Immunodiagnosis of Ehrlichia canis infection with recombinant proteins

Ehrlichia canis causes a potentially fatal rickettsial disease of dogs that requires rapid and accurate diagnosis in order to initiate appropriate therapy leading to a favorable prognosis. We recently reported the cloning of two immunoreactive E. canis proteins, P28 and P140, that were applicable for serodiagnosis of the disease. In the present study we cloned a new immunoreactive E. canis surface protein gene of 1,170 bp, which encodes a protein with a predicted molecular mass of 42.6 kDa (P43). The P43 gene was not detected in E. chaffeensis DNA by Southern blot, and antisera against recombinant P43 (rP43) did not react with E. chaffeensis as detected by indirect fluorescent antibody (IFA) assay. Forty-two dogs exhibiting signs and/or hematologic abnormalities associated with canine ehrlichiosis were tested by IFA assay and by recombinant Western immunoblot. Among the 22 samples that were IFA positive for E. canis, 100% reacted with rP43, 96% reacted with rP28, and 96% reacted with rP140. The specificity of the recombinant proteins compared to the IFAs was 96% for rP28, 88% for P43 and 63% for P140. The results of this study demonstrate that the rP43 and rP28 are sensitive and reliable serodiagnostic antigens for E. canis infections.

Coinfection with Borrelia burgdorferi and the agent of human granulocytic ehrlichiosis suppresses IL-2 and IFN gamma production and promotes an IL-4 response in C3H/HeJ mice

Previously we demonstrated that Borrelia burgdorferi transmission by Ixodes scapularis suppressed IL-2 and IFN gamma production and promoted IL-4 production in mice. The present studies were conducted to determine whether coinfection with the human granulocytic ehrlichiosis (HE) agent would promote a Th2 cytokine response in mice. Transmission to the spleen of the agent of human granulocytic ehrlichiosis (aoHGE) and B. burgdorferi occurred 4 and 7 days, respectively, after tick infestation. Coinfection synergized to suppress splenic IL-2 production 7-14 days after tick infestion. Transmission of B. burgdorferi or aoHGE alone significantly decreased splenic IFN gamma 4-7 days after tick infestation, while coinfection suppressed IFN gamma production 7-14 days after tick infestation. Splenic IL-4 production was significantly increased 4 days after coinfection, and by day 10, aoHGE plus B. burgdorferi induced greater splenic IL-4 (57.2 pg/ml, 348% of control values) than either organism transmitted alone (aoHGE, 22.7 pg/ml, B. burgdorferi, 25.1 pg/ml). Coinfection enhanced expansion of splenic T cells, CD4+ lymphocytes and B cells while decreasing CD8+ T cells. These data demonstrate that aoHGE and B. burgdorferi, when cotransmitted, suppress a systemic IL-2 and IFN gamma response, while strongly promoting systemic IL-4 production in the susceptible host. The antigen(s) responsible for this polarization are unknown and will be the subject of future studies.

[Serologic and clinical evidence for endemic occurrences of human granulocytic ehrlichiosis in North-Eastern Switzerland]

BACKGROUND

Tick-borne human granulocytic ehrlichiosis (HGE) has not been diagnosed in Switzerland, although the HGE agent has been identified in ticks and animal reservoirs and human infections have been suspected on the basis of serological surveys.

METHODS

We retrospectively tested sera of 48 persons with antibodies to B. burgdorferi and/or tick-borne encephalitis virus for the presence of antibodies to E. phagocytophila (a surrogate marker of the agent of HGE), and reviewed their charts with regard to clinical manifestations possibly associated with a tick-borne infection. We then prospectively examined EDTA blood of 80 patients who presented with fever 7 to 21 days after a tick bite for the presence of the HGE agent (using nested PCR and microscopic examination of blood smears) and anti-E. phagocytophila antibodies. We also collected clinical data.

