Announcement

**alert** · May 11, 2013, 07:40 PM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

Time to send to ProMED? Lots of details in this article, including a possible refutation of the fact that the two most recent cases had contact....

http://www.houstonchronicle.com/news/houston-texas/houston/article/Mystery-illness-linked-to-2-deaths-doctors-4507149.php

Mystery illness linked to 2 deaths; doctors stumped

So far the 17-year-olds appear to have never had any close contact with each other before getting sick. Katie once attended the same junior high in Porter as the hospitalized teen, but they were never close friends before she switched districts and began attending Humble ISD's Kingwood Park, said her aunt, Casey Dedow

[snip]

The infectious disease team has worked tirelessly to discover what made these teens so ill, said Dedow. The U.S. Centers for Disease Control and Prevention is monitoring the cases, but declined comment.

**alert** · May 12, 2013, 07:10 AM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

And the international media is picking up the story here:

感谢您的浏览！ - 新华网

http://news.xinhuanet.com/english/health/2013-05/10/c_132372738.htm

Unidentified disease kills 2 teens in Texas

English.news.cn 2013-05-10 12:47:49

HOUSTON, May 9 (Xinhua) -- An unidentified disease has killed two high school students in the U.S. state of Texas since March, officials said.

A third student was in critical condition due to same disease, local TV channel KHOU quoted state health officials as reporting Thursday.

The three students, all from the Houston area, shared similar pneumonia-like symptoms, including fever, coughing and later, seizures and respiratory failure, according to the report.

The first patient, aged 17, got sick in February and died on March 10. A teenage girl died on April 29 and a teenage boy with similar symptoms is currently in critical condition. The autopsy results won't be available for several months.

**alert** · May 12, 2013, 07:14 AM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

The original story has been updated, and now reads:

Access Denied

http://www.khou.com/news/health/Mystery-Illness-Claims-Two-Teens-Third-is-Critical-206702811.html

HOUSTON -- A hospital spokeswoman at Texas Children's in Houston said in a written statement that a 17-year-old boy in their facility is not believed, by them, to be connected two cases in which area teens died from a mystery illness.

But the lead doctor in charge of Montgomery County's Health Department said all of the teens have similar symptoms.

"Like fever, cough, like respiratory failure, pneumonia, seizures," said Dr. Syed Ibrahim, MD, MPH. "In the child who's admitted at Texas Children's Hospital now, he's having liver enlargment and spleen enlargment."

The hospital confirmed that the teen is in critical condition.

[snip]

...before continuing as above.

**alert** · May 13, 2013, 06:34 AM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

And a ProMED post (with some more possible etiologies, but no mention of influenza):

Published Date: 2013-05-12 17:34:34
Subject: PRO/EDR> Undiagnosed deaths - USA: (TX) teenager, RFI
Archive Number: 20130512.1707679

UNDIAGNOSED DEATHS - USA: (TEXAS) TEENAGER, REQUEST FOR INFORMATION
************************************************** *****************
A ProMED-mail post

Home - ProMED - ProMED-mail

http://www.promedmail.org

ProMED is the largest publicly-available surveillance system conducting global reporting of infectious diseases outbreaks. Subscribe today.

ProMED-mail is a program of the
International Society for Infectious Diseases

The International Society for Infectious Diseases (ISID) - ISID

http://www.isid.org

The International Society for Infectious Diseases (ISID) brings together a network of individuals from around the world.

Date: Thu 9 May 2013
Source: Houston Chronicle [edited]

Two dead, one in critical condition from unknown disease in Houston area

http://blog.chron.com/healthzone/2013/05/two-dead-one-in-critical-condition-from-unknown-disease-in-houston-area/

Health officials have reported that an unidentified illness has taken the lives of two area high school students from Montgomery and Liberty counties according to KHOU Channel 11. Officials said th…

Health officials have reported that an unidentified illness has taken the lives of 2 high school students from Montgomery and Liberty counties [2 counties that are part of the Houston-Sugar Land-Baytown metropolitan area, that is, Greater Houston, in Southeast Texas with a population of over 2 million residents in 2010], according to KHOU Channel 11.

