Minnesota Department of Health (MDH) Bug Bytes
April 19, 2002
Vol. 3: No. 6
On March 25, a metro-area hospital ICP reported a case of lepromatous and tuberculoid Hansen's disease (leprosy) in a young Hispanic adult, born in Mexico, who had been living in the U.S. for several years. The individual, who had been symptomatic for 2 years, presented at a primary care clinic with a worsening toe ulcer. Examination revealed typical signs of Hansen's disease, including skin lesions on the abdomen, ear, fingers, and legs; bone degradation and peripheral neuropathy. The patient was admitted to the hospital for further evaluation and to start antibiotic therapy.
Hansen's disease typically is diagnosed by clinical findings, since the causative agent, Mycobacterium leprae, normally cannot be grown in the laboratory. Dr. Gerhard Armauer Hansen, a Norwegian scientist, first discovered the Hansen's disease bacillus in 1873. Smears of skin scrapings often are positive for acid-fast bacilli, and a skin biopsy should be obtained when possible. Treatment of the multibacillary (lepromatous) form of Hansen's disease consists of multi-drug antibiotic therapy (including rifampin, dapsone, and clofazimine) for at least 12 months. Paucibacillary (tuberculoid) Hansen's disease is treated with a single dose of multi-drug therapy or (for patients with more than one skin lesion) daily dapsone and once a month rifampin (supervised) for 6 months. Patients typically lose infectiousness within 3 days of treatment with rifampin.
Although transmission of Hansen's disease is through close prolonged contact, it is not highly contagious or easily transmitted. Organisms enter the upper respiratory tract or broken skin. In addition, 95% of the world's population is believed to have natural immunity. Therefore, contact follow-up normally consists of monitoring only household contacts for physical signs of the disease once per year for 5 years.
WHO estimates that there were 640,000 incident cases of Hansen's disease worldwide in 1999, and 738,284 cases were identified in 2000. Cases occur primarily in tropical areas. 108 cases were reported in the U.S. in 1999. Most U.S. cases occur in California, Texas, Hawaii, Louisiana, Florida, New York, and Puerto Rico. Prior to 2002, the last case reported in Minnesota was in 1996 (a second case was also reported in 1996 but had onset overseas prior to arrival in the U.S.).
More information may be obtained from the National Hansen's Disease Program's web site at http://bphc.hrsa.gov/nhdp/default.htm or by contacting the MDH Tuberculosis Program (651-201-5414), to which the diagnosis of Hansen's disease in Minnesota should be reported.
2. Enterobacter sakazakii Update
In the February 20 issue of Bug Bytes we reported a fatal case of Enterobacter sakazakii meningitis in a neonate. We've completed that investigation and were unable to find the source of infection for the infant including being unable to culture E. sakazakii from powdered human milk fortifier the infant had received.
The April 12 MMWR (http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm5114a1.htm) reports on an investigation last year into the death of infant from E. sakazakii meningitis. This infant was hospitalized in an NICU and received Portagen, a commercial powdered formula recommended for infants with nutritional malabsorption problems. Cultures of formula from both opened and unopened cans of Portagen from a single batch grew E. sakazakii. Isolates of E. sakazakii from the CSF culture of the infant with meningitis and from the cultures of formula were indistinguishable by pulsed-field gel electrophoresis. Water and all environmental cultures were negative. The implicated lot of Portagen was voluntarily recalled by the manufacturer (Mead Johnson) on March 29 and CDC/FDA have published interim recommendations concerning preparation of powdered milk formulas in the NICU setting. In addition, FDA has issued a letter to health professionals on E. sakazakii infections associated with use of powdered infant formulas in the NICU (http://www.cfsan.fda.gov/~dms/inf-ltr3.html) as well as an FDA "Talk Letter" (http://www.fda.gov/bbs/topics/
CDC is also investigating a recent case of E. sakazakii meningitis in an infant who had been fed the same type of powdered fortifier as our case. It is unlikely that this is an issue relating to only one manufacturer or one powdered product. Powdered formulas are not sterile and may contain opportunistic bacterial pathogens such as E. sakazakii. We are interested in receiving reports of E. sakazakii cultured from infants.
3. Foodborne Disease
FoodNet is part of the Emerging Infections Program conducted by MDH and eight other states (California, Colorado, Connecticut, Georgia, Maryland, New York, Oregon, and Tennessee) representing 37.8 million people in the U. S. Surveillance for nine foodborne pathogens is conducted. Preliminary data for 2001 were just released (http://www.cdc.gov/mmwr/preview/
During 2001, Salmonella was the most common reported infection in the nine FoodNet sites, followed by Campylobacter and Shigella. There was wide variation by site; for example, Minnesota had the highest incidence of cryptosporidiosis, E. coli O157:H7 infections, and HUS, and the lowest incidence of Vibrio and Listeria infections. Incidence of foodborne diseases also varied by age, with the highest incidence of most infections among infants (<1 year old) and young children (1-4 years old).
During 1996-2001, there was a decrease in the estimated incidence of Yersinia, Listeria, Campylobacter, and Salmonella infections. The incidence rates for Shigella, E. coli O157:H7, and Vibrio infections varied annually, so no significant trends were observed. In addition, the incidence of cryptosporidiosis decreased during 1997-2001.
Thank you to all ICPs, clinicians, and laboratorians for your prompt and accurate reporting of these reportable diseases. The information you provide to us through our surveillance system contributes to this national picture of foodborne diseases.
4. Erythromycin-resistant Group A Streptococci
In last week's New England Journal of Medicine was an article describing a clonal outbreak of erythromycin-resistant group A Streptococci pharyngeal isolates. We have tested susceptibility to erythromycin on isolates that are submitted for invasive cases of group A Streptococcal (GAS) disease among Minnesota residents since 1998; 23 of 605 (4%) of isolates submitted for cases from 1998 through 2001 were non-susceptible to erythromycin. In 1999, five clinics from different areas of the state submitted a sample of pharyngeal GAS isolates collected between January and May; 10 of 514 (2%) of the pharyngeal isolates were non-susceptible to erythromycin. Invasive GAS isolates are routinely compared using pulsed-field gel electrophoresis (PFGE) and PFGE was also carried out on a proportion of the pharyngeal isolates. One PFGE subtype has been noted to be associated with erythromycin resistance in both invasive and pharyngeal GAS isolates.
Thanks to the astute Bug Bytes reader who noticed an error in the last issue. The recommendation to use cefazolin for intrapartum antibiotic prophylaxis for GBS in women who have a penicillin allergy was for women who are able to tolerate cephalosporins (not unable!)(the error has been corrected in the archive version on our website). The GBS consensus guidelines are undergoing revision and are expected to be published in the MMWR later this year. As always, we appreciate your comments.
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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