Download:
pdf |
pdfRetrieve Data
Reset Radio Buttons
Reset Form
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Tick-Borne Rickettsial Disease Case Report
Use for: Rocky Mountain spotted fever (RMSF),
ehrlichiosis (human monocytic ehrlichiosis [HME]), and human granulocytic ehrlichiosis [HGE]).
(1-4)
CDC#
Form Approved
OMB 0920-0009
– PATIENT/PHYSICIAN INFORMATION –
Patient's
name:
Date submitted:
Physician’s
name:
Address:
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(5-6)
(7-8)
(9-12)
Phone
no.:
(number, street)
NETSS ID No.: (if reported)
City:
Case ID
Site (19-21)
(13-18)
State (22-23)
– DEMOGRAPHICS –
1. State of residence:
Postal
abrv:
(24-25)
2. County of residence:
(63-64)
6. Race:
(65-68)
8. INDICATE DISEASE TO BE REPORTED: (71)
1
■
■ White
2 ■ Black
1
(69)
RMSF
American Indian
Alaskan Native
Asian
3
4
HME
2
3
HGE
4. Sex:
(51-59)
5
Pacific Islander
9
Not specified
(60)
■ Male
2 ■ Female
1
__ __ __ __ __ - __ __ __ __
■ Check, if history of travel outside county of residence within 30 days of onset of symptoms
5. Date of
birth: __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(61-62)
3. Zip code:
(26-50)
7. Hispanic
ethnicity:
1
(70)
2
■ Yes
■ No
Ehrlichiosis (unspecified, or other agent)
4
– CLINICAL SIGNS,SYMPTOMS, AND OUTCOMES –
9. Was a clinically compatible illness present? (72)
(fever or rash, plus one or more of the following signs: headache, myalgia,
anemia, thrombocytopenia, leukopenia, or elevated hepatic transaminases)
10. Date of Onset of Symptoms:
YES
1
2
■ NO
9
Unk
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(73-74)
11. Was an underlying immunosuppressive condition present? (81)
1
■ YES
2
■ NO
9
■ Unk
2
______________________________________________________
8
1
■ YES
2
NO
9
■ Unk
(86-87)
(82)
3
Meningitis/encephalitis
Disseminated intravascular coagulopathy (DIC) 4 Renal failure
9 ■ None
Other: _______________________________________________________________
(If yes, date)
14. Did the patient die because of this illness? (92) (If yes, date)
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(84-85)
(77-80)
■ Adult respiratory distress syndrome (ARDS)
1
Specify condition(s):
13. Was the patient hospitalized because of this illness? (83)
(75-76)
12. Specify any life-threatening complications in the clinical course of illness:
1
■ YES
2
NO
9
Unk
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(93-94)
(88-91)
(95-96)
(97-100)
– LABORATORY DATA –
15. Name of
laboratory:________________________________________________ City:________________________________ State: __ __ Zip: __ __ __ __ __ - __ __ __ __
Below, indicate Y (Yes) or N (No), ONLY if the test or procedure was performed. Lack of selection indicates that the test or procedure was not performed.
COLLECTION DATE
16.
Serologic
Tests
(mm/dd/yyyy)
Serology 1 __ __ /__ __/__ __ __ __
(101-2)
(103-4)
Titer
COLLECTION DATE
(105-8)
(109-10) (111-12)
Titer
Positive?
(mm/dd/yyyy)
(113-16)
Positive?
(_____)
1
YES
2
NO
(117)
(_____)
1
YES
2
■ NO (118)
IFA - IgM
(_____)
(121-130)
Other
test: ______________ ( _ _ _ _ _ )
1
YES
2
NO
(119)
(_____)
1
■ YES
2
■ NO (120)
1
■ YES
2
■ NO (131)
(_____)
1
■ YES
* Was there a fourfold change in antibody titer between the two serum specimens?
1
YES
IFA - IgG
17.
Serology 2* __ __ /__ __/__ __ __ __
■ NO (132)
2 ■ NO (137)
2
Other Diagnostic
Tests ?
