Blastocystis colonization and associations with population parameters in Thai adults.

BACKGROUND: Blastocystis is a unicellular eukaryote commonly found in the intestinal tract of humans and other animals. The prevalence of Blastocystis has been investigated in both developed and developing countries, yet its occurrence and distribution in rural locations has been less studied. Herein, we aimed to examine the distribution of Blastocystis colonization in Thai adults representing background populations along a rural/peri-urban gradient, as well as associations between colonization and personal characteristics. METHODOLOGY: A total of 238 participants were recruited from rural and peri-urban areas situated in three provinces. The presence of Blastocystis in feces was evaluated using PCR and qPCR. Information on gender, age, region (province), rural/peri-urban location, and body mass index (BMI) was collected. PRINCIPAL FINDINGS: The overall rate of Blastocystis carriage was 67.2%. Univariate analysis revealed significant associations between Blastocystis carriage and region (p<0.05), location (p<0.001) and age group (p<0.05). Logistic regression analysis revealed that rural/peri-urban location and BMI were significantly associated with Blastocystis carriage. Nine subtypes (ST1-ST7, ST10 and ST23) were identified with ST3, ST7 and ST1 as the most abundant ones, in this order. The greatest diversity of subtypes, in terms of numbers, was found in the middle aged group (nine subtypes), while the least diversity was found in the young adult and obese (three subtypes each) groups. CONCLUSIONS: This study increases the understanding of the epidemiology of Blastocystis colonization and its association with population parameters and characteristics in middle-income countries.

Comparative genomics of Cryptosporidium parvum reveals the emergence of an outbreak-associated population in Europe and its spread to the United States.

The zoonotic parasite Cryptosporidium parvum is a global cause of gastrointestinal disease in humans and ruminants. Sequence analysis of the highly polymorphic gp60 gene enabled the classification of C. parvum isolates into multiple groups (e.g., IIa, IIc, Id) and a large number of subtypes. In Europe, subtype IIaA15G2R1 is largely predominant and has been associated with many water- and food-borne outbreaks. In this study, we generated new whole-genome sequence (WGS) data from 123 human- and ruminant-derived isolates collected in 13 European countries and included other available WGS data from Europe, Egypt, China, and the United States (n = 72) in the largest comparative genomics study to date. We applied rigorous filters to exclude mixed infections and analyzed a data set from 141 isolates from the zoonotic groups IIa (n = 119) and IId (n = 22). Based on 28,047 high-quality, biallelic genomic SNPs, we identified three distinct and strongly supported populations: Isolates from China (IId) and Egypt (IIa and IId) formed population 1; a minority of European isolates (IIa and IId) formed population 2; and the majority of European (IIa, including all IIaA15G2R1 isolates) and all isolates from the United States (IIa) clustered in population 3. Based on analyses of the population structure, population genetics, and recombination, we show that population 3 has recently emerged and expanded throughout Europe to then, possibly from the United Kingdom, reach the United States, where it also expanded. The reason(s) for the successful spread of population 3 remain elusive, although genes under selective pressure uniquely in this population were identified.

Rodent-adapted Cryptosporidium infection in humans: Seven new cases and review of the literature.

