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North Carolina STARI Introduction Barbara Johnson, PhD – [email protected] – CDC, Foothills Campus, 3150 Rampart Road, Fort Collins, CO 80521 – Phone: 970-221-6463 – Fax: 970-225-4257 Southern Tick-Associated Rash Illness (STARI) Erythema migrans-like rash after Amblyomma americanum bite 19 x 11 cm rash area Estimated Distribution of A. americanum 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) Reported Cases of Lyme Disease -- United States, 2004 1 dot placed randomly within county of residence for each reported case STARI in Missouri Peak incidence: May - June Occurs: April - October Tick bite to rash onset: 6 +/- 4 days Symptoms (n=21) 19 % fatigue Wormser et al. 2005 CID 14 % fever or chills 14 % muscle pain Central clearing 75% 8.3 +/- 2.2 cm 10% paresthesias 5% joint pain 5% cough Multiple EMs: 5% STARI Patients States of Probable Exposure To Unknown Agent Enrolled patients 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 10x 40x All images: H & E stains Patient 4 (Maryland): Moderate superficial perivascular infiltrates; predominantly mononuclear inflammatory cells 10x 40x Patient 5 (Tennessee): Panniculitis (inflammation of subcutaneous adipose tissue; mononuclear infiltrates between adipocytes 10x 40x Patient 16 (South Carolina and/or Georgia exposure): Diffuse mixed inflammatory cell infiltrates in the dermis; abundant eosinophils (bright red cells) 10x 40x Patient 19 (South Carolina): Mild perivascular infiltrates (superficial and deep); predominantly mononuclear inflammatory cells 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. Distinctive features of STARI images: (R. MÜllegger, used with permission) 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