PCR
Morulae visualization*
Immunostain
Culture
Positive?
1
YES
■ YES
1 ■ YES
1 ■ YES
1
2
NO
(133)
■ NO (134)
2 ■ NO (135)
2
2
NO
(136)
* Visualization of morulae not applicable for RMSF.
– FINAL DIAGNOSIS –
18. Classify case based on the CDC case definition (see criteria below):
(138)
1
4
■
RMSF 2
HME 3 ■ HGE
Ehrlichiosis (unspecified, or other agent):
____________________________________
(139-148)
}
State Health Department Official who reviewed this report:
(149)
1
CONFIRMED
2
PROBABLE
Name: ____________________________________________________________
Title: __________________________________ Date: __ __ /__ __/__ __ __ __
(mm/dd/yyyy)
COMMENTS:
CDC CASE DEFINITION
.....................................................................................................................................................................................................................................
Confirmed RMSF: A clinically compatible case with 1) a fourfold change in antibody
titer to Rickettsia rickettsii antigen by IFA, CF, latex agglutination, microagglutination,
or indirect hemagglutination antibody test in two serum samples, or 2) a positive PCR
assay, or 3) immunostaining of antigen in a skin biopsy or autopsy sample, or 4)
isolation and culture of R. rickettsii from a clinical specimen.
Probable RMSF: A clinically compatible case with 1) a single positive antibody titer
by IFA (≥1:64 if IgG); or 2) a single CF titer ≥1:16; or 3) a single titer ≥1:128 by a latex
agglutination, indirect hemagglutination antibody, or microagglutination test; or 4) a
fourfold rise in titer or a single titer >1:320, by Proteus OX-19 or OX-2 test.
Confirmed Ehrlichiosis: A clinically compatible case with 1) a fourfold change in
antibody titer to antigen from an Ehrlichia species by IFA in two serum samples, or
2) a positive PCR assay, or 3) the visualization of morulae in white blood cells with a
single serum positive antibody titer by IFA, or 4) immunostaining of antigen in a
skin biopsy or autopsy sample, or 5) isolation and culture of an Ehrlichia species
from a clinical specimen.
Probable Ehrlichiosis: A clinically compatible case with 1) a single positive antibody
titer by IFA, or 2) the visualization of morulae in white blood cells.
Public reporting burden of this collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA 30333; ATTN: PRA (0920-0009).
CDC 55.1 Rev. 01/2001
1st COPY STATE HEALTH DEPARTMENT
Save Data
Print
Email Form
Next Page
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Tick-Borne Rickettsial Disease Case Report
Use for: Rocky Mountain spotted fever (RMSF),
ehrlichiosis (human monocytic ehrlichiosis [HME]), and human granulocytic ehrlichiosis [HGE]).
(1-4)
CDC#
Form Approved
OMB 0920-0009
–vR
INFORMATION –
4KHgkO
lH
IjbMgX
njiUkbjBnIoF
j9ibtFnjR
jOH
IjbMgT
jgN
imZhGphKDvR
jbWkgT
jgN
imZhGphKDvR
jbWk4KHygnT
jgN
imZhGphKDvR
jbWkgnT
jgN
imZhGphKD
jbPATIENT/PHYSICIAN
Wkg4KBnIoF
j9ibtFnjygnT
jgN
imZhGph
KDvR
jbWkgT
jgN
imZhGphKDvR
jbWkg4KngkZ
lhGgN
imZhGphKDvR
jbWkg4KngkO
lBHbMgX
njiUkbjBnIoF
j9ibtFT
jgN
imvR
jOH
IjbMgX
nj9ibFnjT
jgN
imWkgT
jgN
ikZhBphKDvR
jbWkg4KkgkO
lH
IjbMgX
nji
U9bFnPatient's
jname:
T
jgN
imZhHphKDvR
jbWkgnT
jgN
imZhGphKDvR
jbWkgOBHbMgX