Cases of cryptosporidiosis in humans have been reported with strong indication of transmission from rodents. Here, we report seven new human cases of cryptosporidiosis involving rodent-adapted species (Cryptosporidium ditrichi [n = 1], Cryptosporidium mortiferum [n = 4; previously known as Cryptosporidium chipmunk genotype I], Cryptosporidium tyzzeri [n = 1], and Cryptosporidium viatorum [n = 1]) and review cases of human infection caused by these four species published to date. The seven new cases were detected in Denmark within a period of twelve months from 2022 to 2023. Only the C. tyzzeri and C. viatorum cases were associated with travel outside Denmark. The total number of human cases of cryptosporidiosis due to C. ditrichi and C. tyzzeri documented to date globally are still limited (4 and 7, respectively), whereas cases involving C. viatorum and C. mortiferum have been detected to a larger extent (43 and 63 cases, respectively). The four new cases of C. mortiferum were all of the XIVaA20G2T1 subtype, which is the only subtype identified so far in Scandinavia, and which is a subtype not yet found outside of Scandinavia. The new C. viatorum case was identified as the XVaA3g subtype. The C. tyzzeri case was subtyped as IXbA6. No subtype data were produced for C. ditrichi due to lack of a subtype assay. Review of existing data suggests the presence of C. ditrichi and C. mortiferum primarily in northern countries and C. tyzzeri and C. viatorum primarily in warmer climates. While our data may further support the role of Cryptosporidium as a cause of zoonotic disease, case descriptions should be obtained where possible to determine if Cryptosporidium species primarily adapted to rodents are the likely cause of symptoms or just an incidental finding.

Impact of COVID-19 Restrictions on Incidence of Enteropathogenic Bacteria, Virus, and Parasites in Denmark: A National, Register-Based Study.

Diarrheal diseases caused by enteric pathogens are a significant public health concern. It is widely considered that close contact between persons, poor hygiene, and consumption of contaminated food are the primary causes of gastroenteritis. Clinical microbiology laboratory observations indicate that the incidence of enteropathogenic microorganisms may have been reduced in Denmark during the COVID-19 pandemic. All Departments of Clinical Microbiology in Denmark provided data on the monthly incidence of Salmonella spp., Escherichia coli, Campylobacter spp., Clostridioides difficile, Norovirus GI+GII, Giardia duodenalis, and Cryptosporidium from March 2018 to February 2021. The data were divided into three periods as follows: Control Period 1 (March 2018 to February 2019); Control Period 2 (March 2019 to February 2020); and the Restriction (pandemic) Period (March 2020 to February 2021). The incidences of pathogenic Salmonella spp.-, Escherichia coli-, and Campylobacter spp.-positive samples decreased by 57.3%, 48.1%, and 32.9%, respectively, during the restriction period. No decrease in C. difficile was observed. Norovirus GI+GII-positive samples decreased by 85.6%. Giardia duodenalis-positive samples decreased by 66.2%. Cryptosporidium species decreased by 59.6%. This study demonstrates a clear decrease in the incidence of enteropathogenic bacteria (except for C. difficile), viruses, and parasites during the SARS-CoV-2 restriction period in Denmark.

Genetic diversity and host specificity of Blastocystis in reptiles, Eastern Thailand.

Blastocystis inhabits the digestive tracts of a diverse range of hosts. Transmission patterns, including host specificity, and the clinical and public health significance of Blastocystis in humans remain poorly understood. This study aimed to investigate the distribution and genetic diversity of Blastocystis in herbivorous and carnivorous reptiles in Eastern Thailand. A total of 501 faecal samples were collected from 363 iguanas, 79 bearded dragons, 50 tortoises, and nine snakes in an animal breeding farm in Chonburi Province, Eastern Thailand. Detection and differentiation of Blastocystis was based on amplification, sequencing, and phylogenetic analysis of specific small subunit (SSU) ribosomal RNA genes from faecal DNA extracted from the samples. Altogether 101/501 samples (20 %) were polymerase chain reaction (PCR) and sequencing-positive for Blastocystis, 90 (89 %) of which were from iguanas; the remaining positive samples were from African spurred tortoise (n=6), Bearded dragon (n=3), Leopard tortoise (n=1), and Red-footed tortoise (n=1). Phylogenetic analysis revealed that most of the Blastocystis sequences from iguanas were largely similar, and they were distinct from those of the tortoises. Subtype 17 was found in the three bearded dragons and likely reflected Blastocystis from prey animals. This is the largest survey of Blastocystis in reptiles to date. Remarkable differences in Blastocystis colonization rates and genetic diversity were observed between iguanas and other reptile orders, and what was considered Blastocystis colonization was only observed in herbivorous reptiles.

