On December 13, 2013, MMWR published a report describing three cases of sudden cardiac death associated with Lyme carditis. State public health departments and CDC conducted a follow-up investigation to determine 1) whether carditis was disproportionately common among certain demographic groups of patients diagnosed with Lyme disease, 2) the frequency of death among patients diagnosed with Lyme disease and Lyme carditis, and 3) whether any additional deaths potentially attributable to Lyme carditis could be identified. Lyme disease cases are reported to CDC through the Nationally Notifiable Disease Surveillance System; reporting of clinical features, including Lyme carditis, is optional. For surveillance purposes, Lyme carditis is defined as acute second-degree or third-degree atrioventricular conduction block accompanying a diagnosis of Lyme disease. During 2001-2010, a total of 256,373 Lyme disease case reports were submitted to CDC, of which 174,385 (68%) included clinical information. Among these, 1,876 (1.1%) were identified as cases of Lyme carditis. Median age of patients with Lyme carditis was 43 years (range = 1-99 years); 1,209 (65%) of the patients were male, which is disproportionately larger than the male proportion among patients with other clinical manifestations (p<0.001). Of cases with this information available, 69% were diagnosed during the months of June-August, and 42% patients had an accompanying erythema migrans, a characteristic rash. Relative to patients aged 55-59 years, carditis was more common among men aged 20-39 years, women aged 25-29 years, and persons aged ≥75 years.

Lyme disease is a multisystem illness caused by Borrelia burgdorferi, a spirochete transmitted by certain species of Ixodes ticks. Approximately 30,000 confirmed and probable cases of Lyme disease were reported in the United States in 2012, primarily from high-incidence states in the Northeast (Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont) and upper Midwest (Minnesota and Wisconsin). Common manifestations include cutaneous, neurologic, and rheumatologic signs and symptoms. Symptomatic infection of the heart is rare in recognized Lyme disease cases and usually resolves promptly with appropriate antibiotic therapy. Nonetheless, cardiac involvement occasionally can cause life-threatening cardiac conduction abnormalities. During November 2012-July 2013, one woman and two men (ranging in age from 26 to 38 years) from high-incidence Lyme disease states experienced sudden cardiac death and, on postmortem examination, were found to have evidence of Lyme carditis. The three deaths were investigated by the Connecticut Department of Public Health, Massachusetts Department of Public Health, New Hampshire Department of Public Health, New York State Department of Health, and CDC. Donated corneas from two decedents had been transplanted to three recipients before the diagnosis of Lyme disease was established, but no evidence of disease transmission was found. Although death from Lyme carditis is rare, it should be considered in cases of sudden cardiac death in patients from high-incidence Lyme disease regions. Reducing exposure to ticks is the best method for preventing Lyme disease and other tickborne infections.

September 2012 marked the beginning of the largest reported outbreak of infections associated with epidural and intra-articular injections. Contamination of methylprednisolone acetate with the black mold, Exserohilum rostratum, was the primary cause of the outbreak, with >13,000 persons exposed to the potentially contaminated drug, 741 confirmed drug-related infections, and 55 deaths. Fatal meningitis and localized epidural, paraspinal, and peripheral joint infections occurred. Tissues from 40 laboratory-confirmed cases representing these various clinical entities were evaluated by histopathological analysis, special stains, and IHC to characterize the pathological features and investigate the pathogenesis of infection, and to evaluate methods for detection of Exserohilum in formalin-fixed, paraffin-embedded (FFPE) tissues. Fatal cases had necrosuppurative to granulomatous meningitis and vasculitis, with thrombi and abundant angioinvasive fungi, with extensive involvement of the basilar arterial circulation of the brain. IHC was a highly sensitive method for detection of fungus in FFPE tissues, demonstrating both hyphal forms and granular fungal antigens, and PCR identified Exserohilum in FFPE and fresh tissues. Our findings suggest a pathogenesis for meningitis involving fungal penetration into the cerebrospinal fluid at the injection site, with transport through cerebrospinal fluid to the basal cisterns and subsequent invasion of the basilar arteries. Further studies are needed to characterize Exserohilum and investigate the potential effects of underlying host factors and steroid administration on the pathogenesis of infection.

