Alpha-Gal Syndrome in the Infectious Diseases Clinic: A Series of 5 Cases in Central North Carolina.

Background: Alpha-gal syndrome (AGS) is a recently described allergy to galactose-α-1,3-galactose, an oligosaccharide present in mammalian meat. AGS can present with angioedema, urticaria, and anaphylaxis arising 3-6 hours after ingestion, although symptoms such as gastrointestinal distress, fatigue, and arthralgias are also reported. Because AGS appears to be associated with tick bites, patients may present to infectious diseases (ID) clinics for evaluation. Methods: We documented a series of 5 patients referred to the University of North Carolina ID Clinic between 2020 and 2022 for various tick-borne infections that were found to have symptoms and laboratory testing consistent with AGS. Patients were subsequently referred to the Allergy and Immunology Clinic. Results: Patients were referred to the ID Clinic for persistent symptoms following positive tick-borne disease testing or presumed tick-borne infection. All patients had an elevated alpha-gal immunoglobulin E and clinical presentation consistent with AGS. Common symptoms included episodic gastrointestinal distress (eg, cramping, nausea, diarrhea), fatigue, arthralgias, and subjective cognitive impairment, but a notable absence of severe anaphylaxis. Four patients were seen by at least 1 nonallergy specialist prior to referral to ID. Patients reported substantial improvement in their symptoms following dietary restriction. Conclusions: ID physicians should be aware of AGS as a cause of persistent, nonspecific symptoms following a tick exposure or tick-borne illness. Further research is needed to determine the prevalence of alpha-gal sensitization and AGS following tick-borne bites.

Remember to Screen the Spleen: A Case Study of Spontaneous Splenic Rupture

Introduction: Splenic rupture is a potentially life-threatening condition often associated with trauma or viral infection. Most cases of splenic rupture are due to trauma, viral infection, lymphoproliferative disease, malaria, tick borne illness, splenic neoplasms, connective tissue disease, or in one case, sneezing. Spontaneous splenic rupture (SSR) is a rare condition with less than five cases reported. In this case, we present a 20-year-old male who was seen with abdominal pain who was found to have an SSR with no clear etiology. Case Description/Methods: A 20-year-old male with no relevant past medical history presented with abdominal pain that radiated to the left shoulder. The patient reported the pain began after an episode of emesis which occurred 12 hours prior to arrival. He reported experiencing shortness of breath and pain on inspiration. He denied any fall or trauma, recent travel or sick contacts, fevers, weight loss, or night sweats. His social history was significant for occasional marijuana use. Upon physical exam, the patient had diffuse abdominal tenderness most pronounced in the left upper quadrant without any palpable masses. Relevant labs included a hemoglobin of 12.2, WBC count within normal limits and unremarkable manual differential, and an INR of 1. Blood parasite, heterophile antibodies, COVID, influenza, CMV, and HIV were negative. Computed tomography angiography (CTA) revealed hematoma at the splenic hilum. Interventional radiology was consulted and did not recommend intervention at time of initial presentation. Patient was admitted;his hemoglobin remained stable and he was monitored with serial abdominal exam then discharged the following day. Imaging was repeated one month later which revealed near complete resolution of hematoma. (Figure) Discussion: SSR should be considered on the differential diagnosis of physicians when encountering patients who present with LUQ pain with unclear etiology. The patient presented with the characteristic Kehr's sign (left diaphragmatic irritation resulting in referred pain to the left shoulder) but not the Ballance sign (palpable tender mass in the left upper quadrant). The incidence of SSR is estimated to be around 1 to 7% with a mortality rate of 12.2% so a broad differential for young patients presenting with abdominal pain must be entertained and should include splenic rupture as it is a potentially life-threatening condition.

