, regardless of host species or fair, were >99.5% identical, indicating that 1 virus strain was widely circulating among exhibition swine in Ohio during 2012.

  • Feeding Period Required by Amblyomma aureolatum Ticks for Transmission of Rickettsia rickettsii to Vertebrate Hosts PDF Version [PDF - 997 KB - 7 pages]
    D. G. Saraiva et al.
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    As opposed to unfed ticks, transmission of R. rickettsii occurred in <10 minutes of attachment by adult fed ticks.

    Feeding by A. aureolatum and Transmission of R. rickettsii

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    Rocky Mountain spotted fever is endemic to the São Paulo metropolitan area, Brazil, where the etiologic agent, Rickettsia rickettsii, is transmitted to humans by adult Amblyomma aureolatum ticks. We determined the minimal feeding period required by A. aureolatum nymphs and adults to transmit R. rickettsii to guinea pigs. Unfed nymphs and unfed adult ticks had to be attached to the host for >10 hours to transmit R. rickettsii. In contrast, fed ticks needed a minimum of 10 minutes of attachment to transmit R. rickettsii to hosts. Most confirmed infections of Rocky Mountain spotted fever in humans in the São Paulo metropolitan area have been associated with contact with domestic dogs, the main host of A. aureolatum adult ticks. The typical expectation that transmission of tickborne bacteria to humans as well as to dogs requires ≥2 hours of tick attachment may discourage persons from immediately removing them and result in transmission of this lethal bacterium.

  • Distance from Construction Site and Risk for Coccidioidomycosis, Arizona, USA PDF Version [PDF - 510 KB - 8 pages]
    J. E. Blair et al.
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    Working adjacent to a project involving excavation of desert soil did not increase the risk for infection.

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    Coccidioides spp. fungi, which are present in soil in the southwestern United States, can become airborne when the soil is disrupted, and humans who inhale the spores can become infected. In 2012, our institution in Maricopa County, Arizona, USA, began a building project requiring extensive excavation of soil. One year after construction began, we compared the acquisition of coccidioidomycosis in employees working adjacent to the construction site (campus A) with that of employees working 13 miles away (campus B). Initial testing indicated prior occult coccidioidal infection in 20 (11.4%) of 176 campus A employees and in 19 (13.6%) of 140 campus B employees (p = 0.55). At the 1-year follow-up, 3 (2.5%) of 120 employees from campus A and 8 (8.9%) of 90 from campus B had flow cytometric evidence of new coccidioidal infection (p = 0.04). The rate of coccidioidal acquisition differed significantly between campuses, but was not higher on the campus with construction.

  • Genomic Epidemiology of Salmonella enterica Serotype Enteritidis based on Population Structure of Prevalent Lineages PDF Version [PDF - 629 KB - 9 pages]
    X. Deng et al.
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    Major lineages emerged during the 17th–18th centuries and diversified during the 1920s and 1950s.

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    Salmonella enterica serotype Enteritidis is one of the most commonly reported causes of human salmonellosis. Its low genetic diversity, measured by fingerprinting methods, has made subtyping a challenge. We used whole-genome sequencing to characterize 125 S. enterica Enteritidis and 3 S. enterica serotype Nitra strains. Single-nucleotide polymorphisms were filtered to identify 4,887 reliable loci that distinguished all isolates from each other. Our whole-genome single-nucleotide polymorphism typing approach was robust for S. enterica Enteritidis subtyping with combined data for different strains from 2 different sequencing platforms. Five major genetic lineages were recognized, which revealed possible patterns of geographic and epidemiologic distribution. Analyses on the population dynamics and evolutionary history estimated that major lineages emerged during the 17th–18th centuries and diversified during the 1920s and 1950s.

  • Medscape CME Activity
    Pneumocystis jirovecii Pneumonia in Patients with or without AIDS, France PDF Version [PDF - 517 KB - 8 pages]
    A. Roux et al.
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    Immunosuppressed patients without AIDS had longer time to treatment and a higher rate of death than did patients with AIDS.

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    Pneumocystis jirovecii pneumonia (PCP) in patients without AIDS is increasingly common. We conducted a prospective cohort study of consecutive patients with proven PCP; of 544 patients, 223 (41%) had AIDS (AIDS patients) and 321 (59%) had other immunosuppressive disorders (non-AIDS patients). Fewer AIDS than non-AIDS patients required intensive care or ventilation, and the rate of hospital deaths—17.4% overall—was significantly lower for AIDS versus non-AIDS patients (4% vs. 27%; p<0.0001). Multivariable analysis showed the odds of hospital death increased with older age, receipt of allogeneic bone marrow transplant, immediate use of oxygen, need for mechanical ventilation, and longer time to treatment; HIV-positive status or receipt of a solid organ transplant decreased odds for death. PCP is more often fatal in non-AIDS patients, but time to diagnosis affects survival and is longer for non-AIDS patients. Clinicians must maintain a high index of suspicion for PCP in immunocompromised patients who do not have AIDS.



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