Officials said that all 3 had pneumonia-like symptoms, fever, coughing and then went into seizures and respiratory failure.

[A 17-year-old male] was the 1st case when he got sick in February [2013] and died on [10 Mar 2013]. A teenage girl in Montgomery County died on [29 Apr 2013] and a teenage boy with similar symptoms is currently in critical condition. The results of the autopsies won't be available for several months.

Health experts are working together to figure out what is behind it all.

--
Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

******
[2]
Date: Sat 11 May 2013
Source: Houston Chronicle [summ., edited]

http://www.houstonchronicle.com/news/houston-texas/houston/article/Mystery-illness-linked-to-2-deaths-doctors-4507149.php

A month ago, [the boy's mother] started making Internet postings to express her utter grief and frustration over not knowing what killed her athletic 17-year-old son, in a matter of weeks. The healthy junior who attended a tiny Liberty County high school died [10 Mar 2013], just 3 weeks after contracting a mysterious illness that Houston doctors have yet to identify. It started with flu-like body aches and fever, progressing to seizures, medically induced coma, and death. [His mother] says he loved football, hunting, and horseback riding.

The mystery deepened when someone attached an article to [the mother's] post about a 17-year-old [girl], a softball player at Kingwood Park High School, who died under similar baffling circumstances 60 miles [97 km] to the west on [29 Apr 2013]. The mother contacted the girl's family and sent a copy of her son's Memorial Hermann Hospital medical file to the Texas Children's Hospital doctors who had treated her. Their ailments were almost identical.

The 3rd link in the mystery was another 17-year-old, a male student at New Caney High School to the north, whose name was not released. He remains in critical condition at Texas Children's after getting the illness a few weeks ago. His condition also started with a fever, but hasn't developed to seizures. He had severe stomach pains that led to vomiting and diarrhea.

Now Montgomery County epidemiologist Dr Syed Ibrahim is leading an inquiry into whether there's a link between these 3 cases. "This sort of thing, where we don't know the cause, is very rare," said Ibrahim. The hospitals have run scores of tests, ruling out usual suspects such as meningitis or botulism. Doctors have been stumped as to whether the teens contracted the same fast-moving illness or each has something entirely different.

So far the 17-year-olds appear to have never had any close contact with each other before getting sick. [The girl] once attended the same junior high in Porter as the hospitalized teen, but they were never close friends before she switched districts and began attending Humble ISD's Kingwood Park, said her aunt.

[The mother] said: "All kinds of people have been close to these kids and nobody else has gotten sick. Nobody thinks what they contracted is contagious."

An unusual factor in these cases, Ibrahim said, is that the symptoms can sometimes appear to dissipate and then reappear with a vengeance. [The boy] was sent home from school with a fever. After taking antibiotics for a couple of days, he appeared to get well. But the next day, he suddenly relapsed and his family found him collapsed on the floor, experiencing uncontrollable seizures. He had earlier tested positive for mononucleosis, but it's not supposed to swell the brain to twice its size as it did, she said.

[The 2 dead teenager's families are] waiting on autopsy reports to be completed.

"[The girl's] symptoms were very similar to [the boy's]. But we don't see any connection to the 3rd case. It presented very differently. He never had any seizures," said [the girl's] aunt, who is also a nurse. The girl contracted her fever [15 Apr 2013]. She, too, seemed to get better after a few days before digressing again into massive seizures and dying 14 days after her symptoms began.

The infectious disease team has worked tirelessly to discover what made these teens so ill, said [the girl's aunt]. The US Centers for Disease Control and Prevention is monitoring the cases, but declined comment.

[Byline: Cindy Horswell]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The news reports above describe a flu-like illness with fever, body aches, coughing, progressing to seizures and respiratory failure in 2 teenagers over a several-week period of time that terminated in their deaths, one in March 2013 and the other a month later. After taking antibiotics initially for a couple of days, both appeared to get well, and then relapsed with uncontrollable seizures.

