- Email: [email protected]
Heartland Virus Disease–United States, 2012-2013
INFECTIOUS DISEASE/CDC UPDATE
Update on Emerging Infections From the Centers for Disease Control and Prevention Commentators Amy M. Stubbs, MD; Mark T. Steele, MD
Heartland Virus Disease–United States, 2012-2013 [Centers for Disease Control and Prevention. Heartland virus disease–United States, 2012-2013. MMWR Morb Mortal Wkly Rep. 2014;63:270-271.] Heartland virus is a newly identified Phlebovirus that was first isolated from 2 northwestern Missouri farmers hospitalized with fever, leukopenia, and thrombocytopenia in 2009.1 According to the patients’ clinical findings and their reported exposures, the virus was suspected to be transmitted by ticks. After this discovery, the Centers for Disease Control and Prevention (CDC) worked with state and local partners to define the ecology and modes of transmission of Heartland virus, develop diagnostic assays, and identify additional cases to describe the epidemiology and clinical disease. From this work, it was learned that Heartland virus is found in the Lone Star tick (Amblyomma americanum).2 Six additional cases of Heartland virus disease were identified during 2012 to 2013; 4 of those patients were hospitalized, including 1 with comorbidities, who died. A confirmed case of Heartland virus disease was defined as a clinically compatible illness in a person with laboratory evidence of recent Heartland virus infection. A clinically compatible illness was defined as fever (38.0 C [100.4 F]), leukopenia (WBC count <4,500 cells/mm3; normal range¼4,500 to 12,000 cells/mm3), and thrombocytopenia (platelet count <150,000/mm3; normal range¼150,000 to 400,000/mm3) without a more likely clinical explanation. Evidence of recent Heartland virus infection included (1) detection of viral ribonucleic acid by reverse transcriptase–polymerase chain reaction on blood or tissue; or (2) a greater than or equal to 4-fold increase in virus-specific plaque reduction neutralization antibody titers between acute and convalescent serum specimens. During 2012 to 2013, 6 confirmed Heartland virus disease cases were identified; 5 patients were Missouri residents, and 1 was a Tennessee resident. All patients were men aged 50 years or older (median¼58 years; range¼50 to 80 years). Patients had symptom onset during May to September (3 cases in May, 1 in July, and 2 in September). All of the patients had fever, thrombocytopenia, and leukopenia when first evaluated. Of the 5 patients whose acute symptoms were systematically recorded, all reported fatigue and anorexia, and 4 reported headache, nausea, myalgia, or arthralgia. Four of the patients were hospitalized. One patient with multiple comorbidities died. All of the patients reported spending several hours per day outside (eg, working, walking, doing yard work, hunting,
314 Annals of Emergency Medicine
hiking), and 5 of the 6 patients reported tick bites in the 14 days preceding their illness onset. No vaccine or medication is available to prevent or treat Heartland virus disease. Because the virus likely is transmitted through infected ticks or other arthropods, prevention depends on using insect repellents, wearing long sleeves and pants, avoiding bushy and wooded areas, and performing tick checks after spending time outdoors. Health care providers should consider Heartland virus testing in patients who develop fever, leukopenia, and thrombocytopenia without a more likely explanation and who have tested negative for Ehrlichia and Anaplasma infection or have not responded to doxycycline therapy.3 Questions about Heartland virus testing should be directed to state health departments or to the CDC Arboviral Diseases Branch (telephone: 970-221-6400).
Section editors: David A. Talan, MD; Gregory J. Moran, MD; Satish K. Pillai, MD, MPH; Scott Santibanez, MD, MPHTM Author affiliations: From the Department of Emergency Medicine, Truman Medical Center, University of Missouri–Kansas City School of Medicine, Kansas City, MO. http://dx.doi.org/10.1016/j.annemergmed.2014.06.011
REFERENCES 1. McMullan LK, Folk SM, Kelly AJ, et al. A new Phlebovirus associated with severe febrile illness in Missouri. N Engl J Med. 2012;367:834-841. 2. Savage HM, Godsey MS Jr, Lambert A, et al. First detection of Heartland virus (Bunyaviridae: Phlebovirus) from field collected arthropods. Am J Trop Med Hyg. 2013;89:445-452. 3. Centers for Disease Control and Prevention. Heartland Virus. Atlanta, GA: US Dept of Health & Human Services, CDC; 2014; Available at: http://www.cdc.gov/ncezid/dvbd/heartland/index.html. Accessed June 21, 2014.
COMMENTARY [Ann Emerg Med. 2014;64:314-315.] Ticks are one of the most common vectors for zoonotic infections. For patients presenting with a febrile illness, a thorough history, including travel to endemic regions and outdoor activities, should be obtained to ascertain possible tick exposure. However, absence of a recent bite or exposure should not exclude consideration of these diagnoses because patients with a tick-borne illness do not always recall a tick bite.
