1. North Carolina STARI Introduction Barbara Johnson, PhD –Bjj1@cdc.govBjj1@cdc.gov –CDC, Foothills Campus, 3150 Rampart Road, Fort Collins, CO 80521 –Phone: 970-221-6463 –Fax: 970-225-4257

2. 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

3. 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)

5. 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

6. STARI Patients States of Probable Exposure To 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

7. Patient 4 (Maryland): Moderate superficial perivascular infiltrates; predominantly mononuclear inflammatory cells 10x 40x All images: H & E stains

8. Patient 5 (Tennessee): Panniculitis (inflammation of subcutaneous adipose tissue; mononuclear infiltrates between adipocytes 10x40x

9. 10x 40x Patient 16 (South Carolina and/or Georgia exposure): Diffuse mixed inflammatory cell infiltrates in the dermis; abundant eosinophils (bright red cells)

10. Patient 19 (South Carolina): Mild perivascular infiltrates (superficial and deep); predominantly mononuclear inflammatory cells 10x40x

11. 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. M Ü llegger, 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.

12. 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