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Wait, you have what in Missouri? Infections on the Move


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Michele Estabrook, MD
St. Louis Children's Hospital
St. Louis, MO, USA
Estabrook_m@kids.wustl.edu



Having worked in California for many years, coccidioidomycosis was always on my radar but not in St. Louis where I now live. That's why a recent MMWR report "Coccidioidomycosis in a State Where it is not known to be Endemic - Missouri, 2004-2013" definitely got my attention. The impetus for the report was national data showing not only a dramatic increase in total cases reported in the endemic states of Arizona, California, Nevada, New Mexico and Utah but also in many other states (28 in all). The Missouri Department of Health identified 93 cases of confirmed cocci between 2004 and 2013 with a significant increase in incidence over those years. The median age was 58, 46% were hospitalized and 9% died. The most common manifestations were symptomatic lung lesions/pneumonia in 40% and flu-like illness in 33%. When they looked at travel history, 26% had never been to an endemic area. Four of these individuals were diagnosed by positive culture, the gold standard, strongly suggesting acquisition from Missouri soil, a novel finding. I'm sure this will be an evolving story but Valley Fever seems to be on the move.

Coccidioides immitis is a fungus that grows in soil and is acquired by inhalation of airborne arthroconidia when the soil is disturbed such as with construction, dust storms and earthquakes. Solid organ donor derived infection is uncommon but reported. More than half of infections are asymptomatic but clinical manifestations include fever, cough, fatigue, chest pain and arthralgia that can last weeks to months. Chest x-ray can be normal or have infiltrates, cavitary lesions or nodules. In a normal host, disease is self-limited without treatment. The fearsome form of this infection is disseminated disease that occurs with suppression of cellular immunity such as solid organ transplantation, HIV infection, chemotherapy or high dose steroids. The fungus can spread to any site but generally goes to bone, skin and joints and the CNS. Diagnosis is by culture or serology. Treatment is with fluconazole or itraconazole for a very long time.

Lesson learned: consider cocci for community acquired pneumonia not responding to usual antibiotics even in Missouri. And of course, always get a careful travel history.

The other emerging infection that caught my attention is Chikungunya Virus. Something else I wouldn't expect in the middle of the country. Yet in 2014, Missouri had 16 cases. There were over 2,700 travel associated cases in the U.S. that year with New York and Florida leading the count with 803 and 476 respectively. Even more interesting was the first report of locally transmitted cases, all 11 in Florida. The mosquito vectors for this virus, Aedes aegypti and Aedes albopictus are both found in southern and eastern states so stay tuned. This is a relatively new virus first described in Tanzania in 1952. The first reported case in the Americas was 2013 and a year later the first imported and locally acquired cases were reported in the continental U.S. The virus is now widespread throughout the world in warmer climates. Most people who get Chik virus are symptomatic with acute onset of high fever and severe, bilateral, symmetric arthralgia or arthritis. Non-specific viral symptoms are headache, myalgia, conjunctivitis, diarrhea, and maculopapular rash. Lab findings are also non-specific with lymphopenia, low platelets, and elevated hepatic transaminases. Most people feel horrible for 7-10 days and then recover without treatment. Complications are rare but "itis" can occur in any organ system and those at highest risk are neonates exposed intrapartum, older adults, and those with underlying medical conditions. Diagnosis is by RT-PCR or serology and treatment is supportive.

The important point about Chikungunya however, is the clinical similarity and its vector to the Dengue Virus. Same mosquito vectors, much more concerning infection. This virus has four sub types that are endemic in the tropics and sub tropics of much of the world with 50 - 100 million cases and 22,000 deaths annually. Local transmission has not been maintained yet in the continental U.S. but all 48 states report travel associated infections year round. There is no cross protective immunity between the sub types and sequential infections increase the risk of the most severe forms of Dengue, hemorrhage fever and shock syndrome. Clinical presentation can be undifferentiated fever usually in children with their first infection that resolves. Classic Dengue Fever is heralded by severe, retro-orbital headache, high fever, and extreme muscle and joint pain (break-bone fever). Petechial rash, leukopenia, and low platelets occur. This lasts for 2-7 days followed by defervescence and recovery. Or not. For some people, resolution of fever is followed by the hemorrhagic form with or without shock syndrome marked by hemorrhage and plasma leak into pleural and abdominal cavities, disseminated intravascular coagulation, and cardiovascular collapse. Diagnosis is PCR from blood, CSF, or other body fluid; immunoassay for antigen in serum; cell culture; and serology. Treatment is supportive.

Lesson learned: consider mosquito born viruses Chikungunya and Dengue for compatible illnesses even in Missouri. And of course, always get a careful travel history. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. CDC-Increase in reported coccidioidomycosis - United States, 1998-2011. MMWR 2013;62:217-221.
  2. Coccidioidomycosis in a state where it is not known to be endemic - Missouri, 2004-2013. MMWR 2015;64:636-639.



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