Complete sequencing of the Cryptosporidium suis gp60 gene reveals a novel type of tandem repeats-Implications for surveillance.

Cryptosporidiosis is an infectious enteric disease caused by species (some of them zoonotic) of the genus Cryptosporidium that in many countries are under surveillance. Typing assays critical to the surveillance of cryptosporidiosis typically involve characterization of Cryptosporidium glycoprotein 60 genes (gp60). Here, we characterized the gp60 of Cryptosporidium suis from two samples-a human and a porcine faecal sample-based on which a preliminary typing scheme was developed. A conspicuous feature of the C. suis gp60 was a novel type of tandem repeats located in the 5' end of the gene and that took up 777/1635 bp (48%) of the gene. The C. suis gp60 lacked the classical poly-serine repeats (TCA/TCG/TCT), which is usually subject to major genetic variation, and the length of the tandem repeat made a typing assay incorporating this region based on Sanger sequencing practically unfeasible. We therefore designed a typing assay based on the post-repeat region only and applied it to C. suis-positive samples from suid hosts from Norway, Denmark, and Spain. We were able to distinguish three different subtypes; XXVa-1, XXVa-2, and XXVa-3. Subtype XXVa-1 had a wider geographic distribution than the other subtypes and was also observed in the human sample. We think that the present data will inform future strategies to develop a C. suis typing assay that could be even more informative by including a greater part of the gene, including the tandem repeat region, e.g., by the use of long-read next-generation sequencing.

Towards minimizing second-generation mis-identification of Blastocystis.

At least 1-2% of DNA sequences annotated as Blastocystis in GenBank represent organisms other than Blastocystis or sequence artefacts. As well as being biologically incorrect, such practice can lead to overestimates of genetic diversity, underestimated host specificity, and incorrect classification of samples tested for Blastocystis using DNA-based methods.

Cryptosporidium occultus in disguise.

As data accumulate in GenBank, the difficulties of delineating species of Cryptosporidium based on nuclear small subunit ribosomal RNA (ssu rRNA) gene information alone becomes increasingly evident. Here, we summarize currently available evidence suggesting that several ssu rDNA sequences primarily referred to as Cryptosporidium suis (some of them from non-suid hosts) should be considered Cryptosporidium occultus.

Multi-strain probiotics during pregnancy in women with obesity influence infant gut microbiome development: results from a randomized, double-blind placebo-controlled study.

Probiotics have been described to influence host health and prevent the risk of obesity by gut microbiome (GM) modulation. In a randomized double-blinded placebo-controlled feasibility study, we investigated whether Vivomixx® multi-strain probiotics administered to 50 women with obesity during pregnancy altered the GM composition and perinatal health outcomes of their infants up to 9 months after birth. The mothers and infants were followed up with four visits after birth: at 3 d, and at 3, 6, and 9 months after delivery. The infants were monitored by anthropometric measurements, fecal sample analysis, and questionnaires regarding health and diet.The study setup after birth was feasible, and the women and infants were willing to participate in additional study visits and collection of fecal samples during the 9-month follow-up. In total, 47 newborns were included for microbiome analysis.Maternal prenatal Vivomixx® administration did not alter infant GM diversity nor differential abundance, and the probiotic strains were not vertically transferred. However, the infant GM exhibited a decreased prevalence of the obesity-associated genera, Collinsella, in the probiotic group and of the metabolic health-associated Akkermansia in the placebo group, indicating that indirect community-scale effects of Vivomixx® on the GM of the mothers could be transferred to the infant.Moreover, 3 d after birth, the GM of the infant was influenced by mode of delivery and antibiotics administered during birth. Vaginally delivered infants had increased diversity and relative abundance of the metabolic health-associated Bifidobacterium and Bacteroides while having a decreased relative abundance of Enterococcus compared with infants delivered by cesarean section. Maternal antibiotic administration during birth resulted in a decreased relative abundance of Bifidobacteriumin the GM of the infants. In conclusion, this study observed potential effects on obesity-associated infant GM after maternal probiotic supplementation.

