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In the Western Hemisphere, bat-associated rabies viruses (RABVs) have established independent transmission cycles in multiple mammal hosts, forming genetically distinct lineages. In New Mexico, USA, skunks, bats, and gray foxes are rabies reservoir hosts and represent a public health risk because of encounters with humans. During 2015 and 2019, two previously undescribed RABVs were detected in 2 gray foxes (Urocyon cinereoargenteus) in Lincoln County, New Mexico. Phylogenetic analysis of the nucleoprotein gene indicated that the isolates are a novel RABV variant. These 2 cases probably represent repeated spillover events from an unknown bat reservoir to gray foxes. Molecular analysis of rabies cases across New Mexico identified that other cross-species transmission events were the result of viral variants previously known to be enzootic to New Mexico. Despite a robust rabies public health surveillance system in the United States, advances in testing and surveillance techniques continue to identify previously unrecognized zoonotic pathogens.

The mosquitoes Aedes aegypti (L.) and Ae .  albopictus Skuse are the major vectors of dengue, Zika, yellow fever, and chikungunya viruses worldwide. Wolbachia , an endosymbiotic bacterium present in many insects, is being utilized in novel vector control strategies to manipulate mosquito life history and vector competence to curb virus transmission. Earlier studies have found that Wolbachia is commonly detected in Ae .  albopictus but rarely detected in Ae. aegypti . In this study, we used a two-step PCR assay to detect Wolbachia in wild-collected samples of Ae. aegypti . The PCR products were sequenced to validate amplicons and identify Wolbachia strains. A loop-mediated isothermal amplification (LAMP) assay was developed and used for detecting Wolbachia in selected mosquito specimens as well. We found Wolbachia in 85/148 (57.4%) wild Ae. aegypti specimens from various cities in New Mexico, and in 2/46 (4.3%) from St. Augustine, Florida. Wolbachia was not detected in 94 samples of Ae. aegypti from Deer Park, Harris County, Texas. Wolbachia detected in Ae. aegypti from both New Mexico and Florida was the w AlbB strain of Wolbachia pipientis . A Wolbachia -positive colony of Ae. aegypti was established from pupae collected in Las Cruces, New Mexico, in 2018. The infected females of this strain transmitted Wolbachia to their progeny when crossed with males of Rockefeller strain of Ae. aegypti , which does not carry Wolbachia . In contrast, none of the progeny of Las Cruces males mated to Rockefeller females were infected with Wolbachia ., Competing Interests: The authors declare no competing financial interests.

Background: Aedes aegypti mosquitoes are vectors of a variety of emerging viral pathogens, including yellow fever, dengue, chikungunya, and Zika virus. This species has established endemic populations in all cities across southern New Mexico sampled to date. Presently, control of Aedes-borne viruses relies on deployment of insecticides to suppress mosquito populations, but the evolution of insecticide resistance threatens the success of vector control programs. While insecticide resistance is quite common in Ae. aegypti field populations across much of the U.S., the resistance status of this species in populations from New Mexico has not previously been assessed., Results: First, we collected information on pesticide use in cities in southern New Mexico and found that the most commonly used active ingredients were pyrethroids. The use of insecticides with the same mode-of-action over multiple years is likely to promote the evolution of resistance. To determine if there was evidence of resistance in some cities in southern New Mexico, we collected Ae. aegypti from the same cities and established laboratory strains to assess resistance to pyrethroid insecticides and, for a subset of populations, to organophosphate insecticides. F2 or F4 generation mosquitoes were assessed for insecticide resistance using bottle test bioassays. The majority of the populations from New Mexico that we analyzed were resistant to the pyrethroids permethrin and deltamethrin. A notable exception to this trend were mosquitoes from Alamogordo, a city that did not report using pyrethroid insecticides for vector control. We screened individuals from each population for known knock down resistance (kdr) mutations via PCR and found a strong association between the presences of the F1534C kdr mutation in the para gene of Ae. aegypti (homologue to F1534C in Musca domestica L.) and pyrethroid resistance., Conclusion: High-level pyrethroid resistance is common in Ae. aegypti from New Mexico and geographic variation in such resistance is likely associated with variation in usage of pyrethroids for vector control. Resistance monitoring and management is recommended in light of the potential for arbovirus outbreaks in this state. Also, alternative approaches to mosquito control that do not involve insecticides should be explored., Competing Interests: The authors have declared that no competing interests exist.