Hepatotoxicity From Marijuana Gummies

Introduction: We report a case of drug-induced liver injury (DILI) induced by cannabis gummies containing Corydalis Rhizome. Case Description/Methods: A 37-year-old female presented to her primary care clinic with recurrent fevers, night sweats, and myalgias for 7 weeks accompanied by eye redness, brain fog, headache, nausea, and abdominal pain. She denied rashes, tick-bites, cough, dyspnea, chest pain, joint swelling, or genitourinary symptoms. Past medical history was notable for IBS, migraines, and anxiety. She reported edible marijuana use four times a week, rare alcohol use, and denied tobacco use. She denied a family history of liver disease. Physical exam was notable for tachycardia to 110 and scleral injection with the remainder of vitals and exam unremarkable. Initial labs were notable for AST 61, ALT 44 and CRP of 12. CBC, BMP, urinalysis, ESR, blood cultures, blood smear for parasite screen, tests for Lyme disease, Babesia, Tularemia, Anaplasma, Ehrlichia, Rickettsia, EBV, HIV, RPR, ANA, CMV, parvovirus B19, and chest x-ray were all negative. The patient was referred to infectious disease with further testing for West Nile, Leptospira, lymphocytic choriomeningitis virus, and COVID-19 returning negative. Repeat LFTs showed worsening transaminitis with ALT 979 and AST 712, alkaline phosphatase 88, total bilirubin 0.7, and albumin 4.9. Hepatitis workup including hepatitis A, B, and C, HSV, EBV, VZV serologies, AMA, ASMA, antiLKM Ab, acetaminophen level, INR, iron panel, CPK, TSH, and abdominal ultrasound were all normal. It was later discovered that her marijuana gummies contained Corydalis rhizome extract known to be hepatotoxic. Cessation of this drug was strongly advised. She was discharged with hepatology follow-up and underwent a liver biopsy showing patchy periportal and lobular inflammation with extension across the limiting plate, hepatocyte injury and apoptosis, and increased lipofuscin for age compatible with mild to moderate hepatitis. She had complete recovery after cessation of Corydalis-containing gummies. (Figure) Discussion: Our patient consumed '1906 Midnight', an American cannabis brand containing Corydalis rhizopus 100 mg, advertised to improve sleep, pain, and have a liver protective effect. A Korean systematic review on herbal-induced liver injury reported that Corydalis was the 3rd most frequent causative herb, with 36 cases. Although there are several personal accounts on social networking sites and other websites, there are no American-based publications reported on DILI from Corydalis. (Table Presented).

A Perspective on Current Flavivirus Vaccine Development: A Brief Review.

The flavivirus genus contains several clinically important pathogens that account for tremendous global suffering. Primarily transmitted by mosquitos or ticks, these viruses can cause severe and potentially fatal diseases ranging from hemorrhagic fevers to encephalitis. The extensive global burden is predominantly caused by six flaviviruses: dengue, Zika, West Nile, yellow fever, Japanese encephalitis and tick-borne encephalitis. Several vaccines have been developed, and many more are currently being tested in clinical trials. However, flavivirus vaccine development is still confronted with many shortcomings and challenges. With the use of the existing literature, we have studied these hurdles as well as the signs of progress made in flavivirus vaccinology in the context of future development strategies. Moreover, all current licensed and phase-trial flavivirus vaccines have been gathered and discussed based on their vaccine type. Furthermore, potentially relevant vaccine types without any candidates in clinical testing are explored in this review as well. Over the past decades, several modern vaccine types have expanded the field of vaccinology, potentially providing alternative solutions for flavivirus vaccines. These vaccine types offer different development strategies as opposed to traditional vaccines. The included vaccine types were live-attenuated, inactivated, subunit, VLPs, viral vector-based, epitope-based, DNA and mRNA vaccines. Each vaccine type offers different advantages, some more suitable for flaviviruses than others. Additional studies are needed to overcome the barriers currently faced by flavivirus vaccine development, but many potential solutions are currently being explored.

Borrelia miyamotoi Infection in Immunocompromised Man, California, USA, 2021.

