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Biological Health Hazard – Elizabethkingia anophelis (fatal): Wisconsin (Update 2016-08-18)


Published Date: 2016-08-18 16:43:08
Subject: PRO/EDR> Elizabethkingia anophelis – USA (19): (WI) fatal, community acquired
Archive Number: 20160818.4422637

Date: Wed 17 Aug 2016
Source: American Council on Science and Health (ACSH) [edited]

Elizabethkingia: Is This Mysterious Disease Coming from Hospitals?
Occasionally, a rare or unknown microbe rears its ugly head and causes disease in humans. Whether it is due to a previously harmless microbe mutating, a disease of animals jumping into humans, or mankind encountering new habitats (and hence, new microbes), epidemiologists lump these bugs into a broad category called “emerging and re-emerging infectious diseases.”

Some of the latest inductee into this nefarious club is the bacterium _Elizabethkingia anophelis_, named in honor of microbiologist Elizabeth King. The microbe is common in the environment, initially found in the guts of _Anopheles_ mosquitoes [_A. gambiae_ – Mod.LL]. There are 4 known species, but the most problematic for humans appears to be _E. anophelis_, which is resistant to multiple antimicrobials. According to the CDC, the bacterium is responsible for at least 20 deaths in an ongoing outbreak in the American Midwest, mostly [in Wisconsin – Mod.LL] among elderly people with poor health. Currently, no one has identified the source of the outbreak.

In order to gain a better understanding of these enigmatic bacteria, a group of mostly French researchers sequenced the genomes of 2 _E. anophelis_ isolates from Central African Republic that caused meningitis in newborn infants. Then, they compared these sequences with those already known from other _Elizabethkingia_ isolates elsewhere in the world. Their results were reported in the journal Scientific Reports.

The authors used the genome sequences to build a phylogenetic tree (think: family tree), from which they inferred both evolutionary relationships as well as potential geographical histories of the isolates. This genomic analysis divides _E. anophelis_ into 2 lineages, A and B. Lineage A, which contains the African samples (sublineage 5), also contains sublineages isolated from Hong Kong (sublineage 4) and Singapore (sublineage 2), as well as from mosquitoes (sublineage 1). The phylogenetic tree suggests that sublineages 1, 4, and 5 are most closely related, which means the African samples are closest to those strains isolated from Hong Kong and from mosquitoes.

But, the African isolates almost certainly did not come from mosquitoes, since they were collected from newborn babies who were on ventilators in the hospital. Furthermore, some of the strains in sublineages 2 and 3 were also taken from a hospital environment. The authors worry that, despite being associated with mosquitoes and the environment, _Elizabethkingia_ can be transmitted in hospitals, just like several other nasty microbes [including the organism initially called _Flavobacterium meningosepticum_ now _E. meningoseptica_ which cannot be easily differentiated from _E. anophelis_- Mod.LL]. Given its resistance to multiple antimicrobials, that is not a welcome discovery. Midwestern public health officials should take note.

Source: Breurec, S. et al. Genomic epidemiology and global diversity of the emerging bacterial pathogen Elizabethkingia anophelis. Sci. Rep. 6, 30379; doi: 10.1038/srep30379 (2016).

[Byline: Alex Berezow]

Communicated by:
ProMED-mail from HealthMap Alerts

[The latest Wisconsin count remains at 67 total and has not changed since June 2016 (

Wisconsin 2016 _E. anophelis_ outbreak:
Case counts between 1 Nov 2015 and 17 Aug 2016
Confirmed = 63
Under investigation = 0
Possible cases = 4
Total cases reported to Wisconsin DPH = 67

Affected counties include Columbia, Dane, Dodge, Fond du Lac, Jefferson, Milwaukee, Ozaukee, Racine, Sheboygan, Washington, Waukesha, and Winnebago.

There have been 18 deaths among individuals with confirmed _E. anophelis_ infections and an additional one death among possible cases for a total of 19 deaths. It has not been determined if these deaths were caused by the infection or other serious pre-existing health problems. Counties where these deaths occurred are: Columbia, Dodge, Fond du Lac, Milwaukee, Ozaukee, Racine, Sheboygan, Washington, and Waukesha.

This investigation is ongoing. Case counts may change as additional illnesses are identified and more cases are laboratory confirmed.

The possible cases are cases that tested positive for _Elizabethkingia_, but will never be confirmed as the same strain of _E. anophelis_ because the outbreak specimens are no longer available to test.

