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Letter
Human Granulocytic Ehrlichiosis
in Estonia
Tiina Prükk,* Kylliki Ainsalu,† Ene Laja,‡ and Ada Aigro‡
*University of Tartu, Tartu, Estonia; †Internal Medicine Clinic of Tartu
University, Tartu, Estonia; and ‡United Laboratories of Tartu University
Clinics, Tartu, Estonia
Suggested citation
for this article:
Prükk T, Ainsalu K, Laja E, Aigro A. Human granulocytic ehrlichiosis
in Estonia. Emerg Infect Dis [serial online] 2003 Nov [date cited].
Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no11/03-0480.htm
To the Editor: We report a case of a 24-year-old woman living
in a rural area of Estonia who had weakness, chills, and diarrhea on May
10, 2002. On day 5 of the illness, she was admitted to the Department
of Infectious Diseases, University of Tartu, with high fever (38.5°C)
and muscle pains throughout her body. Examination showed mild jaundice,
painful and enlarged liver, and inability to move. Throat was erythematous,
and enlarged lymph nodes were palpable on the neck.
Laboratory findings included the following: leukopenia 2.04x109/L;
erythrocytes 4.08x1012/L; hemoglobin 130 g/L; thrombocytopenia
36x109/L; eosinophils 0%; basophils 1.0%; monocytes 7.5%; lymphocytes
38.0%; neutrophils 51.0%; reactive lymphcytes 2.0%; plasma cells 0.5%;
C-reactive protein 38 mg/L (normal <5 mg/L); bilirubin 95 μmol/L
(normal <17 μmol/L); aspartate aminotransferase 121 U/L (normal
<31 U/L); alanine aminotransferase 108 UL (normal <31 U/L); and
alcaline phosphatase 200 U/L (normal 35–104 U/L). Ehrlichiosis was suspected
by clinical symptoms and leukopenia, thrombocytopenia, and elevated transaminases.
Human granulocytic ehrlichiosis (HGE) is an emerging tick-borne disease
described for the first time in 1994 in the United States (1).
The first European case of HGE was reported in Slovenia in 1996 (2).
Infection with Ehrlichia phagocytophila, the agent of HGE, occurs
in areas endemic for Borrelia burgdorferi (3).
In Estonia, Lyme borrreliosis is frequently diagnosed in humans but the
occurrence of ehrlichiosis has not been established for this region, despite
our having found some seropositive results in Lyme borrreliosis patients
(4).
This case of ehrlichiosis is the first diagnosed in Estonia. The initial
diagnosis was based on a typical clinical spectrum of symptoms and clinical
laboratory findings, which are relatively nonspecific, making the diagnosis
problematic (5). Polymerase chain reaction results for
Ehrlichia were negative, and we did not find morula in the blood
smear. Indirect immunofluorescence assay (IFA, MRL Diagnostics, Cypress,
CA) was used as a confirmatory serologic test. However, results of this
assay are often negative during the initial phase of the disease (5,6).
On day 7 of illness, the serologic results for immunoglobulin (Ig) M type
antibodies to Ehrlichia were positive (1:20) and negative for IgG.
The diagnosis of ehrlichiosis was established, and therapy with doxycycline
was started. After 4 days, the patient became afebrile, and on day 6 she
left for home. One month later, the titers of both types of antibodies
to Ehrlichia were increased: IgM titer was 1:160 and IgG titer
was 1:128; 6 months later, IgM antibodies were negative, and the IgG titer
remained unchanged.
Our patient had a typical spectrum of clinical and laboratory changes
to Ehrlichia, but not very specific findings of infection with
E. phagocytophila. The results of IFA, i.e., IgM antibodies in
the beginning of the disease and increasing titer of IgG antibodies during
the course of the disease, confirmed the diagnosis. Granulocytic ehrlichiosis
should be considered in patients with tick-associated fever.
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