JAK2V617F drives gut microbiota differences in patients with myeloproliferative neoplasms.

BACKGROUND: Essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (MF) are myeloproliferative neoplasms (MPN). Inflammation is involved in the initiation, progression, and symptomology of the diseases. The gut microbiota impacts the immune system, infection control, and steady-state hematopoiesis. METHODS: We analyzed the gut microbiota of 227 MPN patients and healthy controls (HCs) using next-generation sequencing. We expanded our previous results in PV and ET patients with additional PV, pre-MF, and MF patients which allowed us to compare MPN patients collectively, MPN sub-diagnoses, and MPN mutations (separately and combined) vs. HCs (N = 42) and compare within MPN sub-diagnoses and MPN mutation. RESULTS: MPN patients had a higher observed richness (median, 245 [range, 49-659]) compared with HCs (191.5 [range, 111-300; p = .003]) and a lower relative abundance of taxa within the Firmicutes phylum; for example, Faecalibacterium (6% vs. 14%, p < .001). The microbiota of CALR-positive patients (N = 30) resembled that of HCs more than that of patients with JAK2V617F (N = 177). In JAK2V617F-positive patients, only minor differences in the gut microbiota were observed between MPN sub-diagnoses, illustrating the importance of this mutation. CONCLUSION: The gut microbiota in MPN patients differs from HCs and is driven by JAK2V617F, whereas the gut microbiota in CALR patients resembles HCs more.

Detection of zoonotic Cryptosporidium spp. in small wild rodents using amplicon-based next-generation sequencing.

Rodents may serve as reservoirs of zoonotic species of Cryptosporidium; however, data from molecular surveys in support of this hypothesis are still scarce. In this study, we screened faeces and rectal content from murid and cricetid rodents (N = 58) caught around three farms in Zealand, Denmark, for Cryptosporidium spp. by amplicon-based next-generation sequencing (NGS) of ribosomal genes. Selected samples were further examined using nested conventional PCR targeting SSU rRNA, gp60, and actin genes. Cryptosporidium-specific DNA was identified in 40/58 (69%) samples, and in 12 (30%) of the 40 positive animals, mixed cryptosporidial infections were observed. Cryptosporidium ditrichi was the species most commonly identified, found in 28 (48%) of the animals. Cryptosporidium parvum was identified in 4 (7%) of the animals, all of which were co-infected with C. ditrichi. The present study is the first to utilize NGS-based screening for Cryptosporidium species in wild rodents. Moreover, it is the first study to provide molecular data on Cryptosporidium in rodents sampled in Denmark and to detect DNA of C. ditrichi in Mus musculus, Myodes glareolus, and Microtus agrestis. The NGS approach was successfully applied to yield new knowledge, and the results showed that zoonotic species of Cryptosporidium are common in murid and cricetid rodents in Zealand, Denmark.

The opportunistic protist, Giardia intestinalis, occurs in gut-healthy humans in a high-income country.

Giardia intestinalis, a cosmopolitan gastrointestinal protist, is detected mainly in patients with clinical giardiasis in high-income countries. In contrast, there is very little information on the presence of Giardia in asymptomatic individuals. Therefore, the aim of this study was to determine the presence and prevalence of Giardia in gut-healthy volunteers in the Czech Republic and to perform a comparative evaluation of different diagnostic methods, since Giardia diagnostics is complicated. Our results confirmed that the qPCR method is the most sensitive method for detecting Giardia and revealed a prevalence of 7% (22/296) in asymptomatic individuals. In most cases, the colonization intensity ranged from 10-1-101. A conventional PCR protocol targeting the TPI gene was used to identify the assemblages. However, this protocol had limited sensitivity for Giardia amplification, effectively detecting colonization above an intensity of 104. In addition, Giardia was detected in 19% of the animals, which were closely associated with the study participants. However, due to methodological limitations, zoonotic transmission could not be clearly confirmed. Notably, contact with animals proved to be the only factor that had a significant impact on the incidence of Giardia in gut-healthy humans.