Two men from northwestern Missouri independently presented to a medical facility with fever, fatigue, diarrhea, thrombocytopenia, and leukopenia, and both had been bitten by ticks 5 to 7 days before the onset of illness. Ehrlichia chaffeensis was suspected as the causal agent but was not found on serologic analysis, polymerase-chain-reaction (PCR) assay, or cell culture. Electron microscopy revealed viruses consistent with members of the Bunyaviridae family. Next-generation sequencing and phylogenetic analysis identified the viruses as novel members of the phlebovirus genus. Although Koch's postulates have not been completely fulfilled, we believe that this phlebovirus, which is novel in the Americas, is the cause of this clinical syndrome.

Understanding the mechanisms of rabies virus clearance from the CNS will be a significant step towards the treatment of clinical rabies. Although a few animal studies have provided insight about immune responses in the CNS during rabies encephalitis, data about the same are very scarce for humans. In our study, formalin-fixed, paraffinembedded, central nervous system (CNS) tissues from patients who succumbed to rabies following infection with RABV variants common to the tricolored bat ( Perimyotis subflavus ) in the United States, canine RABV present in Haiti, and canine RABV from Afghanistan, as well as tissues from a patient who recovered from clinical laboratory confirmed rabies following cat bite in Colombia, but succumbed as a result of secondary medical intervention, were subjected to comparative immunohistological evaluations identifying particular immune cell populations associated with rabies encephalitis. A non-encephalitic brain from an influenza patient was used as a negative control. Populations of B-cells (CD20), T-cells (CD3), and macrophages (CD68), as well as the presence of rabies virus antigens were compared using a semi-quantitative scale. In addition, gene expression analyses, using the Human Antiviral Response RT² Profiler™ PCR Array, focusing on the expression of 84 key genes involved in the innate antiviral immune response, were performed. No rabies virus antigens were detected in the brain tissue of the patient who survived clinical rabies or in the control brain. T-cells and macrophages were abundant in the parenchyma in all rabies patients, but B-cells were detected only in the perivascular tissue of the putative rabies survivor, and rabies patients infected with canine RABVs. Few T- and B- cells, and only local microglia cells, were detected in the influenza patient. Differences in the expression of multiple genes associated with innate immunity, as well as inflammatory responses, were identified, suggesting the importance of their role in rabies encephalitis and viral clearance from CNS tissue.

Background. Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216 000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs).Methods. A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak.Results. From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100 000 persons.Conclusions. This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control.

To the Editor: Leptospirosis is caused by pathogenic spirochetes of the genus Leptospira and transmitted through direct contact of skin or mucous membranes with urine or tissues of Leptospira-infected animals or through indirect contact with contaminated freshwater or soil.Leptospirosis shares common clinical signs with infl uenza, including fever, headache, myalgia, and sometimes cough and gastrointestinal symptoms.During 2009, acute complicated infl uenza-like illness (ILI) and rapid progressive pneumonia were often attributed to pandemic (H1N1) 2009; however, alternative fi nal diagnoses were reported to be common (1).We report 3 cases of severe leptospirosis in Florida and Missouri with clinical signs similar to those of pandemic (H1N1) 2009.Patient 1 was a 40-year-old Florida man who sought treatment at an emergency department after a 4-day history of fever, myalgia, calf pain, malaise, and headache in July 2009.ILI was diagnosed.Laboratory testing was not performed, and the patient was instructed to take ibuprofen.Three days later, jaundice developed.

The recent influenza pandemic, caused by a novel H1N1 influenza A virus, as well as the seasonal influenza outbreaks caused by varieties of influenza A and B viruses, are responsible for hundreds of thousands of deaths worldwide. Few studies have evaluated the utility of real-time reverse transcription-PCR to detect influenza virus RNA from formalin-fixed, paraffin-embedded tissues obtained at autopsy. In this work, respiratory autopsy tissues from 442 suspect influenza cases were tested by real-time reverse transcription-PCR for seasonal influenza A and B and 2009 pandemic influenza A (H1N1) viruses and the results were compared to those obtained by immunohistochemistry. In total, 222 cases were positive by real-time reverse transcription-PCR, and of 218 real-time, reverse transcription-PCR-positive cases also tested by immunohistochemistry, only 107 were positive. Although formalin-fixed, paraffin-embedded tissues can be used for diagnosis, frozen tissues offer the best chance to make a postmortem diagnosis of influenza because these tissues possess nucleic acids that are less degraded and, as a consequence, provide longer sequence information than that obtained from fixed tissues. We also determined that testing of all available respiratory tissues is critical for optimal detection of influenza virus in postmortem tissues. (J Mol Diagn 2011, 13:123-128; DOI: 10.1016/j.jmoldx.2010.09.004)