Infection with Borrelia miyamotoi in California, USA, has been suggested by serologic studies. We diagnosed B. miyamotoi infection in an immunocompromised man in California. Diagnosis was aided by plasma microbial cell-free DNA sequencing. We conclude that the infection was acquired in California.

Tick-borne encephalitis epidemiology and surveillance in Poland, and comparison with selected European countries before and during the COVID-19 pandemic, 2008 to 2020.

BackgroundTick-borne encephalitis (TBE) is the most common viral central nervous system (CNS) infection in Poland. Previous research suggests that its incidence was underestimated in the pre-pandemic period. The COVID-19 pandemic caused a considerable burden on surveillance systems, which could further impact reporting.AimWe aimed to assess the completeness of reporting of TBE in the years 2008 to 2020 and explore the potential impact of the COVID-19 pandemic on reporting to the epidemiological surveillance system, compared with hospitalisations for TBEV and other viral neuro-infections.MethodsWe compared the Polish epidemiology of TBE and other viral infections of the CNS from national surveillance reports with data on hospitalisations from 2008 to 2020 and data from selected European countries.ResultsBetween 2008 and 2020, 3,016 TBE cases were reported to surveillance compared with 3,620 hospitalisations. There was an increasing trend in hospitalisations, while surveillance data demonstrated the opposite, with the largest discrepancy observed in the first pandemic year (354 hospitalisations vs 159 cases reported to surveillance). Serological testing for TBE was used more in the known endemic region of north-eastern Poland and less in non-endemic areas. Other European countries reported higher TBE case numbers and an increase during the COVID-19 pandemic, whereas Poland observed an opposite trend.ConclusionThe sensitivity of TBE surveillance in Poland requires improvement. There are considerable regional differences. Regions that test for TBE intensively report most cases. Policymakers should be made aware of the value of quality epidemiological data for planning prophylactic measures in risk areas.

Case report: human granulocytic anaplasmosis causes acute myopericarditis with atrial fibrillation.

Background: Tick-borne illness are becoming increasingly common, in a spreading geographic area. Lyme disease is a well-known cause of cardiovascular disease, but anaplasmosis has previously had relatively little reported association with conduction and myocardial disease. Case Summary: A 65-year-old man with fever and malaise was admitted to the intensive care unit in shock. Electrocardiogram showed new atrial fibrillation and conduction abnormalities. Transthoracic echocardiogram demonstrated normal left ventricular ejection fraction but significant right ventricle dysfunction. Cardiac magnetic resonance imaging findings were consistent with myopericarditis. Workup revealed human granulocytic anaplasmosis without Lyme. He recovered with doxycycline. Conclusion: To our knowledge, this is one of the first reported cases of anaplasmosis causing electrical conduction and myocardial disease with haemodynamic instability in an isolated infection. Treatment with appropriate antibiotics and supportive care allowed the patient to recover to his functional baseline within a month from being discharged from the hospital. Recognition of anaplasmosis in the absence of Lyme disease as a potential cause of electrical and myocardial disease is important in the context of increasing anaplasmosis incidence across the United States.

The Troublesome Ticks Research Protocol: Developing a Comprehensive, Multidiscipline Research Plan for Investigating Human Tick-Associated Disease in Australia.

In Australia, there is a paucity of data about the extent and impact of zoonotic tick-related illnesses. Even less is understood about a multifaceted illness referred to as Debilitating Symptom Complexes Attributed to Ticks (DSCATT). Here, we describe a research plan for investigating the aetiology, pathophysiology, and clinical outcomes of human tick-associated disease in Australia. Our approach focuses on the transmission of potential pathogens and the immunological responses of the patient after a tick bite. The protocol is strengthened by prospective data collection, the recruitment of two external matched control groups, and sophisticated integrative data analysis which, collectively, will allow the robust demonstration of associations between a tick bite and the development of clinical and pathological abnormalities. Various laboratory analyses are performed including metagenomics to investigate the potential transmission of bacteria, protozoa and/or viruses during tick bite. In addition, multi-omics technology is applied to investigate links between host immune responses and potential infectious and non-infectious disease causations. Psychometric profiling is also used to investigate whether psychological attributes influence symptom development. This research will fill important knowledge gaps about tick-borne diseases. Ultimately, we hope the results will promote improved diagnostic outcomes, and inform the safe management and treatment of patients bitten by ticks in Australia.