Pronounced gut microbiota signatures in patients with JAK2V617F-positive essential thrombocythemia.

Essential thrombocythemia (ET) is part of the Philadelphia chromosome-negative myeloproliferative neoplasms. It is characterized by an increased risk of thromboembolic events and also to a certain degree hypermetabolic symptoms. The gut microbiota is an important initiator of hematopoiesis and regulation of the immune system, but in patients with ET, where inflammation is a hallmark of the disease, it is vastly unexplored. In this study, we compared the gut microbiota via amplicon-based 16S rRNA gene sequencing of the V3-V4 region in 54 patients with ET according to mutation status Janus-kinase 2 (JAK2V617F)-positive vs JAK2V617F-negative patients with ET, and in 42 healthy controls (HCs). Gut microbiota richness was higher in patients with ET (median-observed richness, 283.5; range, 75-535) compared with HCs (median-observed richness, 191.5; range, 111-300; P < 0.001). Patients with ET had a different overall bacterial composition (beta diversity) than HCs (analysis of similarities [ANOSIM]; R = 0.063, P = 0.004). Patients with ET had a significantly lower relative abundance of taxa within the Firmicutes phylum compared with HCs (51% vs 59%, P = 0.03), and within that phylum, patients with ET also had a lower relative abundance of the genus Faecalibacterium (8% vs 15%, P < 0.001), an important immunoregulative bacterium. The microbiota signatures were more pronounced in patients harboring the JAK2V617F mutation, and highly similar to patients with polycythemia vera as previously described. These findings suggest that patients with ET may have an altered immune regulation; however, whether this dysregulation is induced in part by, or is itself inducing, an altered gut microbiota remains to be investigated. IMPORTANCE Essential thrombocythemia (ET) is a cancer characterized by thrombocyte overproduction. Inflammation has been shown to be vital in both the initiation and progression of other myeloproliferative neoplasms, and it is well known that the gut microbiota is important in the regulation of our immune system. However, the gut microbiota of patients with ET remains uninvestigated. In this study, we characterized the gut microbiota of patients with ET compared with healthy controls and thereby provide new insights into the field. We show that the gut microbiota of patients with ET differs significantly from that of healthy controls and the patients with ET have a lower relative abundance of important immunoregulative bacteria. Furthermore, we demonstrate that patients with JAK2V617F-positive ET have pronounced gut microbiota signatures compared with JAK2V617F-negative patients. Thereby confirming the importance of the underlying mutation, the immune response as well as the composition of the microbiota.

Pulmonary cystic echinococcosis acquired during a short-term tourist travel.

Background: Cystic echinococcosis is non-endemic in Denmark and primarily diagnosed in migrants from endemic areas. Here, we report a case of pulmonary cystic echinococcosis in a Danish woman with no history of longer-term stays abroad, only holiday travelling to tourist destinations. This is the first case reported in international literature from Denmark where the causative parasite was identified to species and genotype level. Case: A 27-year-old pregnant Danish woman was admitted for examination because of haemoptysis for three months.Chest X-ray and computed tomography revealed a cystic structure in the left lung and a left-sided thoracotomy was performed to remove the cyst. Postoperative histopathological examination revealed a hyaline membrane and protoscoleces. Subsequently, infection with Echinococcus granulosus was confirmed by molecular methods. The causative agent was further characterised as E. granulosus sensu stricto G1, which is not known to have an established life cycle in Denmark. It was concluded that the infection was most likely acquired during a tourist travel to an endemic country. The patient was treated with albendazole for four weeks. Conclusion: This case of pulmonary cystic echinococcosis in a person who had lived in Denmark and had history of only short-term tourist travelling abroad highlights that the disease may be acquired during tourist travelling. Thus, a diagnosis of cystic echinococcosis should be considered not only in migrants from endemic countries but also in travellers upon incidental findings of a lung or liver cysts. The case also exemplifies the importance of reaching a diagnosis at species and genotype level.