Plague is a zoonotic disease (transmitted mainly by fleas and maintained in nature by rodents) that causes severe acute illness in humans. We present a human plague case who became infected by the bite of a wild Gunnison's prairie dog, and a good practical example of the One Health approach that resulted in a rapid public health response. The exposure occurred while the animal was being transported for relocation to a wildlife refuge after being trapped in a plague enzootic area. This is the first report of a human plague case resulting from the bite of a Gunnison's prairie dog. Additionally, we present an observation of a longer incubation period for plague in captive prairie dogs, leading to a recommendation for a longer quarantine period for prairie dogs during translocation efforts., (Published 2017. This article is a U.S. Government work and is in the public domain in the USA.)

Our longitudinal study of plague dynamics was conducted in north-central New Mexico to identify which species in the community were infected with plague, to determine the spatial and temporal patterns of the dynamics of plague epizootics, and to describe the dynamics of Yersinia pestis infection within individual hosts. A total of 3156 fleas collected from 535 small mammals of 8 species were tested for Y. pestis DNA. Nine fleas collected from six southern plains woodrats (Neotoma micropus) and from one rock squirrel (Otospermophilus variegatus) were positive for the pla gene of Y. pestis. None of 127 fleas collected from 17 woodrat nests was positive. Hemagglutinating antibodies to the Y. pestis-specific F1 antigen were detected in 11 rodents of 6 species. All parts of the investigated area were subjected to local disappearance of woodrats. Despite the active die-offs, some woodrats always were present within the relatively limited endemic territory and apparently were never exposed to plague. Our observations suggest that small-scale die-offs in woodrats can support maintenance of plague in the active U.S. Southwestern focus.

Those at highest risk are persons in occupations with potential for rodent exposure and American Indian women 40--64 years of age.

Objective: To determine percentages of domestic cats and dogs vaccinated against rabies, identify barriers to vaccination, and assess knowledge about rabies in a semirural New Mexico community after a skunk rabies outbreak., Design: Cross-sectional, door-to-door, bilingual, community-based participatory survey., Sample: 366 residential properties in Eddy County, NM., Procedures: The New Mexico Department of Health and CDC administered surveys and analyzed data., Results: Individuals at 247 of the 366 residential properties participated in the survey. One hundred eighty of the 247 (73%) households owned a dog (n = 292) or cat (163). Cats were more likely than dogs to not have an up-to-date rabies vaccination status (prevalence ratio, 3.2; 95% confidence interval, 2.3 to 4.4). Cost and time or scheduling were the most frequently identified barriers to vaccination. One hundred sixty (65%) respondents did not know livestock can transmit rabies, 78 (32%) did not know rabies is fatal, and 89 (36%) did not know a bat scratching a person can be an exposure. Only 187 (76%) respondents indicated they would contact animal control if they saw a sick skunk, and only 166 (67%) indicated they would contact animal control if bitten by a dog they did not own., Conclusions and Clinical Relevance: Findings indicated that rabies vaccination prevalence among pet dogs and cats was low, despite the fact that the region had experienced a skunk rabies outbreak during the previous 2 years. In addition, substantial percentages of respondents did not have correct knowledge of rabies or rabies exposure.

Tickborne relapsing fever (TBRF) is a zoonosis caused by spirochetes of the genus Borrelia and transmitted to humans by ticks of the genus Ornithodoros. TBRF is endemic in the western United States, predominately in mountainous regions. Clinical illness is characterized by recurrent bouts of fever, headache, and malaise. Although TBRF is usually a mild illness, severe sequelae and death can occur. This report summarizes the epidemiology of 504 TBRF cases reported from 12 western states during 1990-2011. Cases occurred most commonly among males and among persons aged 10‒14 and 40‒44 years. Most reported infections occurred among nonresident visitors to areas where TBRF is endemic. Clinicians and public health practitioners need to be familiar with current epidemiology and features of TBRF to adequately diagnose and treat patients and recognize that any TBRF case might indicate an ongoing source of potential exposure that needs to be investigated and eliminated.

Dengue is caused by infection with any of four mosquito-transmitted dengue viruses (DENV-1-4) and is characterized by fever, headache, myalgia, and leukopenia. Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyperinflammatory syndrome that can be familial or acquired, and is characterized by persistent fever, pancytopenia, hepatosplenomegaly, and increased serum ferritin. Acquired HLH is most frequently associated with Epstein Barr virus infection but also has been associated with dengue. This report describes a fatal case of acquired HLH that was apparently triggered by infection with DENV-3. The patient developed an acute febrile illness in August 2012 during a 1-month vacation in New Mexico. After returning to her home in Texas, she was initially diagnosed with West Nile virus (WNV) infection, developed pancytopenia, liver failure, and disseminated intravascular coagulopathy, and died. DENV-3 was detected in a premortem bone marrow biopsy in which erythrophagocytosis was evident. This case underscores the need for clinicians in the United States to be vigilant for dengue and request diagnostic testing for suspected cases, which should be reported to public health authorities.

