THE WESTERN JOURNAL OF MEDICINE
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OCTOBER 1992
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157
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Uterine rupture is reported to occur in 0.2% to 0.8% of patients having a trial of labor after a previous cesarean sectionl14 and may occur early in labor.6 Although uterine rupture commonly results in fetal distress, maternal death is rare if the event occurs in a hospital.7 To prevent tragic consequences, patients planning to have vaginal delivery after cesarean section should be evaluated early in labor and monitored appropriately in a hospital capable of rapidly mobilizing for obstetric emergencies. REFERENCES 1. Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM: Vaginal birth after cesarean delivery: Results of a 5-year multicenter collaborative study. Obstet Gynecol 1990; 76(pt 1):750-754 2. Chazotte C, Cohen WR: Catastrophic complications of previous cesarean section. Am J Obstet Gynecol 1990; 163:738-742 3. Rosen MG, Dickinson JC, Westhoff CL: Vaginal birth after cesarean: A metaanalysis of morbidity and mortality. Obstet Gynecol 1991; 77:465-470 4. Farmer RM, Kirschbaum T, Potter D, Strong TH, Medearis AL: Uterine rupture during trial of labor after previous cesarean section. Am J Obstet Gynecol 1991; 165:996-1001 5. Scott JR: Mandatory trial of labor after cesarean delivery: An alternative viewpoint. Obstet Gynecol 1991; 77:811-814 6. Jones RO, Nagashima AW, Hartnett-Goodman MM, Goodlin RC: Rupture of low transverse cesarean scars during trial of labor. Obstet Gynecol 1991; 77:815-817 7. Finley BE, Gibbs CE: Emergent cesarean delivery in patients undergoing a trial of labor with a transverse lower-segment scar. Am J Obstet Gynecol 1986; 155:936939
Isolation of Borrelia burgdorferi From Ticks in Southern California HILDY B. MEYERS, MD, MPH DOUGLAS F. MOORE, PhD GEORGE GELLERT, MD, MPH, MPA Santa Ana, California GARY L. EULER, DrPH THOMAS J. PRENDERGAST, MD, MPH MAHER BADRI, MD, MPH San Bemardino, Califomia JAMES P. WEBB, PhD CARRIE L FOGARTY Garden Grove, Califomia
SINCE ITS INITIAL DESCRIPHION in 1975, Lyme disease has been reported from 46 states, although the causative agent of
Lyme disease, Borrelia burgdorferi, has not been as widely identified.1 Three regions in the United States have accounted for the vast majority of cases: the northeastern United States (from Massachusetts to Maryland), the Midwest (Wisconsin and Minnesota), and the West (Oregon and northern California). Until early 1991, no cases of endemic Lyme disease were documented and B burgdorferi had not been isolated in southern California. Borrelia burgdorferi Identification in Orange County From 1984 through August 1991, the Vector Control District of Orange County captured and tested 328 Ixodespacificus ticks, the vector of Lyme disease in California, for B burgdorferi. In February 1991, 31 I pacificus ticks were (Meyers HB, Moore DF, Gellert G, et al: Isolation of Borrelia burgdorferi from ticks in southern California. West J Med 1992 Oct; 157:455-456) From the Orange County Health Care Agency, Santa Ana; the Preventive Medical Services Division, Department of Public Health, San Bernardino County, San Bernardino; and the Orange County Vector Control District, Garden Grove, California. Reprint requests to Hildy B. Meyers, MD, MPH, Medical Director, Communicable Disease Control and Epidemiology, Orange County Health Care Agency, PO Box 6128, Santa Ana, CA 97206-0128.