Distribution of Blastocystis subtypes isolated from various animal hosts in Thailand.

Blastocystis is a parasitic protist of a variety of hosts, including humans. Mapping the distribution of Blastocystis and its genetic variants across different host species can help us understand the epidemiology of this organism and its role in health and disease. This study aimed to identify subtypes of Blastocystis detected in different animal hosts in Thailand. A total of 825 fecal samples belonging to 18 vertebrate orders, 36 families, 68 genera, and 80 species were collected. Of these, 111 specimens were Blastocystis-positive by culture. Seventy-nine samples were subjected to small subunit (SSU) ribosomal DNA amplification by PCR, and reliable subtype data were obtained for 61 specimens. At least 14 subtypes (ST), namely ST1 to ST10, ST14/ST24/ST25 complex, ST23, ST26, and ST29 were detected. In addition, Blastocystis was found in tortoises. ST1 (3.2%) and ST5 (11.5%) were found in pigs, ST2 (1.6%) and ST3 (3.2%) in non-human primates, ST4 (14.7%) in rodents and ruminants, ST6 (4.9%), ST7 (30%), ST9 (1.6%), and ST29 (1.6%) in birds, ST8 (6.6%) in Green peafowl and East Asian Porcupine, and ST10 (4.9%), ST14/ST24/ST25 (9.8%), ST23 (1.6%) and ST26 (1.6%) in ruminants. The sequence recovered from the elongated tortoises (Indotestudo elongata) (3.2%) was phylogenetically placed within the reptilian cluster of Blastocystis, for which no subtype system is available yet. Of note, we did not obtain Blastocystis sequences from any of the many canids and felids sampled in the study, and our data are in support of host specificity of Blastocystis, according to both colonization and subtype distribution.

Metabarcoding of colonic cleansing fluid reveals unique bacterial members of mucosal microbiota associated with Inflammatory Bowel Disease.

BACKGROUND: Inflammatory Bowel Disease (IBD) is a group of chronic idiopathic inflammatory diseases of the gastrointestinal (GI) tract associated with the dysbiosis of gut microbiota. Metabarcoding-based profiling of the gut microbiota of IBD patients is generally based on the stool samples collected from individual patients which rarely represent the mucosa-associated microbiota. The ideal sampling strategy for routine monitoring of the mucosal component of IBD has yet to be determined. METHODS: We hereby compare the microbiota composition of the colonic cleansing fluid (CCF) collected during colonoscopy with stool samples from IBD patients. The relationship between IBD and gut microbiota was revealed through the application of the 16S rRNA amplicon sequencing-based metabarcoding approach. CCF and stool samples were collected from IBD patients with Crohn's disease and ulcerative colitis. RESULTS: The present study shows significant differences in the microbial composition of CCF samples, presumably indicating changes in the mucosal microbiota of IBD patients as compared to the control group. Short-chain fatty acid-producing bacteria under the family Lachnospiraceae, the actinobacterial genus Bifidobacterium, the proteobacterial Sutterella and Raoultella are found to contribute to the microbial dysbiosis of the mucosal flora in IBD patients. CONCLUSIONS: CCF microbiota has the capacity to distinguish IBD patients from healthy controls and, thus, may constitute an alternative analysis strategy for the early diagnosis and disease progression in IBD biomarker research.

Molecular characterization of Blastocystis and Entamoeba of muskoxen and sheep in Greenland.