Background: Although new pathogen-vehicle combinations are increasingly being identified in produce-related disease outbreaks, fresh produce is a rarely recognized vehicle for listeriosis. We investigated a nationwide listeriosis outbreak that occurred in the United States during 2011., Methods: We defined an outbreak-related case as a laboratory-confirmed infection with any of five outbreak-related subtypes of Listeria monocytogenes isolated during the period from August 1 through October 31, 2011. Multistate epidemiologic, trace-back, and environmental investigations were conducted, and outbreak-related cases were compared with sporadic cases reported previously to the Listeria Initiative, an enhanced surveillance system that routinely collects detailed information about U.S. cases of listeriosis., Results: We identified 147 outbreak-related cases in 28 states. The majority of patients (127 of 147, 86%) were 60 years of age or older. Seven infections among pregnant women and newborns and one related miscarriage were reported. Of 145 patients for whom information about hospitalization was available, 143 (99%) were hospitalized. Thirty-three of the 147 patients (22%) died. Patients with outbreak-related illness were significantly more likely to have eaten cantaloupe than were patients 60 years of age or older with sporadic illness (odds ratio, 8.5; 95% confidence interval, 1.3 to ∞). Cantaloupe and environmental samples collected during the investigation yielded isolates matching all five outbreak-related subtypes, confirming that whole cantaloupe produced by a single Colorado farm was the outbreak source. Unsanitary conditions identified in the processing facility operated by the farm probably resulted in contamination of cantaloupes with L. monocytogenes., Conclusions: Raw produce, including cantaloupe, can serve as a vehicle for listeriosis. This outbreak highlights the importance of preventing produce contamination within farm and processing environments.

One human plague case was reported in Oregon in September 2010 and another in New Mexico in May 2011. Misidentification of Yersinia pestis by automated identification systems contributed to delayed diagnoses for both cases.

In 2010, 41 patients ill with Escherichia coli O157:H7 isolates determined to be indistinguishable by pulsed-field gel electrophoresis were identified among residents of five Southwestern U.S. states. A majority of patients reported consuming complimentary samples of aged raw-milk Gouda cheese at national warehouse chain store locations; sampling Gouda cheese was significantly associated with illness (odds ratio, 9.0; 95 % confidence interval, 1.7 to 47). Several Gouda samples yielded the O157:H7 outbreak strain, confirming the food vehicle and source of infections. Implicated retail food-sampling operations were inconsistently regulated among affected states, and sanitation deficiencies were common among sampling venues. Inspection of the cheese manufacturer indicated deficient sanitation practices and insufficient cheese curing times. Policymakers should continue to reexamine the adequacy and enforcement of existing rules intended to ensure the safety of raw-milk cheeses and retail food sampling. Additional research is necessary to clarify the food safety hazards posed to patrons who consume free food samples while shopping.

Socioeconomic indicators associated with temporal changes in the distribution of human plague cases in New Mexico were investigated for 1976-2007. In the 1980s, cases were more likely in census block groups with poor housing conditions, but by the 2000s, cases were associated with affluent areas concentrated in the Santa Fe-Albuquerque region.

Within the United States, the majority of human plague cases are reported from New Mexico. We describe climatic factors involved in intra- and inter-annual plague dynamics using animal-based surveillance data from that state. Unlike the clear seasonal pattern observed at lower elevations, cases occur randomly throughout the year at higher elevations. Increasing elevation corresponded with delayed mean time in case presentation. Using local meteorological data (previous year mean annual precipitation, total degrees over 27 degrees C 3 years before and maximum winter temperatures 4 years before) we built a time-series model predicting annual case load that explained 75% of the variance in pet cases between years. Moreover, we found a significant correlation with observed annual human cases and predicted pet cases. Because covariates were time-lagged by at least 1 year, intensity of case loads can be predicted in advance of a plague season. Understanding associations between environmental and meteorological factors can be useful for anticipating future disease trends.