A 3rd teenager remains hospitalized in critical condition, with reportedly a different illness: he had fever, severe abdominal pain, vomiting, and diarrhea, without ever having developed seizures. The 3 lived in the Greater Houston, Texas area, but are said not to have had any contact with one another. There are also said to be no secondary cases among their contacts. Little additional detail is given, except one of the teenagers who died was said to be a hunter and horseback rider; he also had a positive test for Epstein-Barr virus (EBV) infection. However, we are not told which type of test was used, heterophile, EBV-specific immunoassay, or both. Also we are not told if the other 2 teenagers had these serologies done.

EBV usually infects people who are under 30 years old. In immunocompetent patients, primary infection is usually asymptomatic or presents as infectious mononucleosis. Infectious mononucleosis, an acute infectious disease, is characterized by fever, pharyngitis, generalized lymphadenopathy, and splenomegaly. In patients with the typical clinical findings of infectious mononucleosis, a complete blood cell count and a test for heterophile antibodies can usually establish the diagnosis of an EBV infection.

The presence of heterophile antibodies is highly specific for infectious mononucleosis, but false-positive results have been rarely reported for several conditions, including leukemia, rubella, malaria, systemic lupus erythematosus, pancreatic carcinoma, viral hepatitis, and human immunodeficiency virus infection (1), which should have been ruled in the patient's extensive work-up. Using EBV-specific immunoassays, the specificity of the blood tests for infectious mononucleosis approaches 100 percent (2). A rare immunodeficiency syndrome associated with EBV infection in young boys is X-linked lymphoproliferative (XLP) syndrome, which often leads to death from bone marrow failure, irreversible hepatitis, and malignant lymphoma, which were not described in this patient (http://emedicine.medscape.com/article/203780-overview).

However, EBV infection itself in an immunocompetent patient can cause acute viral encephalomyelitis, as well as post-infectious acute disseminated encephalomyelitis (ADEM) (3). ADEM is an immune-mediated inflammatory demyelinating disease of the brain that usually occurs following a viral infection, but may follow vaccination, such as, brain tissue-based rabies vaccine. Viral infections, in addition to EBV infection, thought to induce ADEM include infections due to influenza virus, enterovirus, measles, mumps, rubella, varicella zoster, cytomegalovirus, herpes simplex virus, hepatitis A, and coxsackievirus (http://emedicine.medscape.com/article/1147044-clinical). Some bacterial infections implicated include infections due to _Mycoplasma pneumoniae_, _Borrelia burgdorferi_, and _Leptospira_ (4). There is usually a clearly defined phase of afebrile improvement lasting 1-20 days or more before onset of neurologic findings. The diagnosis of ADEM is based on clinical features and neuroimaging, such as, MRI findings.

In addition, the 2 Houston teenagers who died were said to have respiratory symptoms and respiratory failure. Severe pneumonitis is a rare complication of EBV infection in immunocompetent individuals, although several cases have been reported in the literature (http://cid.oxfordjournals.org/content/21/1/206.abstract).

Other unusual pathogens that can cause a febrile illness with pneumonitis and encephalitis in the Houston area are rickettsial and rickettsial-like diseases, such murine typhus (_Rickettsia typhi_) (http://cid.oxfordjournals.org/content/46/6/913.full), Rocky Mountain spotted fever (_Rickettsia rickettsii_) (http://www.cdc.gov/rmsf/symptoms/), and human monocytic ehrlichiosis (_Ehrlichia chaffeensis_) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC145301/), as well as leptospirosis (_Leptospira_ spp.).

References
----------
1. van Essen GG, Lieverse AG, Sprenger HG, et al: False-positive Paul-Bunnell test in HIV seroconversion. Lancet 1988; 2(8613): 747-8.
2. Gerber MA, Shapiro ED, Ryan RW, Bell GL: Evaluations of enzyme-linked immunosorbent assay procedure for determining specific Epstein-Barr Virus serology and of rapid test kits for diagnosis of infectious mononucleosis. J Clin Microbiol. 1996; 34(12): 3240-1; available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC229495/.
3. Bahadori HR, Williams VC, Turner RP, et al: Acute disseminated encephalomyelitis following infectious mononucleosis. J Child Neurol 2007; 22(3): 324-8; abstract available at http://jcn.sagepub.com/content/22/3/324.long.
4. Tenembaum S, Chitnis T, Ness J, Hahn JS; International Pediatric MS Study Group: Acute disseminated encephalomyelitis. Neurology 2007; 68(16 Suppl 2): S23-36; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17438235.