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ABBREVIATIONS USED IN TEXT CDHS = California Department of Health Services EIA = enzyme immunoassay
collected from a ravine in San Clemente, near the border with San Diego County. One tick was culture-positive for B burgdorferi. This organism grew in Kelly-Stoner-Barbour II medium and was confirmed as B burgdorferi by the California Department of Health Services (CDHS) Microbial Disease Laboratory. The identity was confirmed by immunofluorescent microscopy using monoclonal antibodies H5332 (directed against OspA) and H68 (directed against OspB), both of which are specific for B burgdorferi.* This was the first isolation ofB burgdorferi from a tick in southern California. Lyme Disease Reported in San Bernardino County In April 1991 a case of possible Lyme disease meeting surveillance criteria was reported to the San Bernardino County Department of Public Health. The patient, a 55-yearold man, gave a history of a tick bite February 24, 1991, while hiking in Cucamonga Canyon in the San Gabriel Mountains (including an area known locally as "Tick Overlook"). The tick was removed from the lower left abdomen. An erythematous rash occurred on February 26 that eventually reached 8 cm in diameter. No fever, myalgia, or other symptoms were noted. The patient sought medical care the same day, and Lyme disease was diagnosed. A regimen of tetracycline, 500 mg four times a day for ten days, was prescribed. A serologic test on April 3 was negative (total antibody by enzyme immunoassay [EIA], 0.33; positive >0.80). On June 13 the patient was examined by another health care provider because of swelling and pain in the left knee. A second EIA was negative (0.29). The left knee symptoms subsided after five days. The tick was identified as Ixodespacificus by an entomologist with Vector Control in San Bernardino and by the CDHS Microbial Disease Laboratory. Borrelia burgdorferi was not cultured from this tick. This may have been a falsenegative result due to the improper preservation of the tick. This case report, however, led to the trapping of ticks in the same vicinity in March 1991. Subsequent culture of these ticks was positive for B burgdorferi at the CDHS Microbial Disease Laboratory. This is the first positive identification of this organism from ticks in San Bernardino County.
Discussion Lyme disease became legally reportable in California in April 1989. From April 1989 through April 1991, San Bernardino and Orange counties reported 14 and 12 cases, respectively. Of these, five cases from San Bernardino and two cases from Orange may have been locally acquired (no out-of-county travel histories). Only three cases presented with the characteristic lesion of erythema migrans, and in none of these patients was it possible to isolate the causative organism. Ixodes pacificus, or the western black-legged tick, can be found in many areas of San Bernardino and Orange counties. The data presented here, however, show a low prevalence of B burgdorferi in ticks in Orange County. This rate is even *Allen Barbour, MD, provided the monoclonal antibodies for confirming the identification of Borrelia burgdorferi.
456
lower than that reported in northern California (1% to 2% overall, Robert Murray, DrPH, CDHS, oral communication, April 1992). Both these rates are lower than those seen in the northeastern United States. These lower rates may be due to a difference in the host-parasite relationship. Immature stages of Ipacificus, unlike those of Ixodes dammini, the northern deer tick of the northeastern and midwestern United States, feed on lizards and small mammals. This may play a role in reducing B burgdorferi transmission because it is thought that lizards do not sustain infection with B burgdorferi. For these reasons a Lyme disease incidence of a similar magnitude to that observed in the northeastern US is not expected in southern California. Preventive measures for infection with B burgdorferi are based on avoiding tick contact. This includes avoiding grass and brush vegetation, wearing light-colored long-sleeved shirts and long pants tucked into socks or boots, applying a tick repellent to clothes, and doing frequent body checks for ticks. Ticks adhering to skin should be removed with forceps or tweezers using a gentle and steady pulling motion that avoids crushing the tick and releasing its bodily fluids. The tick may be kept alive by placing in a vial with a moist piece of cotton for submission to a public health laboratory. Physicians should contact their local health department for the availability of tick identification and isolation of B burgdorferi. The case reported in San Bernardino has not been proved to be Lyme disease; however, the fact that the serologic test
ALERTS, NOTICES, AND CASE REPORTS