Molecular characterisation of endobionts that are shared among human and non-human hosts can help shed light on the epidemiology and inform studies that aim to unravel the role of these organisms in health and disease. Two of the most common of shared endobionts include the single-celled intestinal protists Blastocystis and Entamoeba. Here, we present the first known data on genetic diversity and host specificity of these two genera in Greenland. Faecal DNA samples from 243 muskoxen and 44 sheep were submitted to metabarcoding of nuclear small subunit ribosomal DNA. Entamoeba- and Blastocystis-specific sequences were clustered, and consensus sequences were subjected to taxonomic query. Using MinION-based sequencing, near-complete nuclear small subunit ribosomal DNA sequences were obtained from four faecal samples. Of the 243 muskox samples, 180 (74%) and 19 (8%) were positive for Blastocystis and Entamoeba, respectively. Forty (91%) and six (14%) of the 44 sheep samples were positive for Blastocystis and Entamoeba, respectively. Blastocystis subtypes (ST) 10, 14, 21, 24-26, and a novel subtype (ST40) were identified. Colonisation by more than one subtype was common. ST40 was common in muskoxen but limited to Northeast Greenland. Entamoeba bovis and the E. bovis-associated ribosomal lineages (RL) 1 and 8 were found, and three conditional lineages (CL) 3, 4, and 10 were confirmed; CL10 was promoted to RL12. Several novel lineages were identified, all of which were linked to the E. bovis complex. In conclusion, Blastocystis was far more common than Entamoeba and found in approximately three of every four animals; both can be considered common colonisers of large herbivorous mammals in Greenland. Multiple subtypes/lineages of both genera were commonly observed, some of which were novel, but most of which are seen in many other parts of the world.

Identification of the tapeworm Mosgovoyia pectinata (Anoplocephalidae) in Faroese mountain hares (Lepus timidus).

The mountain hares (Lepus timidus L., 1758) in the Faroe Islands, an archipelago located in the North Atlantic, are known to be commonly infected by tapeworms, the identity of which was unknown. The mountain hare, which now populates 15 of the 18 islands, was introduced from Norway in 1855. In this study, tapeworms collected from four mountain hares from four geographic areas of the Faroe Islands were subjected to molecular identification using the nuclear ribosomal DNA (28S), the mitochondrial cytochrome oxidase subunit 1 (cox1) and the NADH dehydrogenase subunit 1 (nad1) genes. The results indicate unambiguously that the tapeworms were Mosgovoyia pectinata (Goeze, 1782) (Cestoda: Anoplocephalidae sensu stricto). The phylogenetic position and origin of the Faroese M. pectinata are discussed. Given that the parasite is quite common in Norway, from where the mountain hares were introduced, it is conceivable that co-introduction of M. pectinata from Norway to the Faroe Islands took place. The phylogenetic analyses revealed high similarity of the M. pectinata sequences from three regions and the position of the Faroese isolate as the sister lineage of the isolates from Finland and East Siberia.

Neoehrlichia mikurensis-An emerging opportunistic tick-borne infection in immunosuppressed patients.

BACKGROUND: Neoehrlichia mikurensis (N. mikurensis) is a newly discovered tick-borne pathogen that can inflict life-threatening illness in immunocompromised patients. N. mikurensis infection is only detectable by polymerase chain reaction (PCR)-based methodologies. We describe three distinct clinical manifestations of N. mikurensis infection (neoehrlichiosis) in Danish patients receiving B-lymphocyte-depleting therapy, rituximab, for underlying hematological, rheumatological, or neurological disorders. All three patients went through a protracted pre-diagnostic period. METHODS: N. mikurensis DNA was detected and confirmed using two methods. Blood was tested by specific real-time PCR targeting the groEL gene and by 16S and 18S profiling followed by sequencing. Bone marrow was analyzed by 16S and 18S profiling. RESULTS: N. mikurensis was detected in blood samples in all three cases and in bone marrow from one of the three. The severity of the symptoms ranged from prolonged fever lasting more than 6 months to life-threatening hyperinflammation in the form of hemophagocytic lymphohistiocytosis (HLH). Interestingly, all patients presented with splenomegaly and two with hepatomegaly. After starting doxycycline therapy, symptoms were relieved within a few days, and biochemistry and organomegaly quickly normalized. CONCLUSION: We present three Danish patients recognized by the same clinician over a period of 6 months, strongly suggesting that many cases are going unrecognized. Second, we describe the first case of N. mikurensis-induced HLH and emphasize the potential severity of undetected neoehrlichiosis.