Pasteurella multocida Infections with Unusual Modes of Transmission from Animals to Humans: A Study of 79 Cases with 34 Nonbite Transmissions.

Pasteur discovered the causative agent of fowl cholera (Pasteurella multocida) in 1880. Since then, multiple zoonotic infections affecting humans have been reported. P. multocida infections usually result from bites of cats or dogs. The earliest reports of nonbite transmissions (NBTs) were attributed to cat scratches and lung colonization. More recently, multiple modes of unusual NBTs have been reported, including animal exposures with no direct contact. Here, we report 79 cases of pet-associated infections, with 34 NBTs. Previously unreported and unsuspected, novel modes of NBTs presented include stepping on dog drool infecting a submetatarsal ulcer, contamination of a wound by socks covered with cat hair and dander resulting in P. multocida bacteremia, stumbling over a dog and falling while drunk and abrasions contaminated with dog saliva resulting in wound infection, and severe epiglottitis and supraglottitis after eating peanut butter and crackers half eaten by a dog. Cat bites were more common than dog bites. Both bite and nonbite infections were more common in the elderly, with more older patients in the nonbite group. Upper extremity bites were more than lower extremity bites for both cats and dogs. NBTs were associated with more co-morbidities and resulted in more life-threatening infections than bites, confirming the findings of a prior smaller series. Open wounds were the most common point of entry for nonbite infections, with majority in the lower extremity. Based on this study and prior reports, pet owners must protect open wounds and individuals with certain underlying conditions and infants should avoid pet exposure completely. Our findings and animal transmission of bite and nonbite P. multocida infections reported in literature are summarized.

First case report of inducible heart block in Lyme disease and an update of Lyme carditis.

BACKGROUND: Lyme disease (LD), is the most common vector-borne illness in the US and Europe, with predominantly cutaneous, articular, cardiac and neuro-psychiatric manifestations. LD affects all layers of the heart and every part of the conducting system. Carditis is a less common manifestation of LD. Heart block (HB) as the initial and sole manifestation of LD is rare. Inducible HB has never been reported in LD. We report a case of heart block (HB) inducible with exercise and reversible with rest. CASE PRESENTATION: A 37-year-old male presented to the emergency department after experiencing two episodes of syncope while at work. He presented, with a heart rate of 57 bpm, and the ECG showed sinus bradycardia with first degree AV block. The PR interval was 480 ms (NL 120-200 ms). Physical exam was unremarkable. The cardiologist's initial impression was vaso-vagal attack. He developed high degree AV block during a stress test for the initial work up, which resolved on cessation of exercise. A similar episode while walking in the hallway, resolved at rest. The high degree AV block appeared inducible with exercise and reversible with rest. His Lyme serology was strongly positive. He was treated with ceftriaxone and doxycycline. After completing treatment, the patient had a normal ECG and returned to work without limitations, doing manual labor. CONCLUSIONS: Manifestations of Lyme carditis (LC) vary from asymptomatic and symptomatic electrocardiographic changes and heart block (HB) reversible with treatment, to sudden death. HB as the sole and initial presentation of LC is rare. There have been no reports of inducible HB in LD. Here we present a case of inducible and reversible high degree HB in a case of LC and an update of literature. Exercise and stress testing should be avoided in suspected cases of LC until resolution of carditis. Lyme carditis should be suspected in individuals with cardiac manifestations in an endemic area, particularly in the younger patients with no other etiology evident.

Report of Non-Lyme, Erythema Migrans Rashes from New Jersey with a Review of Possible Role of Tick Salivary Toxins.

Erythema migrans (EM) rashes once considered pathognomonic of Lyme disease (LD) have been reported following bites of arthropods that do not transmit LD and in areas with no LD. Also, EM rashes have been reported in association with organisms other than members of Borrelia burgdorferi sensu lato complex. Arthropod saliva has chemicals that have effects on the host and pathogen transmission. Tick saliva has protein families similar to spiders and scorpions and even substances homologous to those found in snakes and other venomous animals. Ticks "invertebrate pharmacologists" have a sophisticated arsenal of chemicals that assist in blood feeding, pathogen transmission, and suppressing host defenses. No organisms have been isolated from many EM rashes. We propose that tick salivary toxins may play a role in the causation of rashes and laboratory abnormalities in tick-borne diseases. The role of tick salivary toxins needs further exploration. Cases of Lyme-like EM rashes referred to as STARI (Southern Tick-Associated Rash Illness) following bites of the lone star tick, Amblyomma americanum, in the United States have been reported predominantly in Southeastern Missouri and a few in South Carolina, North Carolina, Georgia, and one case each in Mississippi and Long Island, New York. Although there is one report of Borrelia lonestari in a patient with a rash, biopsies of 31 cases of STARI, with cultures and PCR, failed to show a relationship. Distribution of A. americanum, whose bites are associated with STARI, now extends along the East Coast of the United States, including New Jersey, up to the Canadian border. As far as we are aware, there have been no prior reports of Lyme-like rashes in New Jersey. In this study, we present case examples of 2 Lyme-like rashes, variations of EM rashes, and a brief review of studies that suggest a role of tick salivary toxins in tick-borne diseases.