njiUkbjBnUkbjBnIoF
j9ibtFnjkgnT
jgN
imZhGphgkO
lH
IjbMgX
U
jikbjBnIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjkgknjUkZ
jhGphF
9ibtFnjT
jgN
imZhGph Date submitted: __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
KDvR
jbWKDphKDvR
jbWkgnT
jbWkg4KMgkylgkKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbjBnIoF
jiOH
IjbMgX
njhiKDvR
jbWkZhGphKDvR
jbWkROH
IjbMgX
U
jiikbjBngWB
j
(5-6)
(7-8)
(9-12)
kNkZX
U
jikbjOH
IjbMgX
njhiKDvR
jbnIoF
jgN
itmZhGphKDvkgOH
IjbWkgT
jgN
ikZhBphKDvR
jbH
IjbMgX
U
jikbjZhBphF
9ibtFnjIoF
jiktbjBH
jbMgX
nj9ibFnjT
jbWkg4F
9ibtFnjT
jgN
iUkbjBnIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjZgknjBkZ
jhBphF
9ibtFnjj
Phone
TgN
iHZhGphKDvR
jbWKDphKDvR
jbWkgnT
jUkbjBkIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjkgknjUkZ
jhGphFiktZkbMgX
U
jikbjBnIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjkgknjUkZ
jhGphF
9ibtFnjT
jgN
imZhGphKDvR
jbWKDphK Physician’s
DvR
jbAddress:
WkgnT
jbWkg4KMgkylgkKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbjBnIoF
jiOH
IjBhKKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbjBnIoF
jiOH
IjbMgX
njhiKDvR
j name:
no.:
bWk(number,
ZhGphKDvR
jbWkstreet)
ROH
IjbMgX
U
jiikbjBngWB
jkNkZXniT
jgN
imZhGphKDvR
jbWKDphKDvR
jbWkgnT
jbWkg4KMgkylgkKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbj
BnIoF
jiOH
IjBhKKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbjBnIoF
jiOH
IjbMgX
njhiKDvR
jbWkZhGphKDvR
jbWkROH
IjbMgX
U
jiikbjBngWB
jkNRbH
IjbMgX
U
jikbjZhBphF
9ibtFnjIoF
jiktbjBH
jb
MgX
jCity:
n
9ibFnjT
jbWkg4F
9ibtFnjT
jgN
iUkbjBnIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjZgknjBkZ
jhBphF
9ibtFnjT
jgN
iHZhGphKBvR
jbWkg4KkgkO
lH
IjbMgX
njiU9bFnjT
jgN
imZhHphKDvR
jbWkgnT
jgN
imZhGphKDvR
jbWkgOBH NETSS ID No.: (if reported)
bMgX
njiUkbjBnUkbjBnIoF
j9ibtFnjkgnT
jgN
imZhGphgkO
lH
IjbMgX
U
jikbjBnIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjkgknjUkZ
jhGphF
9ibtFnjT
jgkibjBnIoF
jiktbjBnIoF
jnitgkO
lH
IjbMgX
njiUkbjkgknjUkZ
jhGphF
9ibtFnjT
jgN
imZhGphKDvR
jbWKDphKDvj
RbWkgnT
jbWkg4KMgkylgkKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbjBnIoF
jiOH
IjBhKKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jikbjBnIoF
jiOH
IjbMgX
njhiKDvR
jb
Case ID (13-18)
Site (19-21)
WkZhGphKDvR
jbWkROH
IjbMgX
U
jiikbjBngWB
jkNkZXniT
jgN
imZhGphKDvR
jbWKDphKDvR
jbWkgnT
jbWkg4KMgkylgkKDvR
jbZhGphR
jOH
IjbMgOH
IjbMgX
hjiKDvR
jHbMgX
U
jiknjFnjj
State (22-23)
– DEMOGRAPHICS –
1. State of residence:
Postal
abrv:
(24-25)
2. County of residence:
(63-64)
6. Race:
(69)
(65-68)
8. INDICATE DISEASE TO BE REPORTED: (71)
1
White
3
2
Black
4
RMSF
1
American Indian
Alaskan Native
Asian
HME
2
3
HGE
4. Sex:
(51-59)
__ __ __ __ __ - __ __ __ __
■ Check, if history of travel outside county of residence within 30 days of onset of symptoms
5. Date of
birth: __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(61-62)
3. Zip code:
(26-50)
Pacific Islander
5
9
7. Hispanic
ethnicity:
■ Not specified
Male
2
Female
1
(70)
(60)
1
2
■ Yes
■ No
Ehrlichiosis (unspecified, or other agent)
4
– CLINICAL SIGNS,SYMPTOMS, AND OUTCOMES –
9. Was a clinically compatible illness present? (72)
(fever or rash, plus one or more of the following signs: headache, myalgia,