Evaluation of Crimean-Congo Hemorrhagic Fever Cases During the COVID-19 Pandemic Period

Introduction: Crimean-Congo Hemorrhagic Fever (CCHF) is a zoonotic disease that progresses with fever and bleeding and is endemic in our region. In this study, we aimed to determine the symptoms, transmission routes and risk factors in CCHF patients who have similar clinical features with COVID-19, and to investigate the relationship between CCHF cases and COVID-19 restrictions in our region where CCHF is endemic. Materials and Methods: One hundred fifty-nine patients diagnosed with CCHF in the infectious diseases and clinical microbiology clinic between April 2021 and September 2021 were included in the study. A questionnaire consisting of a set of questions was filled in for patients diagnosed with CCHF, in which demographic data, admission complaints, risk factors and habits during the COVID-19 pandemic were evaluated. Results: The mean age of the 159 CCHF patients included in the study was 50.9 +/- 18.5 years and 59.7% were male. The most frequently reported complaints by the patients were fatigue (94.5%), muscle-joint pain (79.9%) and fever (74.2%). During the disease period, COVID-19 was suspected in 62.3% of them, PCR test was applied to all of them, and the result was positive in only one patient. There was no change of residence of the patients during the illness period. There was no significant increase in the population of the residence area or the frequency of visits due to the pandemic. The number of patients who reported an increase in the number of ticks in their environment was 44 (27.8%). It was determined that there was no significant increase in the number of activities such as visiting rural areas or having a picnic due to the COVID-19 pandemic. Only 32.2% of patients engaged in animal husbandry or field work reported an increase in the frequency of these jobs compared to the pre-pandemic period. Conclusion: The reason for the increase in the number of CCHF cases in our center was not associated with the increase in the frequency of visits to rural areas or the change of residence during the COVID-19 pandemic period.

Our People: Pursuing Positivity in the Pandemic - 'Pause Power up Push on'

Background The pandemic has highlighted the importance of wellbeing and supporting each other. A UK Parliament study showed that 50% of NHS staff felt their mental health declined during the first two months. The 'Pause Power Up, Push On' (PPP) initiative focuses on positivity and wellbeing, not only during the pandemic but in the recovery phase and beyond. Wellbeing research shows regular breaks are crucial for replenishing energy and when taken with others the wellbeing effects are heightened. Aims ////. To empower teams to take a break together. . To boost morale through promoting balanced working environments. Methods The PPP initiative was implemented using a Quality Improvement (QI) model. A 'Rooftop Rota' encouraged every specialty to take at least one break during the week using the 'Rooftop Garden' (in line with social-distancing guidance). Departments were able to 'tick' attendance and encouraged to take photos promoting inter-specialty competition. A logo and slogan were shared through posters screensavers and pin-badges. Presentations were delivered at forums including Senior Management Leadership Workforce Leads, Junior Doctor Forum and departmental meetings - encompassing different seniorities specialties and disciplines. This project did not require ethics approval but was endorsed by the senior leadership team following a risk assessment. Results An initial questionnaire demonstrated 27% of staff never take a break during the working day. The PPP initiative was piloted for two months to improve this evidenced by rooftop attendance. A follow-up questionnaire will be completed in September 2021 as part of the ongoing QI cycle. Discussion/Conclusion Feedback is unanimously positive. Staff report feeling 'enthusiastic and energised' by PPP and empowered to incorporate breaks into their day. The initiative has also highlighted departments which have not participated and can prompt investigation into why. Despite the challenges we face through supporting each other we can continue to shine together.