West Nile virus infection can result in prolonged subjective complaints of cognitive and functional decline even in the absence of a neuroinvasive form of infection. Persistent cognitive and functional complaints could be a result of general somatic symptoms, emotional distress, or residual central nervous system damage or dysfunction. Most studies of cognition in postacute West Nile virus infection rely on self-report. This descriptive study aimed to document cognitive deficits in a sample of the 2003 infected population reported in New Mexico. Patients with clinically defined neuroinvasive disease or who were impaired on brief mental status screening were seen for comprehensive neuropsychological assessment. We found that one year after symptom onset, more than half of the sample had objectively measurable neuropsychological impairment in at least two cognitive domains. Impairment was not related to subjective complaints of physical or emotional distress, or premorbid intellectual abilities. Persistent cognitive impairment in West Nile virus infection may be due to prolonged or permanent damage to the central nervous system.

We describe an analytic approach to provide fine-scale discrimination among multiple infection source hypotheses. This approach uses mutation-rate data for rapidly evolving multiple locus variable-number tandem repeat loci in probabilistic models to identify the most likely source. We illustrate the utility of this approach using data from a North American human plague investigation.

A 56-year time series of human plague cases (Yersinia pestis) in the western United States was used to explore the effects of climatic patterns on plague levels. We found that the Pacific Decadal Oscillation (PDO), together with previous plague levels and above-normal temperatures, explained much of the plague variability. We propose that the PDO's impact on plague is conveyed via its effect on precipitation and temperature and the effect of precipitation and temperature on plague hosts and vectors: warmer and wetter climate leading to increased plague activity and thus an increased number of human cases. Our analysis furthermore provides insights into the consistency of plague mechanisms at larger scales.

Plague is a rare but often fatal zoonosis endemic to the western United States. Previous studies have identified contact with pets as a potential risk factor for infection. We conducted a matched case-control study to better define the risks associated with pets at both the household and individual levels. Using a written questionnaire, we surveyed nine surviving plague patients, 12 household members of these patients, and 30 age- and neighbourhood-matched controls about household and individual exposures. Overall, 79% of households had at least one dog, 59% had at least one cat and 33% used flea control, with no significant differences between case and control households. Four (44%) case households reported having a sick dog versus no (0%) control households [matched odds ratio, (mOR) 18.5, 95% confidence interval (CI) 2.3-infinity], and four (44%) patients reported sleeping in the same bed with a pet dog versus three (10%) controls (mOR 5.7, 95% CI 1.0-31.6). Within case households with multiple members, two (40%) of five patients slept with their dogs versus none (0%) of 12 healthy family members (P=0.13). The exposures to cats were not significant. Sleeping in the same bed as a pet dog remained significantly associated with infection in a multivariate logistic regression model (P=0.046). Our findings suggest that dogs may facilitate the transfer of fleas into the home and that activities with close extended contacts with dogs may increase the risk of plague infection.

Plague and hantavirus pulmonary syndrome (HPS) are severe, often fatal diseases in humans that share a broad epidemiologic focus in the southwestern United States. Prevention of these diseases relies heavily on education and reducing rodent abundance in peridomestic environments. Resources for these activities are limited. Therefore, identifying areas sharing elevated risk for these two relatively rare but severe diseases could be useful for targeting limited public health resources. Using logistic regression and geographic information system-based modeling, we identified environmental predictors of elevated risk for plague (distance to piñon-juniper ecotones and amount of precipitation) and HPS (elevation and amount of precipitation) in northeastern Arizona and northwestern New Mexico. Our models accurately identified case locations as suitable (producer accuracies of 93% for plague and 96% for HPS) and indicated that approximately half of the coverage area was classified as suitable risk for either plague or HPS. The probability of a site being classified as suitable for plague was strongly correlated with its probability of being classified as suitable for HPS (rhos = 0.88). Increased risk for both diseases occurred for approximately 37% of the coverage area.

Yersinia pestis, the causative agent of plague, has been detected in fleas and mammals throughout the western United States. This highly virulent infection is rare in humans, surveillance of the disease is expensive, and it often was assumed that risk of exposure to Y. pestis is high in most of the western United States. For these reasons, some local health departments in these plague-affected regions have hesitated to undertake surveillance and other prevention activities. To aid in targeting limited public health resources, we created a fine-resolution human plague risk map for New Mexico, the state reporting more than half the human cases in the United States. Our GIS-based model included three landscape features-a nonlinear relationship with elevation, distance to water, and distance to the ecotone between Rocky Mountain/Great Basin open and closed coniferous woodlands-and yielded an overall accuracy of approximately 80%. The model classified 17.25% of the state as posing significant risk of exposure to humans on privately or tribally owned land, which suggests that resource requirements for regular surveillance and control of plague could be effectively focused on < 20% of the state.