anemia, thrombocytopenia, leukopenia, or elevated hepatic transaminases)
10. Date of Onset of Symptoms:
1
■ YES
2
■ NO
Unk
9
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(73-74)
11. Was an underlying immunosuppressive condition present? (81)
1
■ YES
2
■ NO
9
■ Unk
2
______________________________________________________
8
1
■ YES
2
■ NO
9
■ Adult respiratory distress syndrome (ARDS)
■ Disseminated intravascular coagulopathy (DIC)
1
Specify condition(s):
13. Was the patient hospitalized because of this illness? (83)
■ Unk
(86-87)
(77-80)
3
(82)
■ Meningitis/encephalitis
■ Renal failure
9
None
Other: _______________________________________________________________
(If yes, date)
4
14. Did the patient die because of this illness? (92) (If yes, date)
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(84-85)
(75-76)
12. Specify any life-threatening complications in the clinical course of illness:
1
■ YES
2
■ NO
9
■ Unk
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(93-94)
(88-91)
(95-96)
(97-100)
– LABORATORY DATA –
15. Name of
laboratory:________________________________________________ City:________________________________ State: __ __ Zip: __ __ __ __ __ - __ __ __ __
Below, indicate Y (Yes) or N (No), ONLY if the test or procedure was performed. Lack of selection indicates that the test or procedure was not performed.
COLLECTION DATE
16.
Serologic
Tests
(mm/dd/yyyy)
Serology 1 __ __ /__ __/__ __ __ __
(101-2)
(103-4)
Titer
COLLECTION DATE
(105-8)
(109-10) (111-12)
Titer
Positive?
(mm/dd/yyyy)
Serology 2* __ __ /__ __/__ __ __ __
(113-16)
Positive?
(_____)
1
YES
2
NO
(117)
(_____)
1
YES
2
NO
(118)
IFA - IgM
(_____)
(121-130)
Other
test: ______________ ( _ _ _ _ _ )
1
YES
2
NO
(119)
(_____)
1
■ YES
2
NO
(120)
1
YES
2
■ NO (131)
(_____)
1
YES
2
NO
(132)
* Was there a fourfold change in antibody titer between the two serum specimens? 1 ■ YES
2
IFA - IgG
17.
Other Diagnostic
Tests ?
PCR
Morulae visualization*
Immunostain
Culture
Positive?
1
■ YES
2
1
YES
2
1
1
■ YES
■ YES
2
2
■ NO (133)
■ NO (134)
NO
(135)
■ NO (136)
* Visualization of morulae not applicable for RMSF.
■ NO (137)
– FINAL DIAGNOSIS –
18. Classify case based on the CDC case definition (see criteria below):
(138)
■
4■
1
RMSF 2
HME 3 ■ HGE
Ehrlichiosis (unspecified, or other agent):
____________________________________
(139-148)
}
State Health Department Official who reviewed this report:
(149)
1
CONFIRMED
2
PROBABLE
Name: ____________________________________________________________
Title: __________________________________ Date: __ __ /__ __/__ __ __ __
(mm/dd/yyyy)
COMMENTS:
CDC CASE DEFINITION
.....................................................................................................................................................................................................................................
Confirmed RMSF: A clinically compatible case with 1) a fourfold change in antibody
titer to Rickettsia rickettsii antigen by IFA, CF, latex agglutination, microagglutination,
or indirect hemagglutination antibody test in two serum samples, or 2) a positive PCR
assay, or 3) immunostaining of antigen in a skin biopsy or autopsy sample, or 4)
isolation and culture of R. rickettsii from a clinical specimen.