An evaluation of the laboratory and clinical data of the Crimean-Congo hemorrhagic fever patients during the COVID-19 pandemic

In this study, the purpose was to investigate the demographic, laboratory, and clinical characteristics of the Crimean-Congo Hemorrhagic Fever (CCHF) cases that were treated in our hospital during the Coronavirus disease-2019 (COVID-19) pandemic. It was also investigated whether the patients hospitalized with a provisional diagnosis of CCHF who tested negative for CCHF PCR were infected with COVID-19. In our study, data (epidemiological, clinical, laboratory, prognosis) from 38 patients diagnosed with CCHF through reverse-transcriptase polymerase chain reaction (PCR) and viral-RNA and/or Immunoglobulin M antibodies using ELISA between May 2020 and November 2022 were investigated retrospectively. Of all the patients, 23 were CCHF PCR (+) and 15 were CCHF PCR (-).15 (65.2%) of PCR (+) patients and 9 (60%) of PCR (-) patients were engaged in farming. 65.2% of PCR (+) and 26.7% of PCR (-) patients presented with a history of tick bites. 21 (91.3%) of PCR (+) and 12 (80%) of PCR (-) patients had a history of rural living. Among the PCR (+) patients, 65.2%, 17.4%, and 17.4% received treatment for CCHF in 2022, 2021, and 2020 respectively. 87% of PCR (+) and 60% of PCR (-) patients were discharged after full recovery. The most common symptoms were fever, diffuse body ache, weakness, and headache. Significant differences were found between PCR (+) and PCR (-) patients in terms of leukocytes, LDH, INR, NEU, PLT, fibrinogen, and NLR values. 3 patients hospitalized with a provisional diagnosis of CCHF tested negative for CCHF PCR and positive for COVID-19 PCR. Thoracic CT, clinical, and laboratory findings of these patients showed no differences from the other patients. The possibility of misdiagnosis should be considered in CCHF and COVID-19 infections due to their similar symptoms and indications. Extensive multicentric studies need to be conducted to investigate the causes of the increased number of CCHF cases during the pandemic. © 2023 Ondokuz Mayis Universitesi. All rights reserved.

[Influence of the COVID-19 pandemic on the occurrence of neurological infectious diseases]. / Einfluss der COVID-19-Pandemie auf das Auftreten neuroinfektiologischer Erkrankungen.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic a wide range of hygiene measures were implemented to contain the spread of infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Besides a mitigation of SARS-CoV­2, a decline in the number of other respiratory tract infections could be observed. Interestingly, the numbers for some infections of the central nervous system (CNS) decreased as well. OBJECTIVE: This review article shows the development of important CNS infections in Germany during the COVID-19 pandemic. MATERIAL AND METHOD: This article is based on relevant literature on the epidemiology of CNS infections during the COVID-19 pandemic up to autumn 2022. RESULTS: During the COVID-19 pandemic the frequency of bacterial meningitis caused by Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae significantly declined. The frequency of viral meningitis, particularly those caused by Enterovirus, decreased as well. In contrast, the number of patients suffering from tick-borne encephalitis significantly increased within the first year of the pandemic. DISCUSSION: During the pandemic there was a decrease in cases of bacterial and viral meningitis, most likely due to the general containment strategies and social contact restrictions. The increase of infections transmitted by ticks could be a consequence of changed leisure activities during the pandemic.

Redox Imbalance and Its Metabolic Consequences in Tick-Borne Diseases.