ProMED-mail would greatly appreciate more information on these cases along with results of ongoing investigations.

Houston can be located on the HealthMap/ProMED-mail interactive map at http://healthmap.org/r/276D. - Mod.ML]

[There is no evidence that the condition is transmissible. - Mod.CP]

[It is ProMED's policy not to identify individuals by name even when they are identified in media reports. - Mod.LM]]

See Also
2012
----
Murine typhus - USA: (TX) fatal 20120526.1145817
2011
----
Murine typhus - USA (04): background 20110918.2841
Murine typhus - USA (02): (TX) 20110701.2000
Murine typhus - USA: (TX) 20110607.1734
2009
----
Murine typhus - USA (04): (TX) 2008-2009 20091120.3995
Murine typhus - USA (02): (TX) 20090617.2240
Murine typhus - USA: (TX) 20090616.2228
2007
----
Ehrlichiosis, fatal - USA (MO) 20070607.1849
Rocky Mountain spotted fever, fatal - USA (NC) (02) 20070606.1835
Rocky Mountain spotted fever, fatal - USA (NC) 20070604.1807
2004
----
Leptospirosis, human, canine - USA (TX)(03) 20040911.2527
Leptospirosis, human, canine - USA (TX)(02) 20040907.2499
Leptospirosis, human, canine - USA (TX) 20040904.2472
Leptospirosis, fatal - USA (AS) 20040820.2307
.................................................s b/ml/mj/lm

**Emily** · May 13, 2013, 10:35 AM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

And a ProMED post (with some more possible etiologies, but no mention of influenza)

There was an outbreak of a flu-like illness at a Houston area greyhound racetrack in Spring of 2012:

Mysterious illness sickens Gulf Greyhound dogs

Some media sources say it was H3N8, but it sounds like the pathogen was never actually identified.

Texas Racing Commission spokeswoman Jean Cook a necropsy at Texas A&M University?s College of Veterinary Medicine did not provide a　diagnosis.

**alert** · May 13, 2013, 10:57 AM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

H3N8 canine influenza has never infected humans before, so would be a remarkable find if it were involved here. The first case had swine contact, but apparently two months before onset, so too long for influenza. I don't see any links of any of the three cases to dog racing.

If any of these cases are indeed influenza, I would think given the ages involved that it is probably H1N1pdm09.

**Emily** · May 13, 2013, 11:07 AM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

The first case had swine contact, but apparently two months before onset, so too long for influenza.

He was keeping a baby feral pig acquired during the hunt at home, also, but one article said it was examined for known zoonotic disease.

Regarding the racetrack outbreak, it was never confirmed as H3N8, so I wondered about something new circulating. This study says the Central Flyway is understudied as far as avian flu.

**Laidback Al** · December 18, 2013, 05:12 PM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

Update ? Third teen died in July 2013

No information on the autopsy results of the first two youths is available online.

Tyler Lane Budro (17M) of Batson, TX, onset February 22, died March 10, 2013.

Tributes.com

http://www.tributes.com/show/Tyler-Lane-Budro-95407236

Tributes.com is the online source for current local and national obituary news. We believe that Every Life has a Story which should be told and preserved.

Katie Rios (17F) of Porter, TX, onset April 11, 2013 and died April 29, 2013.

breaking news-KATIE RIOS HAS PASSED AWAY

http://montgomerycountypolicereporter.com/breaking-news-katie-rios-has-passed-away/

Katie Rios, the 17-year-old from Porter who everyone has come to love as one of the best softball players in the area has passed away. On April 11, 2013, a beautiful healthy 17 year old girl came down with symptoms of the flu. She had fever, body aches, malaise and it stood to reason that Katie ha

Besides exhibiting symptoms of ILI, both Tyler and Katie suffered seizures during their illness before they died.