Probable RMSF: A clinically compatible case with 1) a single positive antibody titer
by IFA (≥1:64 if IgG); or 2) a single CF titer ≥1:16; or 3) a single titer ≥1:128 by a latex
agglutination, indirect hemagglutination antibody, or microagglutination test; or 4) a
fourfold rise in titer or a single titer >1:320, by Proteus OX-19 or OX-2 test.
Confirmed Ehrlichiosis: A clinically compatible case with 1) a fourfold change in
antibody titer to antigen from an Ehrlichia species by IFA in two serum samples, or
2) a positive PCR assay, or 3) the visualization of morulae in white blood cells with a
single serum positive antibody titer by IFA, or 4) immunostaining of antigen in a
skin biopsy or autopsy sample, or 5) isolation and culture of an Ehrlichia species
from a clinical specimen.
Probable Ehrlichiosis: A clinically compatible case with 1) a single positive antibody
titer by IFA, or 2) the visualization of morulae in white blood cells.
Public reporting burden of this collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA 30333; ATTN: PRA (0920-0009).
CDC 55.1 Rev. 01/2001
2nd COPY – CDC
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Tick-Borne Rickettsial Disease Case Report
Use for: Rocky Mountain spotted fever (RMSF),
ehrlichiosis (human monocytic ehrlichiosis [HME]), and human granulocytic ehrlichiosis [HGE]).
(1-4)
CDC#
Form Approved
OMB 0920-0009
– PATIENT/PHYSICIAN INFORMATION –
Patient's
name:
Date submitted:
Physician’s
name:
Address:
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(5-6)
(7-8)
(9-12)
Phone
no.:
(number, street)
NETSS ID No.: (if reported)
City:
Case ID
Site (19-21)
(13-18)
State (22-23)
– DEMOGRAPHICS –
1. State of residence:
Postal
abrv:
(24-25)
2. County of residence:
(63-64)
6. Race:
(65-68)
8. INDICATE DISEASE TO BE REPORTED: (71)
1
■
Indian
■ American
Alaskan Native
4 ■ Asian
■ White
2 ■ Black
1
(69)
RMSF
2
■
3
HME
3
■
HGE
4
9
■ Not specified
(60)
■ Male
2 ■ Female
1
7. Hispanic
ethnicity:
Pacific Islander
5
■
4. Sex:
(51-59)
__ __ __ __ __ - __ __ __ __
■ Check, if history of travel outside county of residence within 30 days of onset of symptoms
5. Date of
birth: __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(61-62)
3. Zip code:
(26-50)
1
(70)
2
■ Yes
■ No
Ehrlichiosis (unspecified, or other agent)
– CLINICAL SIGNS,SYMPTOMS, AND OUTCOMES –
9. Was a clinically compatible illness present? (72)
(fever or rash, plus one or more of the following signs: headache, myalgia,
anemia, thrombocytopenia, leukopenia, or elevated hepatic transaminases)
10. Date of Onset of Symptoms:
YES
1
2
■ NO
Unk
9
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(73-74)
11. Was an underlying immunosuppressive condition present? (81)
1
■ YES
2
■ NO
9
2
13. Was the patient hospitalized because of this illness? (83)
2
■ NO
(82)
1
______________________________________________________
YES
(77-80)
Adult respiratory distress syndrome (ARDS)
3
Meningitis/encephalitis
Disseminated intravascular coagulopathy (DIC) 4 ■ Renal failure
9 ■ None
8 ■ Other: _______________________________________________________________
Unk
Specify condition(s):
1
(75-76)
12. Specify any life-threatening complications in the clinical course of illness:
9
■ Unk
(If yes, date)
14. Did the patient die because of this illness? (92) (If yes, date)
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(84-85)
(86-87)
1
■ YES
2
■ NO
9
Unk
__ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(93-94)
(88-91)
(95-96)
(97-100)
– LABORATORY DATA –
15. Name of
laboratory:________________________________________________ City:________________________________ State: __ __ Zip: __ __ __ __ __ - __ __ __ __
Below, indicate Y (Yes) or N (No), ONLY if the test or procedure was performed. Lack of selection indicates that the test or procedure was not performed.