One of the growing global health problems are vector-borne diseases, including tick-borne diseases. The most common tick-borne diseases include Lyme disease, tick-borne encephalitis, human granulocytic anaplasmosis, and babesiosis. Taking into account the metabolic effects in the patient's body, tick-borne diseases are a significant problem from an epidemiological and clinical point of view. Inflammation and oxidative stress are key elements in the pathogenesis of infectious diseases, including tick-borne diseases. In consequence, this leads to oxidative modifications of the structure and function of phospholipids and proteins and results in qualitative and quantitative changes at the level of lipid mediators arising in both reactive oxygen species (ROS) and ROS enzyme-dependent reactions. These types of metabolic modifications affect the functioning of the cells and the host organism. Therefore, links between the severity of the disease state and redox imbalance and the level of phospholipid metabolites are being searched, hoping to find unambiguous diagnostic biomarkers. Assessment of molecular effects of oxidative stress may also enable the monitoring of the disease process and treatment efficacy.

Difficulties of differential diagnosis of polyneuropathy developed after Gam-COVID-Vac vaccination on the background of combined infectious pathology (clinical case).

The clinical case describes the difficulties of differential diagnosis of polyneuropathy that developed, after Gam-Covid-Vac vaccination on the background, of combined, infectious pathology (HIV infection, tick-borne borreliosis, COVID-19) in a young woman. It is shown that various infectious and noninfectious diseases with similar clinical symptoms (peripheral nervous system, affliction.) occurring simultaneously in one patient can significantly affect each other's course and. complicate the establishment of the true cause of polyneuropathy. It should, be noted, that in this example, the establishment of a final diagnosis was carried out collectively, by consensus, and. was based, on the effectiveness of etiotropic (antibacterial) treatment, which in fact was an exjuvantibus therapy option, which made it possible to establish the most probable etiology of polyneuropathy -tick-borne borreliosis. In turn, HIV infection and. possibly vaccination, according to the authors, could, cause immunosuppression, which, affected, the degree of dissemination, of Borrelia burgdorferi. It is also likely that the insufficient immune response in combination. with the cascade plasma filtration session affected the initial dubious results of the serological tests, which further complicated. the diagnosis.Copyright © 2022 Authors. All rights reserved.

Difficulties of differential diagnosis of polyneuropathy developed after Gam-COVID-Vac vaccination on the background of combined infectious pathology (clinical case).

The clinical case describes the difficulties of differential diagnosis of polyneuropathy that developed, after Gam-Covid-Vac vaccination on the background, of combined, infectious pathology (HIV infection, tick-borne borreliosis, COVID-19) in a young woman. It is shown that various infectious and noninfectious diseases with similar clinical symptoms (peripheral nervous system, affliction.) occurring simultaneously in one patient can significantly affect each other's course and. complicate the establishment of the true cause of polyneuropathy. It should, be noted, that in this example, the establishment of a final diagnosis was carried out collectively, by consensus, and. was based, on the effectiveness of etiotropic (antibacterial) treatment, which in fact was an exjuvantibus therapy option, which made it possible to establish the most probable etiology of polyneuropathy -tick-borne borreliosis. In turn, HIV infection and. possibly vaccination, according to the authors, could, cause immunosuppression, which, affected, the degree of dissemination, of Borrelia burgdorferi. It is also likely that the insufficient immune response in combination. with the cascade plasma filtration session affected the initial dubious results of the serological tests, which further complicated. the diagnosis.Copyright © 2022 Authors. All rights reserved.

Evaluation of Crimean-Congo Hemorrhagic Fever Cases During the COVID-19 Pandemic Period.