Plague is a rare but highly virulent flea-borne zoonotic disease caused by the Gram-negative bacterium Yersinia pestis Yersin. Identifying areas at high risk of human exposure to the etiological agent of plague could provide a useful tool for targeting limited public health resources and reduce the likelihood of misdiagnosis by raising awareness of the disease. We created logistic regression models to identify landscape features associated with areas where humans have acquired plague from 1957 to 2004 in the four-corners region of the United States (Arizona, Colorado, New Mexico, and Utah), and we extrapolated those models within a geographical information system to predict where plague cases are likely to occur within the southwestern United States disease focus. The probability of an area being classified as high-risk plague habitat increased with elevation up to approximately 2300 m and declined as elevation increased thereafter, and declined with distance from key habitat types (e.g., southern Rocky Mountain piñon--juniper [Pinus edulis Engelm. and Juniperus spp.], Colorado plateau piñon--juniper woodland, Rocky Mountain ponderosa pine (Pinus ponderosa P.& C. Lawson var. scopulorum), and southern Rocky Mountain juniper woodland and savanna). The overall accuracy of the model was >82%. Our most conservative model predicted that 14.4% of the four-corners region represented a high risk of peridomestic exposure to Y. pestis.

Mental status after acute West Nile virus infection has not been examined objectively. We compared Telephone Interview for Cognitive Status scores of 116 patients with West Nile fever or West Nile neuroinvasive disease. Mental status was poorer and cognitive complaints more frequent with West Nile neuroinvasive disease (p = 0.005).

In November 2002, a couple from New Mexico traveled to New York where both had fever and unilateral inguinal adenopathy. The husband was in septic shock when he sought medical care and was admitted to an intensive care unit, where he developed ischemic necrosis of his feet which later required bilateral amputation. Yersinia pestis was grown from his blood. Immunohistochemical assays using anti-Y pestis antibodies demonstrated multiple bacteria and granular antigens in and around vessels of the ischemic amputation tissues obtained 20 days after initiation of antibiotics; however, no evidence of Y pestis was present in viable tissues. Immunohistochemical evidence of Y pestis inside vessels of gangrenous feet in this patient underscores the importance of adequate excision of necrotic or partially necrotic tissues because antibiotics cannot be effectively delivered to necrotic and poorly perfused tissues.

Streptomycin, an antimicrobial with limited availability, is the treatment of choice for plague, a fulminating and potentially epidemic disease that poses a bioterrorism concern. We evaluated the efficacy of gentamicin and tetracyclines for treating human plague. A medical record review was conducted on all 75 patients with plague who were reported in New Mexico during 1985-1999. Fifty patients were included in an analysis that compared streptomycin-treated patients (n=14) with those treated with gentamicin and/or a tetracycline (n=36). The mean numbers of fever days, hospital days, and complications and the number of deaths did not differ between patients treated with streptomycin and those treated with gentamicin. One patient who received tetracycline alone experienced a serious complication. Gentamicin alone or in combination with a tetracycline was as efficacious as streptomycin for treating human plague. The efficacy of a tetracycline alone could not be determined from the study.

Exposure to cats infected with Yersinia pestis is a recently recognized risk for human plague in the US. Twenty-three cases of cat-associated human plague (5 of which were fatal) occurred in 8 western states from 1977 through 1998, which represent 7.7% of the total 297 cases reported in that period. Bites, scratches, or other contact with infectious materials while handling infected cats resulted in 17 cases of bubonic plague, 1 case of primary septicemic plague, and 5 cases of primary pneumonic plague. The 5 fatal cases were associated with misdiagnosis or delays in seeking treatment, which resulted in overwhelming infection and various manifestations of the systemic inflammatory response syndrome. Unlike infections acquired by flea bites, the occurrence of cat-associated human plague did not increase significantly during summer months. Plague epizootics in rodents also were observed less frequently at exposure sites for cases of cat-associated human plague than at exposure sites for other cases. The risk of cat-associated human plague is likely to increase as residential development continues in areas where plague foci exist in the western US. Enhanced awareness is needed for prompt diagnosis and treatment.