COLLECTION DATE
16.
Serologic
Tests
(mm/dd/yyyy)
Serology 1 __ __ /__ __/__ __ __ __
(101-2)
(103-4)
Titer
COLLECTION DATE
(105-8)
(109-10) (111-12)
Titer
Positive?
(mm/dd/yyyy)
Serology 2* __ __ /__ __/__ __ __ __
(113-16)
Positive?
(_____)
1
■ YES
2
NO
(117)
(_____)
1
YES
2
■ NO (118)
IFA - IgM
(_____)
(121-130)
Other
test: ______________ ( _ _ _ _ _ )
1
YES
2
NO
(119)
(_____)
1
■ YES
2
■ NO (120)
1
■ YES
2
NO
(131)
(_____)
1
■ YES
* Was there a fourfold change in antibody titer between the two serum specimens?
1
YES
IFA - IgG
■ NO (132)
2 ■ NO (137)
2
17.
Other Diagnostic
Tests ?
PCR
Morulae visualization*
Immunostain
Culture
Positive?
■ NO (133)
■ NO (134)
2 ■ NO (135)
2 ■ NO (136)
1
YES
2
1
YES
2
1
YES
1
■ YES
* Visualization of morulae not applicable for RMSF.
– FINAL DIAGNOSIS –
18. Classify case based on the CDC case definition (see criteria below):
(138)
1
4
■
RMSF 2
HME 3
HGE
Ehrlichiosis (unspecified, or other agent):
____________________________________
(139-148)
}
State Health Department Official who reviewed this report:
(149)
1
CONFIRMED
2
PROBABLE
Name: ____________________________________________________________
Title: __________________________________ Date: __ __ /__ __/__ __ __ __
(mm/dd/yyyy)
COMMENTS:
CDC CASE DEFINITION
.....................................................................................................................................................................................................................................
Confirmed RMSF: A clinically compatible case with 1) a fourfold change in antibody
titer to Rickettsia rickettsii antigen by IFA, CF, latex agglutination, microagglutination,
or indirect hemagglutination antibody test in two serum samples, or 2) a positive PCR
assay, or 3) immunostaining of antigen in a skin biopsy or autopsy sample, or 4)
isolation and culture of R. rickettsii from a clinical specimen.
Probable RMSF: A clinically compatible case with 1) a single positive antibody titer
by IFA (≥1:64 if IgG); or 2) a single CF titer ≥1:16; or 3) a single titer ≥1:128 by a latex
agglutination, indirect hemagglutination antibody, or microagglutination test; or 4) a
fourfold rise in titer or a single titer >1:320, by Proteus OX-19 or OX-2 test.
Confirmed Ehrlichiosis: A clinically compatible case with 1) a fourfold change in
antibody titer to antigen from an Ehrlichia species by IFA in two serum samples, or
2) a positive PCR assay, or 3) the visualization of morulae in white blood cells with a
single serum positive antibody titer by IFA, or 4) immunostaining of antigen in a
skin biopsy or autopsy sample, or 5) isolation and culture of an Ehrlichia species
from a clinical specimen.
Probable Ehrlichiosis: A clinically compatible case with 1) a single positive antibody
titer by IFA, or 2) the visualization of morulae in white blood cells.
Public reporting burden of this collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA 30333; ATTN: PRA (0920-0009).
CDC 55.1 Rev. 01/2001
3rd COPY – LOCAL HEALTH DEPARTMENT
| File Type | application/pdf |
| File Title | Tick-Borne Rickettsial Disease Case Report |
| Subject | Tick-Borne Rickettsial Disease Case Report |
| Author | M. Cunningham |
| File Modified | 2006-05-31 |
| File Created | 2001-02-08 |