The report cited and a parallel more clinical one are shown below with their abstracts but none of the isolates are from North America:

Breurec S, Criscuolo A, Diancourt L, et al: Genomic epidemiology and global diversity of the emerging bacterial pathogen Elizabethkingia anophelis. Sci Rep. 2016 Jul 27;6:30379. doi: 10.1038/srep30379

_Elizabethkingia anophelis_ is an emerging pathogen involved in human infections and outbreaks in distinct world regions. We investigated the phylogenetic relationships and pathogenesis-associated genomic features of 2 neonatal meningitis isolates isolated 5 years apart from one hospital in Central African Republic and compared them with _Elizabethkingia_ from other regions and sources. Average nucleotide identity firmly confirmed that _E. anophelis_, _E. meningoseptica_ and _E. miricola_ represent demarcated genomic species. A core genome multilocus sequence typing scheme, broadly applicable to _Elizabethkingia_ species, was developed and made publicly available ( Phylogenetic analysis revealed distinct E. anophelis sublineages and demonstrated high genetic relatedness between the African isolates, compatible with persistence of the strain in the hospital environment. CRISPR spacer variation between the African isolates was mirrored by the presence of a large mobile genetic element. The pan-genome of _E. anophelis_ comprised 6880 gene families, underlining genomic heterogeneity of this species. African isolates carried unique resistance genes acquired by horizontal transfer. We demonstrated the presence of extensive variation of the capsular polysaccharide synthesis gene cluster in _E. anophelis_. Our results demonstrate the dynamic evolution of this emerging pathogen and the power of genomic approaches for _Elizabethkingia_ identification, population biology and epidemiology.

Lau SK, Chow WN, Foo CH, et al: Elizabethkingia anophelis bacteremia is associated with clinically significant infections and high mortality. Sci Rep. 2016 May 17;6:26045. doi: 10.1038/srep26045

Unlike _Elizabethkingia meningoseptica_, the clinical importance of _E. anophelis_ is poorly understood. We determined the clinical and molecular epidemiology of bacteremia caused by _Elizabethkingia_-like species from 5 regional hospitals in Hong Kong. Among 45 episodes of _Elizabethkingia_-like bacteremia, 21 were caused by _Elizabethkingia_, including 17 _E. anophelis_, 3 _E. meningoseptica_ and one _E. miricola_; while 24 were caused by other diverse genera/species, as determined by 16S rRNA gene sequencing. Of the 17 cases of _E. anophelis_ bacteremia, 15 (88 percent) were clinically significant. The most common diagnosis was pneumonia (n = 5), followed by catheter-related bacteremia (n = 4), neonatal meningitis (n = 3), nosocomial bacteremia (n = 2) and neutropenic fever (n = 1). _E. anophelis_ bacteremia was commonly associated with complications and carried 23.5 percent mortality. In contrast, of the 24 episodes of bacteremia due to non-_Elizabethkingia_ species, 16 (67 percent) were clinically insignificant. Compared to non-_Elizabethkingia_ bacteremia, _Elizabethkingia_ bacteremia was associated with more clinically significant infections (P less than 0.01) and positive cultures from other sites (P less than 0.01), less polymicrobial bacteremia (P less than 0.01), and higher complication (P less than 0.05) and mortality (P less than 0.05) rates. _Elizabethkingia_ bacteremia is predominantly caused by _E. anophelis_ instead of _E. meningoseptica_. _Elizabethkingia_ bacteremia, especially due to _E. anophelis_, carries significant morbidity and mortality, and should be considered clinically significant unless proven otherwise.

In the May/June 2016 issue of Genetic Announcements, 4 of the North American 2015-2016 outbreak strains had complete genetic sequencing done. A number of reassortment configurations were found (Nicholson AC, Whitney AM, Emery BD, et al: Complete genome sequences of four strains from the 2015-2016 Elizabethkingia anopheles outbreak. Genome Annouc 2016;4 (3):e00563-16 doi:10.1128/genomeA.00563-16). – Mod.LL

A HealthMap/ProMED-mail map can be accessed at:]

See Also

Elizabethkingia anophelis – USA (18): (WI) fatal, community acquired 20160622.4302947
Elizabethkingia anophelis – USA (17): (WI) fatal, community acq 20160611.4277339
Elizabethkingia anophelis – USA (16): (WI) fatal, community acquired 20160505.4203699
Elizabethkingia anophelis – USA (15): (WI) possible neonatal case 20160429.4190297
Elizabethkingia anophelis – USA (14): (WI) fatal, community acquired 20160427.4187853
Elizabethkingia anophelis – USA (13): (WI,IL) fatal, community acq 20160422.4176668
Elizabethkingia anophelis – USA (12): (WI,IL) fatal, community acq 20160421.4174417
Elizabethkingia anophelis – USA (11): (WI) fatal, community acq 20160415.4162001
Elizabethkingia anophelis – USA (10): (WI, IL) fatal, community acquired 20160413.4158063
Elizabethkingia anophelis – USA (09): (WI) fatal, community acquired 20160408.4146997
Elizabethkingia anophelis – USA (08): (WI) fatal, community acquired 20160331.4129125
Elizabethkingia anophelis – USA (07): (WI,MI) fatal, community acq 20160324.4116626
Elizabethkingia anophelis – USA (06): (WI,MI) fatal, community acq 20160322.4110826
Elizabethkingia anophelis – USA (05): (WI,MI) fatal, community acquired 20160318.4104623
Elizabethkingia anophelis – USA (04): (WI) fatal, community acquired 20160317.4099438
Elizabethkingia anophelis – USA (03): (WI) fatal, community acquired 20160311.4083895
Elizabethkingia anophelis – USA (02): (WI) fatal, community acq., comment, RFI 20160309.4080818
Elizabethkingia anophelis – USA: (WI) fatalities, community acquired, RFI 20160303.4067424

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