RESULTS

The retrospective study revealed 12 persons (25%) with anti-E. phagocytophila antibody titers > or = 1:80, suggesting coinfection with HGE and either Lyme Borrelia or tick-borne encephalitis virus. Among these, 7 patients presented with clinical manifestations compatible with HGE disease. The prospective investigation identified 8 patients (10%) with anti-E. phagocytophila antibody titers > or = 1:80, and 7 of these presented with signs and symptoms suggesting HGE. The HGE agent, however, was detected neither by PCR nor by microscopic examination.

CONCLUSIONS

Serological and clinical data suggest the occurrence of an HGE-like agent as well as of coinfections with HGE and B. burgdorferi or tick-borne encephalitis virus in Switzerland. However, the HGE agent was not identified in persons living in Switzerland.

Serologic and molecular evidence of Ehrlichia spp. in coyotes in California

In order to determine the role of coyotes in the epidemiology of granulocytic and monocytic ehrlichial agents in California (USA), we tested 149 serum samples for antibodies against Ehrlichia equi, E. risticii, and E. canis, using an indirect immunofluorescent antibody test. Polymerase chain reaction (PCR) assay was used to survey for the presence of members of the E. phagocytophila genogroup, E. risticii and E. canis in blood samples of 95 coyotes. Sixty-eight (46%) samples were seropositive for E. equi, two (1%) for E. risticii and none of the samples had antibodies reactive to E. canis. Two and one coyote were positive for E. risticii and members of the E. phagocytophila genogroup by PCR assay, respectively. In contrast, the 95 samples were negative for E. canis by PCR. Ninety-five percent of the 68 E. equi seropositive coyotes and the one coyote PCR positive for members of the E. phagocytophila genogroup originated from a coastal area. However, the two E. risticii seropositive coyotes and the two coyotes PCR positive for E. risticii were from northern California. Sequence analysis of the three amplified PCR products revealed the agent to be similar in two coyotes to the sequences of E. risticii from horses originating from northern California and identical in one coyote to the agent of human granulocytic ehrlichiosis and E. equi from California. Thus, coyotes are exposed to granulocytic ehrlichiae and E. risticii and may play a role in the epidemiology of these ehrlichial agents in California.

Effects of the dose of Ehrlichia phagocytophila on the severity of experimental infections in lambs

Twenty-one lambs were used to investigate whether their response to an infection with Ehrlichia phagocytophila was dose-dependent Four groups of four lambs were infected intravenously with a dilution in physiological saline of E phagocytophila-infected sheep blood containing either 1.3 x 10(5) infected cells, or approximately 43 infected cells, 4.3 infected cells, or 1.3 infected cells (mean values) and four lambs were left uninfected. The incubation period was significantly shorter in the lambs infected with the highest dose of E phagocytophila. However, the clinical and haematological changes observed, and the weekly weight gains of the lambs were independent of the dose of E phagocytophila. As little as one Ephagocytophila infected cell may be enough to transmit the infection.

Canine monocytic ehrlichiosis presenting as acute blindness 36 months after importation into the UK

A four-year-old Labrador retriever developed sudden-onset blindness, associated with bilateral uveitis, intraocular haemorrhage and retinal detachment. It had been imported into the UK from Sardinia 36 months before presentation. Haematological abnormalities included non-regenerative anaemia, thrombocytopenia and neutropenia. Serum and urine protein electrophoresis demonstrated a monoclonal gammopathy. An immunofluorescent antibody test for Ehrlichia canis was positive, with a titre of 1:320, confirming a diagnosis of chronic monocytic ehrlichiosis. This case highlights how the prolonged subclinical phase of monocytic ehrlichiosis could enable infected dogs to enter the UK without signs of disease. Chronic monocytic ehrlichiosis should be considered in dogs which have been imported from E canis-endemic countries and present with bleeding disorders and gammopathy, even if signs develop many years after importation.

