Pediatric Human Granulocytic Anaplasmosis is Rare in Europe.

Abstract

6 358 | www.pidj.com The Pediatric Infectious Disease Journal • Volume 35, Number 3, March 2016 fever up to 39.7°C accompanied by chills, headache, neck and lumbar pain and passing of dark urine. The patient lived in a rural area and reported being bitten by numerous ticks in the preceding month. He had no underlying illnesses and at the age of 12 had completed a 3-dose basic tick-borne encephalitis (TBE) vaccination. On admission, he was afebrile with jaundice and a discrete maculopapular rash on the trunk and neck. A systolic murmur was heard in the precordium, and the abdomen was tender to palpation below the right costal margin and in the right flank region. Elevated C-reactive protein (10.1 mg/dL), normal white blood cells count (4300/mm) with 19% band forms, thrombocytopenia (91,000/mm), elevated transaminases (aspartate aminotransferase, 1.96; alanine aminotransferase, 1.47; gamma-glutamyltransferase, 1.96 μkat/L; normal values, <0.58, <0.74 and <0.92 μkat/L, respectively), lactate dehydrogenase (8.67 μkat/L; normal level < 4.13) and bilirubin (total, 64 μmol/L; direct, 18 μmol/L; upper normal values, 17 and 5 μmol/L, respectively) as well as prolonged prothrombin time (0.63, international normalized ratio, 1.32) were found. Serum electrolytes, urea and creatinine were normal. The patient was given cefotaxime and flucloxacillin for suspected sepsis but remained febrile. Because blood, urine and stool cultures were negative, white blood cells (nadir 1600/mm) and platelet (53,000/mm) counts further decreased and transaminase levels increased (maximum values aspartate aminotransferase, 3.59; alanine aminotransferase, 3.05 and γ-GT, 3.80 μkat/L) and tests for A. phagocytophilum infection [demonstration of morulae in peripheral blood smear, detection of A. phagocytophilum genome in blood with polymerase chain reaction (PCR) and immunofluorescence assay for detection of A. phagocytophilum antibodies] were performed on day 3 of hospital stay. Based on a positive specific PCR result, treatment with doxycycline 100 mg/12 hours was accompanied by prompt defervescence and normalization of laboratory values. Differential diagnoses included tests for hantavirus infection (serology) and infection with Leptospira sp. (PCR in urine) that were negative, whereas serology for TBE was compatible with postvaccination levels (positive IgG and negative IgM). The patient made an uneventful recovery after 10 days of doxycycline treatment. The test results for A. phagocytophilum and Ehrlichia chaffeensis infection are shown in Table 1. HGA is rare in Europe and affects predominately adults with only 2 cases described in children. In a prospective Pediatric Human Granulocytic Anaplasmosis is Rare in Europe Letters to the editor