Successful Treatment of Human Granulocytic Ehrlichiosis in Children Using Rifampin

Abstract

ABSTRACT. Human granulocytic ehrlichiosis (HGE) is an emerging tick-borne infectious disease caused by Anaplasma phagocytophilum. Clinical features include a flu-like illness that usually resolves within 1 week. More serious infection may occur that requires hospital admission or culminates in death. Doxycycline is the treatment of choice for HGE but may cause permanent staining of teeth in children younger than 8 years of age. We report successful treatment of HGE with rifampin in 2 children, 4 and 6 years old. A course of rifampin for 5 to 7 days should be considered in children younger than 8 years of age who experience non-life-threatening A phagocytophilum infection. Pediatrics 2003;112:e252-e253. URL: http://www.pediatrics.org/cgi/content/full/112/3/e252; human granulocytic ehrlichiosis, HGE, A phagocytophilum, rifampin.ABBREVIATIONS. HGE, human granulocytic ehrlichiosis; WBC, white blood cell count.H uman granulocytic ehrlichiosis (HGE), a tickborne zoonoses that was first reported in 1994, is an emerging public health problem in the northeastern and northern Midwestern United States. 1 The name of the causative pathogen was recently changed from "the agent of human granulocytic ehrlichiosis" to Anaplasma phagocytophilum. 2 While its epidemiologic and public health significance remain to be fully defined, HGE has been responsible for hundreds of cases and several fatalities. [3][4][5][6][7][8][9][10] Clinical information on HGE in children is limited to individual case reports. 4,8 Treatment in children is complicated because doxycycline, the antibiotic of choice, may cause permanent staining of the teeth in children younger than 8 years of age. 11,12 We report 2 children who experienced A phagocytophilum infection and were successfully treated with rifampin. CASE REPORTS Case 1A 6-year-old female kindergarten student from northwestern Wisconsin presented on June 17, 1998, with a 1-day history of fever, mild sore throat, intermittent headache, generalized myalgia, malaise, and shaking chills. She had noticed neck pain after the removal of a small brown tick attached behind her left ear 7 days earlier. The physical examination was unremarkable other than a temperature of 39.8°C. The hemogram showed a white blood cell count (WBC) of 10.9 ϫ 10 9 /L with 61% segmented neutrophils, 24% band neutrophils, 10% lymphocytes, and 5% monocytes, and a platelet count of 238 ϫ 10 9 /L. Microscopic examination of 800 leukocytes on a Wright-stained peripheral blood smear failed to reveal diagnostic inclusions (morulae) in neutrophils. The patient was thought to have a viral syndrome, and she was asked to return for follow-up examination in 48 hours. Her fever exceeded 39°C and her other symptoms persisted.At a follow-up visit 2 days later on June 19, 1998, the total WBC was 2.5 ϫ 10 9 /L and the platelet count was 153 ϫ 10 9 /L. Hepatic transaminase concentrations in serum were normal and repeated blood smear evaluation failed to detect morulae. HGE was suspected, and she was given oral rifampin (10 mg/kg orally twice dai...

Evaluation of Antibiotic Susceptibilities of Ehrlichia canis , Ehrlichia chaffeensis , and Anaplasma phagocytophilum by Real-Time PCR

“…This is probably due to a lack of bactericidal activity of these compounds. Rifampin can be used for pregnant women or children, and there are anecdotal reports of successful treatment of infections using this antibiotic (9,14,24,29).…”

Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis — United States

“…Case reports document favorable maternal and pregnancy outcomes in small numbers of pregnant women treated with rifampin for anaplasmosis (196)(197)(198). Small numbers of children also have been treated successfully for anaplasmosis using rifampin (199); however, no clinical trials demonstrating in vivo efficacy of rifampin in the treatment of anaplasmosis or ehrlichiosis have been conducted. Rifampin could be an alternative for the treatment of mild illness due to anaplasmosis in the case of pregnancy or documented allergy to tetracycline-class drugs (173).…”

Human Granulocytic Anaplasmosis

“…[61][62][63] A few pregnant women and pediatric patients have been treated successfully with rifampin. [68][69][70] Thus, patients who have HGA and who are unsuited for tetracycline treatment due to a history of drug allergy or pregnancy, and children younger than 8 years of age who are not seriously ill should be considered for rifampin therapy. Studies with levofloxacin demonstrate some activity in vitro.…”