Plague occurs episodically in many parts of the world, and some outbreaks appear to be related to increased abundance of rodents and other mammals that serve as hosts for vector fleas. Climate dynamics may influence the abundance of both fleas and mammals, thereby having an indirect effect on human plague incidence. An understanding of the relationship between climate and plague could be useful in predicting periods of increased risk of plague transmission. In this study, we used correlation analyses of 215 human cases of plague in relation to precipitation records from 1948 to 1996 in areas of New Mexico with history of human plague cases (38 cities, towns, and villages). We conducted analyses using 3 spatial scales: global (El Niño-Southern Oscillation Indices [SOI]); regional (pooled state-wide precipitation averages); and local (precipitation data from weather stations near plague case sites). We found that human plague cases in New Mexico occurred more frequently following winter-spring periods (October to May) with above-average precipitation (mean plague years = 113% of normal rain/ snowfall), resulting in 60% more cases of plague in humans following wet versus dry winter-spring periods. However, we obtained significant results at local level only; regional state-wide precipitation averages and SOI values exhibited no significant correlations to incidence of human plague cases. These results are consistent with our hypothesis of a trophic cascade in which increased winter-spring precipitation enhances small mammal food resource productivity (plants and insects), leading to an increase in the abundance of plague hosts. In addition, moister climate conditions may act to promote flea survival and reproduction, also enhancing plague transmission. Finally, the result that the number of human plague cases in New Mexico was positively associated with higher than normal winter-spring precipitation at a local scale can be used by physicians and public health personnel to identify and predict periods of increased risk of plague transmission to humans.

To investigate climatic, spatial, temporal, and environmental patterns associated with hantavirus pulmonary syndrome (HPS) cases in the Four Corners region, we collected exposure site data for HPS cases that occurred in 1993 to 1995. Cases clustered seasonally and temporally by biome type and geographic location, and exposure sites were most often found in pinyon-juniper woodlands, grasslands, and Great Basin desert scrub lands, at elevations of 1,800 m to 2,500 m. Environmental factors (e.g., the dramatic increase in precipitation associated with the 1992 to 1993 El Niño) may indirectly increase the risk for Sin Nombre virus exposure and therefore may be of value in designing disease prevention campaigns.

Sin Nombre virus (SNV) causes the zoonotic disease hantavirus pulmonary syndrome (HPS). Its mechanisms of transmission from rodent to human are poorly understood. It is possible that specific genetic signature sequences could be used to determine the probable site of each case-patient's exposure. Environmental assessments suggested 12 possible sites of rodent exposure for 6 HPS patients. Rodents were captured at 11 of the 12 sites and screened for SNV infection within 2 weeks of the patient's diagnosis. Viral sequences amplified from tissues of rodents at each site were compared with those from case-patients' tissues. Rodents bearing viruses with genetic sequence identity to case-patients' viruses across 2 genomic segments were identified in 4 investigations but never at >1 site. Indoor exposures to rodents were especially common at implicated sites. By distinguishing among multiple possible sites of exposure, viral genotyping studies can enhance understanding of the conditions associated with infection by SNV.

Treatment of unsubstantiated Lyme disease has led to serious complications in some cases. Two case-control studies, based on information in clinical records of patients discharged with a diagnosis of Lyme disease during 1990-1992, were conducted at a central New Jersey hospital. Twenty-five patients with biliary disease were identified, and 52 controls were selected from 1352 patients with suspected Lyme disease. Only 3% of 71 evaluatable subjects met the study criteria for disseminated Lyme disease. Patients with biliary disease were more likely than were antibiotic controls to have received ceftriaxone and more likely than ceftriaxone controls to have received a daily ceftriaxone dose > or = 40 mg/kg and to be < or = 18 years old. Fourteen of 25 biliary case-patients underwent cholecystectomy; all had histopathologic evidence of cholecystitis and 12 had gallstones. Thus, treatment of unsubstantiated diagnoses of Lyme disease is associated with biliary complications.

Plague, primarily a disease of rodents and their infected fleas, is fatal in 50% of infected humans if untreated. In the United States, human cases have been concentrated in the southwest. The most common modes of plague transmission are through flea bites or through contact with infected blood or tissues; however, primary pneumonic plague acquired from cats has become increasingly recognized. We report on the case investigation of a patient, presumably exposed to a plague-infected cat in Colorado, who presented with gastrointestinal symptoms, and subsequently died of primary pneumonic plague. Public health officials should be vigilant for plague activity in rodent populations, veterinarians should suspect feline plague in ill or deceased cats, and physicians should have a high index of suspicion for plague in any person who has traveled to plague enzootic areas.