North Carolina STARI Introduction

Barbara Johnson, PhD– Bjj1@cdc.gov

– CDC, Foothills Campus, 3150 Rampart Road, Fort Collins, CO 80521

– Phone:  970-221-6463– Fax:  970-225-4257

Southern Tick-Associated Rash Illness (STARI)

Estimated Distribution of A. americanum

Erythema migrans-like rash after Amblyomma americanum bite

19 x 11 cm rash area

A. americanum adult female

Why we need your help

• Clinical reasons– 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)

1 dot placed randomly within county of residence for each reported case

Reported Cases of Lyme Disease -- United States, 2004

Wormser et al. 2005 CID

STARI in Missouri

Peak incidence: May - June

Occurs: April - October

Tick bite to rash onset: 6 +/- 4 days

Symptoms (n=21)

19 % fatigue

14 % fever or chills

14 % muscle pain

10% paresthesias

5% joint pain

5% cough

Multiple EMs: 5%

Central clearing 75%

8.3 +/- 2.2 cm

STARI Patients States of Probable ExposureTo Unknown Agent

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

Enrolled patients

Patient 4 (Maryland): Moderate superficial perivascular infiltrates;

predominantly mononuclear inflammatory cells

10x10x 40x

All images: H & E stains

Patient 5 (Tennessee): Panniculitis (inflammation of subcutaneous adipose tissue; mononuclear infiltrates between adipocytes

10x 40x

10x 40x

Patient 16 (South Carolina and/or Georgia exposure): Diffuse mixed inflammatory cell infiltrates in the dermis; abundant eosinophils (bright red cells)

Patient 19 (South Carolina): Mild perivascular infiltrates (superficial and deep); predominantly mononuclear inflammatory cells

10x 40x

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.

(R. MÜllegger, used with permission)

Distinctive features of STARI images:

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