The third victim was Benjamin (BJ) Crawford (17M) of Porter, TX (?) who starting exhibiting similar ILI symptoms sometime in early April but did not have any seizures.

two teens die, one critical and still no answers

http://montgomerycountypolicereporter.com/something-in-the-air-whats-killing-the-kids/

On February 19, 2013 Tyler Budro (Craigan) of Daisetta in nearby Liberty County picked her son Tyler from school after the nurse called advising Tyler had a fever and thinking it could have been Mono. The next day the fever continued to rise and Tyler’s family took him to the doctor at

BENEFIT PAGE SET UP FOR B.J. CRAWFORD

http://montgomerycountypolicereporter.com/benefit-page-set-up-for-b-j-crawford/

B.J. had been ill for 2 weeks at home, but he insisted on taking his junior level TAKS test at school. He was then taken by ambulance to Texas Children's Hospital, where the doctors are still trying to agree on a diagnosis, as he lay in critical condition. Kim, his mom, lives in Utah, and struggled

He was hospitalized at Texas Children?s Hospital on April 23, 2013 and 3 weeks later diagnosed with T-Cell and HLH Lymphoma.

A facebook post by BJ?s father on June 1 -

As many of you know BJ was diagnosed after 3 weeks of being on ECMO (lung / heart bypass) with stage 4 Anaplastic Large Cell Lymphoma (ALCL) or Tcell Lymphoma, and HLH due to the ALCL. The HLH caused the multi organ weakness, with the respiratory failure being the most severe. After serious treatment and many weeks (5.5) he has miraculously improved enough to be off the ECMO (this past Thurs eve). He starts the full blown ALCL treatment tomorrow Sun. June 2. This will be an alternating course of chemo and other meds for 6 months.

The treatment was unsuccessful and BJ died on July 9, 2013.
see https://www.facebook.com/teambj

It is not likely that these cases have any relationship to the 8 recent ILI cases (including 4 deaths) in Montgomery County, Texas.
see: http://www.flutrackers.com/forum/sho...d.php?t=214964

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**alert** · December 18, 2013, 05:22 PM

Re: US, Texas: Unidentified Illness (fatal) - 2 died, 1 critical

Nice find, Laidback Al. So the third teen did not have an infectious disease.

I think you are right, there's nothing mysterious here, and nothing related to the current undiagnosed outbreak.

It appears the first teen died of some rare complication of Epstein-Barr virus infection, the second one died of probable influenza, and now we know what killed the third one as well.

**alert** · December 19, 2013, 02:05 PM

Re: US, Texas: Unidentified Illness (fatal) - 3 deaths - 1 probable due to Epstein-Barr virus, 1 probable due to influenza, 1 confirmed due to lymphoma

Apparently, the families aren't as convinced as to these explanations as the ProMED moderators were:

http://www.houstonchronicle.com/news/houston-texas/houston/article/Mystery-surrounds-flu-like-illness-that-has-5077230.php

[snip]

Janie Budro is still waiting for officials to identify the mystery illness that claimed the life of her son, Tyler, on March 10, and that of Katie Rios of Kingwood Park High School on April 29. Both were 17.

A third suspected case in that cluster - a 17-year-old Montgomery County student from New Caney - was eliminated when his death was linked to a form of lymphoma, Budro said.

Moms still in the dark

"But I just talked to Katie's mom last week and we both still don't know what killed our kids," Budro said. "She only knows that her daughter's brain swelling led to her death, but not what caused it to happen, And I still have no answers for my son."

Both teenagers exhibited flu-like symptoms that rapidly progressed to seizures and then death.

Odessa Reed said her son never experienced any seizures, and Montgomery County health authorities said they don't believe the cases are linked.

"It's scary to know that this there's other clusters out there like this," said Budro. "I can't help wondering if there might still be some connection there, somehow. I freak out now if my only other son, who's 16, gets a cold."

[snip]

Announcement

US, Texas: Unidentified Illness (fatal) - 3 deaths - 1 probable due to Epstein-Barr virus, 1 probable due to influenza, 1 confirmed due to lymphoma

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