Expression of interleukin-1beta, tumor necrosis factor alpha, and interleukin-6 in human peripheral blood leukocytes exposed to human granulocytic ehrlichiosis agent or recombinant major surface protein P44

Human granulocytic ehrlichiosis (HGE) is an emerging febrile systemic disease caused by the HGE agent, an obligatory intracellular bacterium of granulocytes. The pathogenicity- and immunity-related mechanisms of HGE are unknown. In this study, several cytokines generated in human peripheral blood leukocytes (PBLs) incubated with the HGE agent or a recombinant 44-kDa major surface protein (rP44) of the HGE agent were examined by reverse transcription-PCR and a capture enzyme-linked immunosorbent assay. The HGE agent induced expression of interleukin-1beta (IL-1beta), tumor necrosis factor alpha (TNF-alpha), and IL-6 mRNAs and proteins in PBLs in a dose-dependent manner to levels as high as those resulting from Escherichia coli lipopolysaccharide stimulation. The kinetics of induction of these three cytokines in PBLs by rP44 and by the HGE agent were similar. Proteinase K treatment of the HGE agent or rP44 eliminated the ability to induce these three cytokines. Induction of these cytokine mRNAs was not dependent on superoxide generation. These results suggest that P44 proteins have a major role in inducing the production of proinflammatory cytokines by PBLs. Expression of IL-8, IL-10, gamma interferon, transforming growth factor beta, and IL-2 mRNAs in response to the HGE agent was not remarkable. Among PBLs, neutrophils and lymphocytes expressed IL-1beta mRNA but not TNF-alpha or IL-6 mRNA in response to the HGE agent, whereas monocytes expressed all three of these cytokine mRNAs. These observations suggest that induction of proinflammatory-cytokine gene expression by the major outer membrane protein of the HGE agent in monocytes, which are not the primary host cells of the HGE agent, contributes to HGE pathogenesis and immunomodulation.

Comparison of a clinic-based ELISA test kit with the immunofluorescence test for the assay of Ehrlichia canis antibodies in dogs

The "gold standard" for the detection of antibodies to Ehrlichia canis, the cause of canine monocytic ehrlichiosis (CME), is the indirect immunofluorescence antibody (IFA) test. The IFA test however is generally available only in selected laboratories and requires extensive equipment and trained personnel. A double-blind study was conducted to compare the ability of an in-clinic standardized enzyme-linked immunosorbent assay (ELISA) test kit to measure E. canis IgG antibodies in dogs compared with the standard IFA technique. A good correlation was found between the 2 techniques (r2 = 0.8793; P < 0.0001). Evidence for the sensitivity of the ELISA technique for the early detection of E. canis IgG antibodies was demonstrated by comparing the appearance of E. canis antibody titers by the IFA and ELISA techniques after artificial infection of 2 sets of dogs. In both experimental infections, both tests were equally sensitive for the early detection of IgG antibodies against E. canis, and the results correlated well with the appearance of fever and clinical signs. Proposed application of the in-clinic ELISA test is to aid in the diagnosis of CME.

Ehrlichia equi infection of horses from Minnesota and Wisconsin: detection of seroconversion and acute disease investigation

Equine granulocytic ehrlichiosis (EGE) is caused by infection with Ehrlichia equi. EGE has been reported primarily in northern California, where E equi is transmitted by the tick Ixodes pacificus. Reports of EGE and the emergence of human granulocytic ehrlichia in Minnesota prompted a seroprevalence study of E equi in horses of Minnesota and Wisconsin. Tick (Ixodes scapularis) endemic areas of Minnesota and Wisconsin were compared to nonendemic regions of Minnesota. Indirect fluorescent antibody was used to detect the presence of serum antibodies to E equi. Serum samples from healthy horses, 375 samples from I scapularis endemic counties, and 366 samples from nonendemic counties were screened at a 1:40 dilution. Results demonstrated a seroprevalence of 17.6% in endemic areas versus 3.8% in nonendemic areas. Ehrlichial DNA from 2 samples was successfully amplified by polymerase chain reaction and 919 base pairs were sequenced. The DNA sequence of 1 Minnesota/Wisconsin strain differed from the GenBank strain (M73223) of E equi at positions 84 and 886 and from the MRK strain of E equi at position 84, and was identical to the human granulocytic ehrlichiosis (HGE) agent. The 2nd Minnesota/Wisconsin strain was identical to the 1st with the exception of a substitution of "A" at position 453 that is not present in E phagocytophila, E equi, or HGE agent strain sequences. Based on the results of this study, we concluded that E equi is present and causes infection in horses in Minnesota and Wisconsin. The occurrence of infection is higher in tick endemic regions.

