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Wormser GP et al The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: Clinical practice guidelines by the Infectious Diseases Society of America Clin Infect Dis 2006 Nov 1;43(9):1089 134 [PMID: 17029130]

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Ehrlichiae and anaplasmae are small tick-borne gramnegative obligate intracellular bacteria The major nonhuman hosts include mice, dogs, and horses These organisms grow as microcolonies in phagosomes of hematopoietic cells and form characteristic inclusions seen with Giemsa stain Human monocytic ehrlichiosis is seen primarily in the Southeast, mid-Atlantic, and South Central states of the United States, though serologic evidence now documents a much more global endemicity (Israel, Japan, Mexico, Europe) Its major vectors are the Lone Star tick (Amblyomma americanus) and the American dog tick (D variabilis) Reported incidences of both human monocytic and granulocytic ehrlichiosis are about 06 and 14 per million, respectively, with the highest attack rate in men over 60 years of age Clinical disease ranges from mild to life-threatening Typically, after about a 9-day incubation period and a prodrome consisting of malaise, rigors, and nausea, worsening fever and headache develop A pleomorphic rash may occur Infections among HIV-positive persons are more apt to be symptomatic Disease is more severe among the elderly Leukopenia, absolute lymphopenia, thrombocytopenia, and transaminitis occur often Serious sequelae include acute respiratory failure and ARDS, encephalopathy, and acute renal failure, which may mimic thrombotic thrombocytopenic purpura Human granulocytic ehrlichiosis (anaplasmosis) has an increasingly recognized ubiquitous geographic area of distribution with clinically consistent cases now reported from the United States (where it is tends to be present in the same geographic area as Borrelia burgdorferi, the causative agent of Lyme disease), Brazil, Israel, and Europe The vectors are ticks of the Ixodes genus, and the reservoirs include woodrats, deer mice, chipmunks, deer, and perhaps horses The incidence peaks in summer, but cases are seen year-round in warmer areas where ticks remain viable The symptoms are similar to those seen with human monocytic ehrlichiosis Persistent fever and malaise are reported to occur for 2 or more years Coinfection with Lyme disease may occur, though patients with granulocytic ehrlichiosis appear to be older and sicker than those with acute Lyme disease.

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Exposure to sheep, goats, cattle, or their products is common; some infections are laboratory acquired An acute or chronic febrile illness with severe headache, cough, prostration, and abdominal pain Extensive pneumonitis, hepatitis, or encephalopathy; rarely, endocarditis or chronic fatigue syndrome

Coxiella burnetii is unique among rickettsiae in that it is usually transmitted to humans not by arthropods but by inhalation or ingestion It is distributed worldwide with few exceptions Coxiella infections occur mostly in cattle, sheep, and goats, in which they cause mild or subclinical disease (Table 32 3) Transmission by cows and goats is principally through the milk and placenta and by sheep through feces, placenta, and milk Dry feces and milk, dust contaminated with them, and the tissues of these animals contain large numbers of infectious organisms that are spread by the airborne route Inhalation of contaminated dust and of droplets from infected animal tissues is the main source of human infection Outbreaks have been described in association with parturient cats There is an occupational risk for animal handlers, slaughterhouse workers, veterinarians, laboratory workers, and other workers exposed to animal products The route of acquisition appears to determine the main clinical syndrome Endocarditis is an uncommon but serious form of Coxiella infection and has been linked with preexisting valvular conditions, immunocompromise, urban residence, and raw milk ingestion Coxiella is resistant to heat and drying, perhaps because the organism forms endospore-like structures Thus, it survives in dust, on the fleece of infected animals, or in inadequately pasteurized milk Spread from one human to another does not seem to occur even in the presence of florid pneumonitis, but maternal fetal infection can occur

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