Transcript Southern Tick-Associated Rash Illness (STARI)

North Carolina STARI
Introduction
Barbara Johnson, PhD
– [email protected]
– CDC, Foothills Campus, 3150 Rampart Road,
Fort Collins, CO 80521
– Phone: 970-221-6463
– Fax: 970-225-4257
Southern Tick-Associated Rash Illness
(STARI)
Erythema migrans-like rash after
Amblyomma americanum bite
19 x 11 cm
rash area
Estimated Distribution of
A. americanum
A. americanum adult female
Why we need your help
• Clinical reasons
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Cause unknown
No laboratory diagnostic test
No scientific basis for treatment
Incidence of serious sequelae unknown
• Public health reasons
– Confused with Lyme disease
• EM is part of the case definition for Ld
• ~4000 cases of Ld reported from southern states
– Impacts understanding of performance of
diagnostic tests (and vaccine efficacy)
Reported Cases of Lyme Disease -- United States, 2004
1 dot placed randomly within county of residence for each reported case
STARI in Missouri
Peak incidence: May - June
Occurs: April - October
Tick bite to rash onset: 6 +/- 4 days
Symptoms (n=21)
19 % fatigue
Wormser et al. 2005 CID
14 % fever or chills
14 % muscle pain
Central clearing 75%
8.3 +/- 2.2 cm
10% paresthesias
5% joint pain
5% cough
Multiple EMs: 5%
STARI Patients
States of Probable Exposure
To Unknown Agent
Enrolled patients
Patients (n=34) donated paired
serum samples, a fresh skin biopsy
specimen, and/or a fixed skin
sample.
Patient’s skin contained B.
lonestari DNA
10x
40x
All images: H & E stains
Patient 4 (Maryland): Moderate superficial perivascular infiltrates;
predominantly mononuclear inflammatory cells
10x
40x
Patient 5 (Tennessee): Panniculitis (inflammation of subcutaneous
adipose tissue; mononuclear infiltrates between adipocytes
10x
40x
Patient 16 (South Carolina and/or Georgia exposure): Diffuse
mixed inflammatory cell infiltrates in the dermis; abundant
eosinophils (bright red cells)
10x
40x
Patient 19 (South Carolina): Mild perivascular infiltrates (superficial
and deep); predominantly mononuclear inflammatory cells
Reference image:
Erythema migrans due to
Borrelia burgdorferi infection
Moderate to severe superficial
and deep mononuclear infiltrate,
mostly perivascular.
Infiltrate mainly lymphocytes and
histiocytes with some plasma
cells.
Distinctive features of STARI
images:
(R. MÜllegger, used with permission)
No findings common to all
samples. Large number of
eosinophils, involvement of
subcutaneous fat, collagen
changes, and absence of plasma
cells.
What will we do with specimens?
• Analyze DNA in skin
– Universal Biosensor
• PCR
• Mass spectrometry
– DNA sequencing
• Place skin and blood in immunodeficient
mice
• Develop experimental serologic test(s)
– Recombinant DNA technology
– Tissue culture