Sero-prevalence of granulocytic Ehrlichia spp. and Borrelia burgdorferi sensu lato in Swedish dogs 1991-94

In Sweden, 2 tick-borne zoonotic diseases, granulocytic ehrlichiosis and borreliosis, are frequently diagnosed in dogs, using serological assays. The aims of this study were to determine the sero-prevalences of antibodies to Ehrlichia spp. and Borrelia burgdorferi sensu lato during 1991-94 in dogs, not clinically suspected to be infected with either of the 2 agents. Samples (n = 611) were selected from a serum bank using a systematic sampling strategy, stratified across the 4-y period. The stored sera had originally been submitted in order to verify or rule out infection with Sarcoptes scabiei. The overall sero-prevalence for Ehrlichia spp. was 17.7% and for Borrelia burgdorferi sensu lato 3.9% (n = 588). Only a few dogs in the northern part of Sweden were sero-positive for Ehrlichia spp. and none were positive for Borrelia burgdorferi sensu lato. An increased sero-prevalence of Ehrlichia spp. was seen during the years studied. The sero-prevalence of Ehrlichia spp. varied with season. Sero-positivity to both agents increased with age. Both diseases are considered zoonotic, and the increase in sero-prevalence of Ehrlichia spp. over the years may reflect the degree of infection in ticks and may have implications for human health.

The emergence of another tickborne infection in the 12-town area around Lyme, Connecticut: human granulocytic ehrlichiosis

Human granulocytic ehrlichiosis (HGE) is an emerging tickborne infection, increasingly recognized in areas in which Lyme disease is endemic, but there are few data on the incidence of HGE. Prospective population-based surveillance was conducted in the 12-town area around Lyme, Connecticut, by means of both active and passive methods, from April through November of 1997, 1998, and 1999. Five hundred thirty-seven residents presenting to their primary care provider with an acute febrile illness suggestive of HGE were identified. Of these, 137 (26%) had laboratory evidence (by indirect fluorescent antibody staining or polymerase chain reaction) of HGE; 89 were confirmed cases, and 48 were probable cases. The incidence of confirmed HGE was 31 cases/100,000 in 1997, 51 cases/100,000 in 1998, and 24 cases/100,000 in 1999. A subset of sera was tested by use of immunoblot assays, and results were in agreement with indirect fluorescent antibody methods for 86% of samples analyzed. Thus, HGE is an important cause of morbidity and is now the second most common tickborne infection in southeastern Connecticut.

Detection of an Ehrlichia bovis-like organism in cultured buffalo monocytes

Monocytes from a buffalo were cultured in RPMI 1640 medium following separation of plasma by the erythrocyte sedimentation technique and subsequent separation of mononuclear cells by density gradient centrifugation. Growth of an organism considered to be Ehrlichia bovis was noticed in the cultured monocytes after 10 days. The inclusions were considered to be those of E. bovis from their morphology, staining characteristics and growth characteristics in culture, and by indirect immunofluorescence examination with an anti-E. canis serum. The utility of peripheral blood monocyte cultures opens the possibility of diagnosing the carrier status of ehrlichiosis in animals.

Serology of culture-confirmed cases of human granulocytic ehrlichiosis

We evaluated the antibody responses in the sera of 24 patients with culture-confirmed human granulocytic ehrlichiosis (HGE). Antibody titers were measured by an indirect immunofluorescent-antibody assay (IFA) by using a local human isolate as the source of antigen. All patients received appropriate antimicrobial treatment. One hundred five serum specimens collected at baseline and at periodic intervals for up to 14 months were included in the study. Seroconversion was observed in 21 of 23 patients (91.3%) from whom convalescent-phase sera were obtained. Antibodies were first detected at an average of 11.5 days after onset of symptoms. Peak titers (>/=2,560 for 71.4% of patients and >/=640 for 95.2% of patients) were obtained an average of 14.7 days after onset of symptoms. Eleven of 13 patients (84.6%) from whom sera were collected between 6 and 10 months after onset of symptoms were still seropositive, and sera from 5 of 10 (50%) patients tested positive between 11 and 14 months after onset of symptoms. For a subset of 71 serum specimens from 17 patients with culture-confirmed HGE also tested by IFA by using either a human isolate from Wisconsin or an Ehrlichia equi isolate from a horse, there was qualitative agreement for 62 serum specimens (87. 3%). Peak titers were higher, however, with the local human HGE isolate, but the difference was not statistically significant. In summary, most patients with culture-confirmed HGE develop antibodies within 2 weeks of onset of symptoms. Antibodies reach high titers during the first month and remain detectable in about one-half of patients at 1 year after onset of symptoms.