Introduction: Crimean-Congo Hemorrhagic Fever (CCHF) is a zoonotic disease that progresses with fever and bleeding and is endemic in our region. In this study, we aimed to determine the symptoms, transmission routes and risk factors in CCHF patients who have similar clinical features with COVID-19, and to investigate the relationship between CCHF cases and COVID-19 restrictions in our region where CCHF is endemic. Material(s) and Method(s): One hundred fifty-nine patients diagnosed with CCHF in the infectious diseases and clinical microbiology clinic between April 2021 and September 2021 were included in the study. A questionnaire consisting of a set of questions was filled in for patients diagnosed with CCHF, in which demographic data, admission complaints, risk factors and habits during the COVID-19 pandemic were evaluated. Result(s): The mean age of the 159 CCHF patients included in the study was 50.9 +/- 18.5 years and 59.7% were male. The most frequently reported complaints by the patients were fatigue (94.5%), muscle-joint pain (79.9%) and fever (74.2%). During the disease period, COVID-19 was suspected in 62.3% of them, PCR test was applied to all of them, and the result was positive in only one patient. There was no change of residence of the patients during the illness period. There was no significant increase in the population of the residence area or the frequency of visits due to the pandemic. The number of patients who reported an increase in the number of ticks in their environment was 44 (27.8%). It was determined that there was no significant increase in the number of activities such as visiting rural areas or having a picnic due to the COVID-19 pandemic. Only 32.2% of patients engaged in animal husbandry or field work reported an increase in the frequency of these jobs compared to the pre-pandemic period. Conclusion(s): The reason for the increase in the number of CCHF cases in our center was not associated with the increase in the frequency of visits to rural areas or the change of residence during the COVID-19 pandemic period.Copyright © Telif Hakki 2022 Flora.

Tick-Borne Illness Ticking Off the Heart: A Case of Cardiomyopathy Due to Anaplasmosis

Background Human granulocytic anaplasmosis (HGA) is a tick-borne disease caused by Anaplasma phagocytophilum. The most common presenting features are transaminitis, leukopenia, thrombocytopenia, fever, and malaise. HGA causing cardiomyopathy likely from myocarditis is uncommon but a serious complication. Case A 70 year-old male with a history of coronary artery disease presented with fever (38.3 C) and dyspnea on exertion. He was found to have hypoxic respiratory failure, pancytopenia, acute kidney injury and transaminitis. He was treated empirically with ceftriaxone and doxycline. Baseline electrocardiogram was unremarkable for ischemia. However, he had troponin elevation and was decompensated on exam. Bedside transthoracic echocardiogram (TTE) showed LVEF of 20-25% for which he was administered dobutamine and monitored in intensive care unit (ICU). Repeat TTE illustrated LVEF 30-35% with moderate diffuse hypokinesis of LV. Blood and urine cultures were negative. He tested positive for Anaplasma DNA-PCR with unremarkable rest of the tick borne, viral and parasitic panel. He was then continued with doxycycline for 14 days for sepsis due to Anaplasmosis. Follow up TTE in a month showed improved LVEF to 40% with resolution of his symptoms. Decision-making Our patient presented with common tick-borne illness symptoms and signs, which prompted initiation of empiric antibiotics. However, the significantly reduced LVEF and elevated troponins were concerning for which he was monitored in ICU. Cardiac magnetic resonance imaging was not pursued due to delay in transfer process to the higher center amidst COVID pandemic and ongoing sepsis due to Anaplasmosis. After the results of HGA PCR, he was continued on a 14-day course of doxycycline which eventually resolved his symptoms. Conclusion There must be a high level of suspicion for cardiomyopathy if the patient is being empirically treated for tick-borne illness and has decompensated heart failure symptoms. PCR is the most sensitive test for diagnosing HGA. However, the test results should not delay the treatment as tick-borne illness responds well to doxycycline which should alleviate the heart failure symptoms as seen in our case.Copyright © 2023 American College of Cardiology Foundation