BACKGROUND: The Centers for Disease Control and Prevention frequently receives inquiries from health care providers, public health officials, and the general public seeking data or guidance on vaccine-safety issues. Past inquiries to public health authorities identified potential problems including viscerotropic illness rarely associated with yellow fever vaccination. OBJECTIVE: To systematically describe vaccine-safety inquiries received at the Centers for Disease Control and Prevention. METHODS: External and internal inquiries were recorded in a database from May 1, 2002 to May 31, 2009. Key variables analyzed included the source of the question, the type of information being sought, and the vaccine type(s) associated with the inquiry. RESULTS: A total of 983 vaccine-safety inquiries were answered and analyzed. Health care workers were the source of 43% of the questions, and the general public accounted for 19% of the questions. Nearly half of the requests (49%) concerned information about the Vaccine Adverse Event Reporting System, and nearly one-fourth (21%) were requests from providers for clinical guidance. The most frequent specific topics of inquiry and vaccines involved were neurologic adverse events (AEs) temporally associated with vaccination (17%) and safety of all vaccines or childhood vaccines (20%), respectively. CONCLUSIONS: Questions about rare but potentially serious AEs and general concerns about vaccine safety were encountered relatively frequently. The substantial number of clinically focused inquires may indicate a need for more provider support tools and resources. Tracking of inquiries can supplement information received through vaccine AE reporting and contribute to an enhanced scientific and communications response to vaccine-safety concerns.

Wun-Ju Shieh,* Dianna M. Blau,* Amy M. Denison,* Marlene DeLeon-Carnes,* Patricia Adem,* Julu Bhatnagar,* John Sumner,* Lindy Liu,* Mitesh Patel,* Brigid Batten,* Patricia Greer,* Tara Jones,* Chalanda Smith,* Jeanine Bartlett,* Jeltley Montague,* Elizabeth White,* Dominique Rollin,* Rongbao Gao, Cynthia Seales,* Heather Jost,* Maureen Metcalfe,* Cynthia S. Goldsmith,* Charles Humphrey,* Ann Schmitz,* Clifton Drew,* Christopher Paddock,* Timothy M. Uyeki, and Sherif R. Zaki*

In the spring of 2009, a novel influenza A (H1N1) virus emerged in North America and spread worldwide to cause the first influenza pandemic since 1968. During the first 4 months, over 500 deaths in the United States had been associated with confirmed 2009 pandemic influenza A (H1N1) [2009 H1N1] virus infection. Pathological evaluation of respiratory specimens from initial influenza-associated deaths suggested marked differences in viral tropism and tissue damage compared with seasonal influenza and prompted further investigation. Available autopsy tissue samples were obtained from 100 US deaths with laboratory-confirmed 2009 H1N1 virus infection. Demographic and clinical data of these case-patients were collected, and the tissues were evaluated by multiple laboratory methods, including histopathological evaluation, special stains, molecular and immunohistochemical assays, viral culture, and electron microscopy. The most prominent histopathological feature observed was diffuse alveolar damage in the lung in all case-patients examined. Alveolar lining cells, including type I and type II pneumocytes, were the primary infected cells. Bacterial co-infections were identified in >25% of the case-patients. Viral pneumonia and immunolocalization of viral antigen in association with diffuse alveolar damage are prominent features of infection with 2009 pandemic influenza A (H1N1) virus. Underlying medical conditions and bacterial co-infections contributed to the fatal outcome of this infection. More studies are needed to understand the multifactorial pathogenesis of this infection.

Since the discovery of the Marburg and Ebola species of filovirus, seemingly random, sporadic fatal outbreaks of disease in humans and nonhuman primates have given impetus to identification of host tropisms and potential reservoirs. Domestic swine in the Philippines, experiencing unusually severe outbreaks of porcine reproductive and respiratory disease syndrome, have now been discovered to host Reston ebolavirus (REBOV). Although REBOV is the only member of Filoviridae that has not been associated with disease in humans, its emergence in the human food chain is of concern. REBOV isolates were found to be more divergent from each other than from the original virus isolated in 1989, indicating polyphyletic origins and that REBOV has been circulating since, and possibly before, the initial discovery of REBOV in monkeys.

Extended abstract of a paper presented at Microscopy and Microanalysis 2009 in Richmond, Virginia, USA, July 26 – July 30, 2009