was negative may have been due to early antibiotic treatment. In one study, among ten patients with early Lyme disease (erythema migrans only) who were treated early in their course, only one had an antibody response.2 The importance of this case is that it led to the identification of ticks positive for B burgdorferi in an area previously thought to be free of the organism. It also illustrates the difficulty in confirming the diagnosis of Lyme disease when early treatment is instituted. Readers are referred to several recent reviews of the diagnosis and treatment of Lyme disease.3`5 Although the risk appears to be low, physicians should be aware that Lyme disease may be contracted in San Bernardino and Orange counties and perhaps other locations in southern California. Public health authorities should continue surveillance for infected tick vectors and human cases of Lyme disease. The appearance of the causative agent of Lyme disease in southern California indicates that reported cases may not remain confined exclusively to previously endemic areas of the country. REFERENCES 1. Centers for Disease Control: Lyme disease surveillance-United States, 19891990. MMWR 1991; 40:417-421 2. Shrestha M, Grodzicki RL, Steere AC: Diagnosing early Lyme disease. Am J Med 1985; 78:235-240 3. Rahn DW, Malawista SE: Lyme disease. West J Med 1991; 154:706-714 4. Rahn DW, Malawista SE: Lyme disease: Recommendations for diagnosis and treatment. Ann Intern Med 1991; 114:472-481 5. Malane MS, Grant-Kels JM, Feder HM, Luger SW: Diagnosis of Lyme disease based on dermatologic manifestations. Ann Intern Med 1991; 114:490-498
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OCTOBER 1992
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157
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Uterine rupture is reported to occur in 0.2% to 0.8% of patients having a trial of labor after a previous cesarean sectionl14 and may occur early in labor.6 Although uterine rupture commonly results in fetal distress, maternal death is rare if the event occurs in a hospital.7 To prevent tragic consequences, patients planning to have vaginal delivery after cesarean section should be evaluated early in labor and monitored appropriately in a hospital capable of rapidly mobilizing for obstetric emergencies. REFERENCES 1. Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM: Vaginal birth after cesarean delivery: Results of a 5-year multicenter collaborative study. Obstet Gynecol 1990; 76(pt 1):750-754 2. Chazotte C, Cohen WR: Catastrophic complications of previous cesarean section. Am J Obstet Gynecol 1990; 163:738-742 3. Rosen MG, Dickinson JC, Westhoff CL: Vaginal birth after cesarean: A metaanalysis of morbidity and mortality. Obstet Gynecol 1991; 77:465-470 4. Farmer RM, Kirschbaum T, Potter D, Strong TH, Medearis AL: Uterine rupture during trial of labor after previous cesarean section. Am J Obstet Gynecol 1991; 165:996-1001 5. Scott JR: Mandatory trial of labor after cesarean delivery: An alternative viewpoint. Obstet Gynecol 1991; 77:811-814 6. Jones RO, Nagashima AW, Hartnett-Goodman MM, Goodlin RC: Rupture of low transverse cesarean scars during trial of labor. Obstet Gynecol 1991; 77:815-817 7. Finley BE, Gibbs CE: Emergent cesarean delivery in patients undergoing a trial of labor with a transverse lower-segment scar. Am J Obstet Gynecol 1986; 155:936939
Isolation of Borrelia burgdorferi From Ticks in Southern California HILDY B. MEYERS, MD, MPH DOUGLAS F. MOORE, PhD GEORGE GELLERT, MD, MPH, MPA Santa Ana, California GARY L. EULER, DrPH THOMAS J. PRENDERGAST, MD, MPH MAHER BADRI, MD, MPH San Bemardino, Califomia JAMES P. WEBB, PhD CARRIE L FOGARTY Garden Grove, Califomia
SINCE ITS INITIAL DESCRIPHION in 1975, Lyme disease has been reported from 46 states, although the causative agent of
Lyme disease, Borrelia burgdorferi, has not been as widely identified.1 Three regions in the United States have accounted for the vast majority of cases: the northeastern United States (from Massachusetts to Maryland), the Midwest (Wisconsin and Minnesota), and the West (Oregon and northern California). Until early 1991, no cases of endemic Lyme disease were documented and B burgdorferi had not been isolated in southern California. Borrelia burgdorferi Identification in Orange County From 1984 through August 1991, the Vector Control District of Orange County captured and tested 328 Ixodespacificus ticks, the vector of Lyme disease in California, for B burgdorferi. In February 1991, 31 I pacificus ticks were (Meyers HB, Moore DF, Gellert G, et al: Isolation of Borrelia burgdorferi from ticks in southern California. West J Med 1992 Oct; 157:455-456) From the Orange County Health Care Agency, Santa Ana; the Preventive Medical Services Division, Department of Public Health, San Bernardino County, San Bernardino; and the Orange County Vector Control District, Garden Grove, California. Reprint requests to Hildy B. Meyers, MD, MPH, Medical Director, Communicable Disease Control and Epidemiology, Orange County Health Care Agency, PO Box 6128, Santa Ana, CA 97206-0128.