Molecular cloning and characterization of the 120-kilodalton protein gene of Ehrlichia canis and application of the recombinant 120-kilodalton protein for serodiagnosis of canine ehrlichiosis

The 120-kDa outer membrane protein (p120) is a potential adhesin of Ehrlichia chaffeensis, and recombinant p120 is very useful for serodiagnosis of human monocytotropic ehrlichiosis. The analogous gene of p120 in Ehrlichia canis was cloned, sequenced, and expressed. Like the E. chaffeensis p120, the E. canis p120 contains tandem repeat units. However, neither the repeat number nor the amino acid sequences in the repeats are identical in the two Ehrlichia species. The repeat units are hydrophilic and by probability analysis are predicted to be surface exposed in both species. The repeat regions of the p120s of the two species have common amino acid sequences that are predicted to be surface exposed. The overall amino acid sequence of the E. canis p120 is 30% homologous to that of E. chaffeensis p120. Protein immunoblotting demonstrated that the recombinant E. canis p120 reacted with convalescent sera from dogs with canine ehrlichiosis. These results indicate that the recombinant p120 is a potential antigen for the serodiagnosis of canine ehrlichiosis.

Serum cytokine responses during acute human granulocytic ehrlichiosis

Human granulocytic ehrlichiosis (HGE) is caused by obligate intracellular bacteria in the Ehrlichia phagocytophila group. The disease ranges from subclinical to fatal. We speculated that cell-mediated immunity would be important for recovery from and potentially in the clinical manifestations of HGE; thus, serum tumor necrosis factor alpha (TNF-alpha), interleukin 1beta (IL-1beta), gamma interferon (IFN-gamma), IL-10, and IL-4 concentrations were studied. IFN-gamma (1,035 +/- 235 pg/ml [mean +/- standard error of the mean]) and IL-10 (118 +/- 46 pg/ml) concentrations were elevated in acute-phase sera versus convalescent sera and normal subjects (P </= 0.013 and P </= 0.018, respectively). TNF-alpha, IL-1beta, and IL-4 levels were not elevated. Cytokine levels in severely and mildly affected patients were not different. HGE leads to induction of IFN-gamma-dominated cell-mediated immunity associated with clinical manifestations, recovery from infection, or both.

Glycosylation of homologous immunodominant proteins of Ehrlichia chaffeensis and Ehrlichia canis

The glycoprotein genes of Ehrlichia chaffeensis (1,644 bp) and Ehrlichia canis (2,064 bp) encode proteins of 548 to 688 amino acids with predicted molecular masses of only 61 and 73 kDa but with electrophoretic mobilities of 120 kDa (P120) and 140 kDa (P140), respectively. The 120-kDa protein gene of E. chaffeensis contains four identical 240-bp tandem repeat units, and the 140-kDa protein gene of E. canis has 14 nearly identical, tandemly arranged 108-bp repeat units. Conserved serine-rich motifs identified in the repeat units of P120 and P140 were also found in the repeat units of the human granulocytotropic ehrlichiosis agent 130-kDa protein and of the fimbria-associated adhesin protein Fap1 of Streptococcus parasanguis. Nearly the entire (99%) E. chaffeensis P120 gene (1,616 bp), the 14-repeat region (78%) of the E. canis P140 gene (1,620 bp), and a 2-repeat region from the E. chaffeensis P120 gene (520 bp) were expressed in Escherichia coli. The recombinant proteins exhibited molecular masses ranging from 1.6 to 2 times larger than those predicted by the amino acid sequences. Antibodies against the recombinant proteins reacted with E. chaffeensis P120 and E. canis P140, respectively. Carbohydrate was detected on the E. chaffeensis and E. canis recombinant proteins, including the two-repeat polypeptide region of E. chaffeensis P120. A carbohydrate compositional analysis identified glucose, galactose, and xylose on the recombinant proteins. The presence of only one site for N-linked (Asn-Xaa-Ser/Thr) glycosylation, a lack of effect of N-glycosidase F, the presence of 70 and 126 Ser/Thr glycosylation sites in the repeat regions of P120 and P140, respectively, and a high molar ratio of carbohydrate to protein suggest that the glycans may be O linked.