Subsequent vaccinations in VITT patients other than SARS-CoV2 vaccination

Introduction Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare, but severe side effect after vaccination with adenovirus vector-based vaccines (ChAdOx1 nCoV-19, AstraZeneca and Ad26.COV2.S, Johnson & Johnson/ Janssen) in which platelet activating anti-platelet factor 4 (PF4) antibodies cause thrombocytopenia and thrombosis at unusual sites. Patients and treating physicians are concerned about whether other vaccinations can also trigger thrombosis in patients with a history of VITT. We showed that VITT patients can safely receive their second and third vaccination against Covid-19 with an mRNA-based vaccine. [1] However, there is limited information on whether other vaccines than against Covid-19 could booster platelet activating anti-PF4 antibodies. Uncertainty increased after a report of VITT caused by human papilloma vaccination. [2] Method In our follow-up study of patients with laboratory confirmed VITT (EUPAS45098), an anti-PF4/heparin IgG enzyme immune assay (EIA) and a PF4-dependent platelet activation assay (PIPA) were performed at regular intervals and after each vaccination reported to us. Results Seventy-one VITT patients (43 female, median age at VITT diagnosis 48, range 18-80) were followed for a median of 56 weeks (range: 13-77 weeks). During the follow-up period, eight vaccinations other than against Covid-19 were reported: Six vaccinations against influenza (three Influvac, two Vaxigrip Tetra, one Influsplit Tetra) and two consecutive vaccinations against tick-borne encephalitis (TBE) in one patient. In six patients who received vaccination against influenza, all patients showed decreasing or stable EIA optical density (OD) levels. None of them showed a reactivation of platelet-activating anti- PF4-antibodies in the PIPA. The patient who was vaccinated against TBE twice showed stable EIA OD levels and remained negative in the PIPA throughout. No new thrombosis or recurrent thrombocytopenia were observed after any vac- cination. Five out of six patients still received therapeutic anticoagulation, one patient did not receive any anticoagulative drug (Fig. 1). Conclusion Similar to observations after consecutive mRNA-vaccinations against Covid-19 in VITT patients, vaccinations against influenza and TBE very unlikely reactivate platelet-activating anti-PF4-antibodies. Further follow up of the VITT patient cohort is performed to detect any new safety signal related to recurrence of VITT. (Table Presented).

Spatiotemporal spread of tick-borne encephalitis in the EU/EEA, 2012 to 2020.

BackgroundTick-borne encephalitis (TBE) is a vaccine-preventable disease involving the central nervous system. TBE became a notifiable disease on the EU/EEA level in 2012.AimWe aimed to provide an updated epidemiological assessment of TBE in the EU/EEA, focusing on spatiotemporal changes.MethodsWe performed a descriptive analysis of case characteristics, time and location using data of human TBE cases reported by EU/EEA countries to the European Centre for Disease Prevention and Control with disease onset in 2012-2020. We analysed data at EU/EEA, national, and subnational levels and calculated notification rates using Eurostat population data. Regression models were used for temporal analysis.ResultsFrom 2012 to 2020, 19 countries reported 29,974 TBE cases, of which 24,629 (98.6%) were autochthonous. Czechia, Germany and Lithuania reported 52.9% of all cases. The highest notification rates were recorded in Lithuania, Latvia, and Estonia (16.2, 9.5 and 7.5 cases/100,000 population, respectively). Fifty regions from 10 countries, had a notification rate ≥ 5/100,000. There was an increasing trend in number of cases during the study period with an estimated 0.053 additional TBE cases every week. In 2020, 11.5% more TBE cases were reported than predicted based on data from 2016 to 2019. A geographical spread of cases was observed, particularly in regions situated north-west of known endemic regions.ConclusionA close monitoring of ongoing changes to the TBE epidemiological situation in Europe can support the timely adaption of vaccination recommendations. Further analyses to identify populations and geographical areas where vaccination programmes can be of benefit are needed.

Powassan Virus Lineage I in Field-Collected Dermacentor variabilis Ticks, New York, USA.

Powassan virus is a tickborne flavivirus that can cause lethal or debilitating neurologic illness. It is canonically transmitted by Ixodes spp. ticks but might spill over to sympatric Dermacentor species. We detected Powassan virus lineage I from a pool of field-collected D. variabilis ticks in New York, USA.