4
455
ABBREVIATIONS USED IN TEXT CDHS = California Department of Health Services EIA = enzyme immunoassay
collected from a ravine in San Clemente, near the border with San Diego County. One tick was culture-positive for B burgdorferi. This organism grew in Kelly-Stoner-Barbour II medium and was confirmed as B burgdorferi by the California Department of Health Services (CDHS) Microbial Disease Laboratory. The identity was confirmed by immunofluorescent microscopy using monoclonal antibodies H5332 (directed against OspA) and H68 (directed against OspB), both of which are specific for B burgdorferi.* This was the first isolation ofB burgdorferi from a tick in southern California. Lyme Disease Reported in San Bernardino County In April 1991 a case of possible Lyme disease meeting surveillance criteria was reported to the San Bernardino County Department of Public Health. The patient, a 55-yearold man, gave a history of a tick bite February 24, 1991, while hiking in Cucamonga Canyon in the San Gabriel Mountains (including an area known locally as "Tick Overlook"). The tick was removed from the lower left abdomen. An erythematous rash occurred on February 26 that eventually reached 8 cm in diameter. No fever, myalgia, or other symptoms were noted. The patient sought medical care the same day, and Lyme disease was diagnosed. A regimen of tetracycline, 500 mg four times a day for ten days, was prescribed. A serologic test on April 3 was negative (total antibody by enzyme immunoassay [EIA], 0.33; positive >0.80). On June 13 the patient was examined by another health care provider because of swelling and pain in the left knee. A second EIA was negative (0.29). The left knee symptoms subsided after five days. The tick was identified as Ixodespacificus by an entomologist with Vector Control in San Bernardino and by the CDHS Microbial Disease Laboratory. Borrelia burgdorferi was not cultured from this tick. This may have been a falsenegative result due to the improper preservation of the tick. This case report, however, led to the trapping of ticks in the same vicinity in March 1991. Subsequent culture of these ticks was positive for B burgdorferi at the CDHS Microbial Disease Laboratory. This is the first positive identification of this organism from ticks in San Bernardino County.
Discussion Lyme disease became legally reportable in California in April 1989. From April 1989 through April 1991, San Bernardino and Orange counties reported 14 and 12 cases, respectively. Of these, five cases from San Bernardino and two cases from Orange may have been locally acquired (no out-of-county travel histories). Only three cases presented with the characteristic lesion of erythema migrans, and in none of these patients was it possible to isolate the causative organism. Ixodes pacificus, or the western black-legged tick, can be found in many areas of San Bernardino and Orange counties. The data presented here, however, show a low prevalence of B burgdorferi in ticks in Orange County. This rate is even *Allen Barbour, MD, provided the monoclonal antibodies for confirming the identification of Borrelia burgdorferi.
456
lower than that reported in northern California (1% to 2% overall, Robert Murray, DrPH, CDHS, oral communication, April 1992). Both these rates are lower than those seen in the northeastern United States. These lower rates may be due to a difference in the host-parasite relationship. Immature stages of Ipacificus, unlike those of Ixodes dammini, the northern deer tick of the northeastern and midwestern United States, feed on lizards and small mammals. This may play a role in reducing B burgdorferi transmission because it is thought that lizards do not sustain infection with B burgdorferi. For these reasons a Lyme disease incidence of a similar magnitude to that observed in the northeastern US is not expected in southern California. Preventive measures for infection with B burgdorferi are based on avoiding tick contact. This includes avoiding grass and brush vegetation, wearing light-colored long-sleeved shirts and long pants tucked into socks or boots, applying a tick repellent to clothes, and doing frequent body checks for ticks. Ticks adhering to skin should be removed with forceps or tweezers using a gentle and steady pulling motion that avoids crushing the tick and releasing its bodily fluids. The tick may be kept alive by placing in a vial with a moist piece of cotton for submission to a public health laboratory. Physicians should contact their local health department for the availability of tick identification and isolation of B burgdorferi. The case reported in San Bernardino has not been proved to be Lyme disease; however, the fact that the serologic test
ALERTS, NOTICES, AND CASE REPORTS
was negative may have been due to early antibiotic treatment. In one study, among ten patients with early Lyme disease (erythema migrans only) who were treated early in their course, only one had an antibody response.2 The importance of this case is that it led to the identification of ticks positive for B burgdorferi in an area previously thought to be free of the organism. It also illustrates the difficulty in confirming the diagnosis of Lyme disease when early treatment is instituted. Readers are referred to several recent reviews of the diagnosis and treatment of Lyme disease.3`5 Although the risk appears to be low, physicians should be aware that Lyme disease may be contracted in San Bernardino and Orange counties and perhaps other locations in southern California. Public health authorities should continue surveillance for infected tick vectors and human cases of Lyme disease. The appearance of the causative agent of Lyme disease in southern California indicates that reported cases may not remain confined exclusively to previously endemic areas of the country. REFERENCES 1. Centers for Disease Control: Lyme disease surveillance-United States, 19891990. MMWR 1991; 40:417-421 2. Shrestha M, Grodzicki RL, Steere AC: Diagnosing early Lyme disease. Am J Med 1985; 78:235-240 3. Rahn DW, Malawista SE: Lyme disease. West J Med 1991; 154:706-714 4. Rahn DW, Malawista SE: Lyme disease: Recommendations for diagnosis and treatment. Ann Intern Med 1991; 114:472-481 5. Malane MS, Grant-Kels JM, Feder HM, Luger SW: Diagnosis of Lyme disease based on dermatologic manifestations. Ann Intern Med 1991; 114:490-498