Seroprevalence of Ehrlichia canis, Ehrlichia equi, and Ehrlichia risticii in sick dogs from North Carolina and Virginia

Ehrlichia canis, E. equi, and E. risticii seroprevalence was determined by microimmunofluorescent antibody testing (IFA) in a sequential population of 1,845 sick dogs admitted during a 1-year period to the North Carolina State University Veterinary Teaching Hospital. A seroreactor was defined by a reciprocal IFA titer of > or =80 to E. canis, E. equi, or E. risticii antigens. Of the 48 IFA seroreactors, 44 dogs were seroreactive to E. canis, 21 to E. equi, and 0 to E. risticii. Seventeen dogs reacted to both E. canis and E. equi antigens. There was concordance of E. canis IFA and western immunoblot (WI) test results for 36/44 dogs. Because of cross-reactivity of E. canis sera with E. equi antigens, WI was of less utility to confirm E. equi exposure. After elimination of E. canis seroreactors, there was concordance of 2/4 E. equi IFA and WI test results. Based upon a retrospective review of medical records, ehrlichiosis was diagnosed in 10/48 (21%) IFA seroreactive dogs, 9 of which were confirmed positive by WI. Of the remaining 38 IFA seroreactors, 29 also were confirmed by E. canis or E. equi WI. These results indicate that (1) ehrlichiosis was not diagnosed in the majority of serologically confirmed cases, (2) based upon E. canis and E. equi WI analysis, IFA testing was not specific (21% false positive), (3) E. canis sera cross-react with E. equi antigens, and (4) serologic evidence of E. risticii infection was lacking in the dog population studied.

Interleukin-12 as an adjuvant promotes immunoglobulin G and type 1 cytokine recall responses to major surface protein 2 of the ehrlichial pathogen Anaplasma marginale

Anaplasma marginale is a tick-transmitted pathogen of cattle closely related to the human ehrlichiae, Ehrlichia chaffeensis and the agent of human granulocytic ehrlichiosis (HGE). These pathogens have in common a structurally conserved outer membrane protein (OMP) designated the major surface protein 2 (MSP-2) in A. marginale and HGE and OMP-1 in E. chaffeensis. Protective immunity against ehrlichial pathogens is believed to require induction of gamma interferon (IFN-gamma) and opsonizing immunoglobulin (Ig) subclasses directed against OMP epitopes that, in concert, activate macrophages for phagocytosis and killing. Because interleukin-12 (IL-12) acts as an adjuvant for protein immunization to induce IFN-gamma and protective immunity against intracellular pathogens, we hypothesized that as an adjuvant with MSP-2, IL-12 would augment type 1 recall responses to A. marginale. IL-12 was coadsorbed with MSP-2 to alum and shown to significantly enhance IFN-gamma production by lymph node cells (LNC) and LNC-derived CD4(+) T-cell lines from immunized calves following recall stimulation with A. marginale. LNC proliferation and IL-2 production were also enhanced in IL-12-treated calves. Elevated recall proliferative responses by peripheral blood mononuclear cells were still evident 9 months after immunization. Serum IgG levels were consistently increased in IL-12 immunized calves, predominantly due to higher IgG1 responses. The results support the use of IL-12 coadsorbed with OMP of ehrlichial pathogens in alum to amplify both antibody and type-1 cytokine responses important for protective immunity.