Volume 64, no. 3 : September 2014
Update on Emerging Infections From the Centers for Disease Control and Prevention Commentators Amy M. Stubbs, MD; Mark T. Steele, MD
Heartland Virus Disease–United States, 2012-2013 [Centers for Disease Control and Prevention. Heartland virus disease–United States, 2012-2013. MMWR Morb Mortal Wkly Rep. 2014;63:270-271.] Heartland virus is a newly identified Phlebovirus that was first isolated from 2 northwestern Missouri farmers hospitalized with fever, leukopenia, and thrombocytopenia in 2009.1 According to the patients’ clinical findings and their reported exposures, the virus was suspected to be transmitted by ticks. After this discovery, the Centers for Disease Control and Prevention (CDC) worked with state and local partners to define the ecology and modes of transmission of Heartland virus, develop diagnostic assays, and identify additional cases to describe the epidemiology and clinical disease. From this work, it was learned that Heartland virus is found in the Lone Star tick (Amblyomma americanum).2 Six additional cases of Heartland virus disease were identified during 2012 to 2013; 4 of those patients were hospitalized, including 1 with comorbidities, who died. A confirmed case of Heartland virus disease was defined as a clinically compatible illness in a person with laboratory evidence of recent Heartland virus infection. A clinically compatible illness was defined as fever (38.0 C [100.4 F]), leukopenia (WBC count <4,500 cells/mm3; normal range¼4,500 to 12,000 cells/mm3), and thrombocytopenia (platelet count <150,000/mm3; normal range¼150,000 to 400,000/mm3) without a more likely clinical explanation. Evidence of recent Heartland virus infection included (1) detection of viral ribonucleic acid by reverse transcriptase–polymerase chain reaction on blood or tissue; or (2) a greater than or equal to 4-fold increase in virus-specific plaque reduction neutralization antibody titers between acute and convalescent serum specimens. During 2012 to 2013, 6 confirmed Heartland virus disease cases were identified; 5 patients were Missouri residents, and 1 was a Tennessee resident. All patients were men aged 50 years or older (median¼58 years; range¼50 to 80 years). Patients had symptom onset during May to September (3 cases in May, 1 in July, and 2 in September). All of the patients had fever, thrombocytopenia, and leukopenia when first evaluated. Of the 5 patients whose acute symptoms were systematically recorded, all reported fatigue and anorexia, and 4 reported headache, nausea, myalgia, or arthralgia. Four of the patients were hospitalized. One patient with multiple comorbidities died. All of the patients reported spending several hours per day outside (eg, working, walking, doing yard work, hunting,
314 Annals of Emergency Medicine
hiking), and 5 of the 6 patients reported tick bites in the 14 days preceding their illness onset. No vaccine or medication is available to prevent or treat Heartland virus disease. Because the virus likely is transmitted through infected ticks or other arthropods, prevention depends on using insect repellents, wearing long sleeves and pants, avoiding bushy and wooded areas, and performing tick checks after spending time outdoors. Health care providers should consider Heartland virus testing in patients who develop fever, leukopenia, and thrombocytopenia without a more likely explanation and who have tested negative for Ehrlichia and Anaplasma infection or have not responded to doxycycline therapy.3 Questions about Heartland virus testing should be directed to state health departments or to the CDC Arboviral Diseases Branch (telephone: 970-221-6400).
Section editors: David A. Talan, MD; Gregory J. Moran, MD; Satish K. Pillai, MD, MPH; Scott Santibanez, MD, MPHTM Author affiliations: From the Department of Emergency Medicine, Truman Medical Center, University of Missouri–Kansas City School of Medicine, Kansas City, MO. http://dx.doi.org/10.1016/j.annemergmed.2014.06.011
REFERENCES 1. McMullan LK, Folk SM, Kelly AJ, et al. A new Phlebovirus associated with severe febrile illness in Missouri. N Engl J Med. 2012;367:834-841. 2. Savage HM, Godsey MS Jr, Lambert A, et al. First detection of Heartland virus (Bunyaviridae: Phlebovirus) from field collected arthropods. Am J Trop Med Hyg. 2013;89:445-452. 3. Centers for Disease Control and Prevention. Heartland Virus. Atlanta, GA: US Dept of Health & Human Services, CDC; 2014; Available at: http://www.cdc.gov/ncezid/dvbd/heartland/index.html. Accessed June 21, 2014.
COMMENTARY [Ann Emerg Med. 2014;64:314-315.] Ticks are one of the most common vectors for zoonotic infections. For patients presenting with a febrile illness, a thorough history, including travel to endemic regions and outdoor activities, should be obtained to ascertain possible tick exposure. However, absence of a recent bite or exposure should not exclude consideration of these diagnoses because patients with a tick-borne illness do not always recall a tick bite.
Volume 64, no. 3 : September 2014