Minnesota Department of Health (MDH) Bug Bytes
April 13, 2001
Vol. 2: No. 8
1. Malaria Fatality in a Minnesota Resident
2. Outbreak of Campylobacteriosis Due to Raw Milk Consumption
3. Invasive Streptococcus pneumoniae
4. Eosinophilia-Myalgia Syndrome
5. Outbreak Among College Students in Acapulco
6. Chicks and Ducklings
1. Malaria Fatality in a Minnesota Resident
MDH recently learned of a fatal case of malaria in a Minnesota resident
that had traveled to Tanzania in late February. In mid-March, nine days
after returning from Africa, the patient developed a fever and hand pain.
The patient sought medical help in Florida, while on vacation there, but
became comatose and died nine days after disease onset. The case was diagnosed
as cerebral malaria, and Plasmodium falciparum parasites were confirmed
by thick and thin blood smears at CDC. Due to an adverse reaction to Mefloquine
(the recommended malaria prophylaxis for Chloroquine-resistant malaria
areas in Africa) during a prior trip, the patient used a combination of
Chloroquine and Paludrine (Proguanil; not available in the U.S.) as prophylaxis.
While these drugs are commonly used by Europeans visiting Africa, the
efficacy of the combination is thought to be declining. It also appears
that the patient discontinued prophylaxis either shortly before or after
returning from Africa. This case underscores the importance of including
malaria in the differential diagnosis for febrile patients with a history
of travel to malaria-endemic parts of the world. In addition, people traveling
to these areas should use the recommended prophylaxis, and be reminded
to be compliant with the dosing schedule. The CDC website (http://www.cdc.gov
Attention: Non-MDH link) has current recommendations
on malaria prophylaxis as part of their "Travelers' Health" section.
2. Outbreak of Campylobacteriosis Due to Raw Milk Consumption During March, routine interviewing of Campylobacter jejuni cases reported to MDH revealed four cases among individuals who were hosted by a farm family in western Minnesota while working in the area as part of a Catholic missionary group. All four consumed raw milk while dining with the family and became ill with Campylobacter gastroenteritis 3 to 4 days later (the classic incubation for Campylobacter infections). Raw milk is a well established vehicle for Campylobacter; numerous outbreaks among groups of farm visitors (e.g., during school field trips or other youth activities) have been documented. Of interest, this and similar farm-related exposures are frequently not documented as risk factors for infections with Campylobacter or other animal-associated pathogens (e.g., E. coli O157:H7, Cryptosporidium) in adults who live on farms, likely because immunity is acquired through frequent exposure to these pathogens. However, young children who live on farms are at increased risk for infection with these pathogens due to the consumption of raw milk and other exposures to cattle feces. E. coli O157:H7 infections can result in severe illness in the form of hemolytic uremic syndrome. We recommend that milk be pasteurized before consumption, especially for children, the elderly, and the immunocompromised.
3. Invasive Streptococcus pneumoniae
Together with eight other sites in the U.S., and with our ICP and
laboratory partners, our Emerging Infections Program conducts population-based
surveillance for invasive infections due to Streptococcus pneumoniae
among residents of the seven-county Minneapolis-St. Paul metropolitan
area. An article published in the April 4 JAMA last week, details
results for 1995-1998. Rates of invasive pneumococcal infection
were highest in children < 2 years and in adults aged 65 and older.
In every age group, rates of illness were highest among African
Americans, overall, about two and a half times higher than rates
among whites. There was some geographic variation in incidence.
For example in 1998, the rate of invasive pneumococcal disease among
Minnesota children < 2 years old was 274 per 100,000 compared to
the lowest rates in the same age group occurring among Maryland
children (113 per 100,000). These differences were hypothesized
to be due to differences in blood culture collection practices and
differences in individual or community risk factors. This report
focused on the potential preventability of these infections. Based
on serotype results from 1998, 82% of the infections in children
< 2 years were due to one of the 7 serotypes included in the new
conjugate vaccine (in Minnesota, from 1995-1999, this was 77% of
isolates from children < 2 years and 74% of isolates from children
< 5 years). For adults aged 65 years or older, 86% of the isolates
were one of the 23 serotypes included in the polysaccharide pneumococcal
vaccine (in Minnesota, from 1995-1999 this was 80% of isolates from
adults 65 years or older). About half of the case-patients aged
2-64 years old had one or more chronic medical conditions included
by ACIP as indications for vaccination with the 23-valent polysaccharide
vaccine. For questions on pneumococcal surveillance, please contact
651-201-5414.
4. Eosinophilia-Myalgia Syndrome
As this issue of Bug Bytes was going to press, we learned of a case
of eosinophilia-myalgia syndrome in a 55-year old woman. You might
recall there was an outbreak of eosinophilia-myalgia syndrome in
1989 in Minnesota, New Mexico, and elsewhere. We traced cases then
to consumption of products containing manufactured tryptophan (New
Engl J Med 1990; 323:357-65). We are beginning an investigation
of this case. We are reporting this case to alert you now; please
report additional cases to us immediately at 651-201-5414. Eosinophilia-myalgia
syndrome is characterized by myalgia and marked peripheral eosinophilia.
There may be scleroderma-like features. Interestingly, the aldolase
level is elevated but the CPK level is usually normal. The diagnosis
is confirmed by muscle biopsy.
5. Outbreak Among College Students in Acapulco
This past week we were notified by CDC of a multi-state outbreak
of acute febrile illness among college students who had traveled
to Acapulco during March. Illness was characterized by fever, chills,
dry cough, chest pain, and headache 7-14 days after return from
Mexico. Preliminary testing suggests acute pulmonary histoplasmosis
in several cases. To date, over 220 possible cases have been reported
from 37 colleges in 18 states. We are investigating several suspect
cases in Minnesota residents. Please report suspect cases of acute
febrile illness in travelers returning from Acapulco to 651-201-5414.
6. Chicks and Ducklings
Handling chicks and ducklings is a common activity in the spring because
it is a traditional favorite around Easter time and because people are
acquiring birds for the "backyard" production of fowl. These activities
have repeatedly been associated with large outbreaks of salmonellosis
in various states during spring months. Several serotypes have been involved.
Last Spring, we experienced an outbreak of Salmonella serotype
Montevideo infections first detected in Montevideo, MN (no kidding). Because
of the repeated occurrence of outbreaks due to the wide scale distribution
of chicks or ducklings during the Spring, the CDC issued the following
guidelines to prevent salmonellosis from this source (MMWR 2000;49:297-9):
".…persons should avoid contact with feces and carefully wash their hands
with soap and water after handling young fowl or anything that has come
in contact with them. Chicks, ducklings, and other young fowl may not
be appropriate pets for children and should not be kept in households
with infants, children aged <5 years, or immunocompromised persons."
Chicks and ducklings are cute but they do carry a risk.
Bug Bytes is a combined effort of the Infectious Disease Epidemiology, Prevention and Control Division and the Public Health Laboratory Division of MDH. We provide Bug Bytes as a way to say THANK YOU to the infection control professionals, laboratorians, local public health professionals, and health care providers who assist us.
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