Clinical distinction between human granulocytic ehrlichiosis and the initial phase of tick-borne encephalitis

OBJECTIVES

The aim of our study was to establish clinical and laboratory differences between patients with acute human granulocytic ehrlichiosis (HGE) and patients with the initial phase of tick-borne encephalitis (TBE).

METHODS

Clinical features and laboratory results of four patients with acute HGE (established by the presence of the specific DNA sequences of the HGE agent in whole blood by polymerase chain reaction and/or by seroconversion to the HGE agent by indirect immunofluorescence assay) and 12 patients with the initial phase of TBE (demonstrated by the presence of serum IgM antibodies to TBE virus) were compared. All these patients were uncovered at the Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia, during 1995-1996, in a prospective study on the aetiology of febrile illnesses occurring within 6 weeks after a tick bite.

RESULTS

Findings were similar for the majority of the examined parameters including severity of illness, level and duration of fever, presence of headache, leukopenia, thrombocytopenia, and liver - function test abnormalities. Statistically significant differences were found only for arthralgia (P=0.026) and elevated concentration of C-reactive protein (P=0.003); both variables were found more often in patients with acute HGE.

CONCLUSIONS

In a patient residing in the central part of Slovenia, who reports a tick bite followed by a febrile illness with leukopenia and/or thrombocytopenia, the presence of arthralgias and/or an elevated C-reactive protein value directs toward the diagnosis of acute HGE and against the initial phase of TBE.

Human granulocytic ehrlichiosis presenting with acute renal failure and mimicking thrombotic thrombocytopenic purpura. A case report and review

We present the case of an elderly female patient presenting with recurrent acute renal failure, fever, altered mental status, abdominal pain, thrombocytopenia and a small number of fragmented red cells on peripheral smear mimicking recurrent thrombotic thrombocytopenic purpura (TTP). Eventually, however, she was diagnosed to have human granulocytic ehrlichiosis (HGE), and after treatment for HGE her clinical and laboratory abnormalities resolved. Ehrlichiosis mimicking TTP, diagnosed at postmortem examination, has been described in a single prior case. As illustrated in this case, there are potential difficulties in diagnosing HGE after plasma exchange, blood transfusion and immunosuppressive therapy. Ehrlichiosis, a potentially curable disease, should be considered in the differential diagnosis of thrombotic microangiopathic disorders.

Epidemiological aspects of human granulocytic Ehrlichiosis in southern Germany

Human granulocytic Ehrlichiosis (HGE) is a newly emerging acute febrile illness which is likely transmitted by ticks of the Ixodes ricinus/I. persulcatus complex. First seroepidemiological surveys on the prevalence of HGE antibodies, detection of DNA of granulocytotropic Ehrlichiae in I. ricinus and one case of HGE from Slovenia confirmed by serology and PCR (polymerase chain reaction) suggest that HGE might exist all over Europe. The purpose of the present study was a) to determine the prevalence of antibodies against the HGE agent in sera collected from persons at high risk for exposure to I. ricinus with that of a control population and b) to determine the prevalence of granulocytic Ehrlichiae in I. ricinus ticks from Southern Germany. We studied sera from 150 forestry workers and 105 patients with an established diagnosis of Lyme disease as tick-exposed populations. Sera from 103 healthy blood donors without a history of known tick bites served as controls. A significantly higher prevalence of HGE antibodies (P < or = 0.01) was present among patients with Lyme borreliosis (12 of 105 were positive; 11.4%) and forestry workers (21 of 150 were positive; 14%) compared to blood donors (2 of 103 were positive; 1.9%). Furthermore, 510 adult and nymphal I. ricinus were investigated by PCR for the presence of granulocytic Ehrlichiae with primers specific for the E. phagocytophila group. In eight (1.6%) of the investigated ticks the expected amplification product was detectable, indicating a low prevalence of infected ticks especially when compared with B. burgdorferi. The presented data strongly suggests that the HGE agent or a closely related organism exists in Southern Germany and therefore HGE should be considered in the differential diagnosis of febrile illnesses. However, final evidence can be provided only after isolation of the organism from patients.