A severe head louse (Pediculus humanus capitis) infestation: Timeline, pathogen detection, kdr-gene screening and morphological anomalies of lice.

Lice are assuming an increasing importance in forensic investigations, given their capacity to provide information about an individual's care. Head louse pediculosis is a frequent condition in school-age children and can be properly controlled using topical treatments combined with good personal hygiene. Prolonged and chronic infestations may result in more serious outcomes including severe iron deficiency anaemia. We conducted entomological and laboratory investigations of a head louse infestation in a 12-year-old girl who experienced severe anaemia and subsequent death. Numerous lice were found postmortem on the head, face and neck of the patient, as well as on bedding and clothing. Analysis of nits on individual hairs determined that the louse infestation had been present for at least 166 days. The lice had some morphological traits characteristic of body lice: the third antennal segment in some specimens was distinctly longer than wide, and the apices of some paratergal plates did not extend into intersegmental membranes, while other morphological features were characteristic of head or body lice. All lice were heterozygous for the T917I kdr genotype, a marker of permethrin resistance. Nineteen (79.2%, 95%CI 59.5%-90.8%) louse DNA samples tested TaqMan positive for Acinetobacter (Moraxellales; Moraxellaceae) sp. Available information and laboratory findings are further discussed regarding their possible contribution to the negative outcome of this case. We stress the impact head louse pediculosis can have on children with limited parental attention, and how severe head louse infestation may serve as warning sign of neglect, and other high-risk situations.

Confirmation of Rickettsia conorii Subspecies indica Infection by Next-Generation Sequencing, Shandong, China.

We describe 3 similar cases of rickettsial disease that occurred after tick bites in a mountainous rural area of Shandong Province, China. Next-generation sequencing indicated the etiologic agent of 1 patient was Rickettsia conorii subspecies indica. This agent may be more widely distributed across China than previously thought.

Pilot survey of mosquitoes (Diptera: Culicidae) from southeastern Georgia, USA for Wolbachia and Rickettsia felis (Rickettsiales: Rickettsiaceae).

BACKGROUND & OBJECTIVES: Mosquito surveillance is one of the critical functions of local health departments, particularly in the context of outbreaks of severe mosquito-borne viral infections. Unfortunately, some viral and parasitic infections transmitted by mosquitoes, manifests non-specific clinical symptoms which may actually be of rickettsial etiology, including Rickettsia felis infections. This study tested the hypothesis that mosquitoes from southeastern Georgia, USA may be infected with Rickettsia felis and Wolbachia, an endosymbiotic bacterium of the order Rickettsiales. METHODS: Specimens of the five most common mosquito species occurring in the region were collected using gravid and light-traps and identified using morphological keys. Mosquitoes were then pooled by species, sex, trap and collection site and their DNA was extracted. Molecular methods were used to confirm mosquito identification, and presence of Wolbachia and R. felis. RESULTS: Wolbachia DNA was detected in 90.8% of the mosquito pools tested, which included 98% pools of Cx. quinquefasciatus Say (Diptera: Culicidae), 95% pools of Ae. albopictus Skuse (Diptera: Culicidae), and 66.7% of pools of Cx. pipiens complex. Samples of An. punctipennis Say (Diptera: Culicidae) and An. crucians Wiedemann (Diptera: Culicidae) were tested negative for Wolbachia DNA. Three genotypes of Wolbachia sp. belonging to Group A (1 type) and Group B (2 types) were identified. DNA of R. felis was not found in any pool of mosquitoes tested. INTERPRETATION & CONCLUSIONS: This study provides a pilot data on the high presence of Wolbachia in Cx. quinque-fasciatus and Ae. albopictus mosquitoes prevalent in the study region. Whether the high prevalence of Wolbachia and its genetic diversity in mosquitoes affects the mosquitoes' susceptibility to R. felis infection in Georgia will need further evaluation.

High prevalence and genetic heterogeneity of rodent-borne Bartonella species on Heixiazi Island, China.

We performed genetic analysis of Bartonella isolates from rodent populations from Heixiazi Island in northeast China. Animals were captured at four sites representing grassland and brushwood habitats in 2011 and examined for the prevalence and genetic diversity of Bartonella species, their relationship to their hosts, and geographic distribution. A high prevalence (57.7%) and a high diversity (14 unique genotypes which belonged to 8 clades) of Bartonella spp. were detected from 71 rodents comprising 5 species and 4 genera from 3 rodent families. Forty-one Bartonella isolates were recovered and identified, including B. taylorii, B. japonica, B. coopersplainsensis, B. grahamii, B. washoensis subsp. cynomysii, B. doshiae, and two novel Bartonella species, by sequencing of four genes (gltA, the 16S rRNA gene, ftsZ, and rpoB). The isolates of B. taylorii and B. grahamii were the most prevalent and exhibited genetic difference from isolates identified elsewhere. Several isolates clustered with strains from Japan and far-eastern Russia; strains isolated from the same host typically were found within the same cluster. Species descriptions are provided for Bartonella heixiaziensis sp. nov. and B. fuyuanensis sp. nov.

Emergence of a new pathogenic Ehrlichia species, Wisconsin and Minnesota, 2009.

BACKGROUND: Ehrlichiosis is a clinically important, emerging zoonosis. Only Ehrlichia chaffeensis and E. ewingii have been thought to cause ehrlichiosis in humans in the United States. Patients with suspected ehrlichiosis routinely undergo testing to ensure proper diagnosis and to ascertain the cause. METHODS: We used molecular methods, culturing, and serologic testing to diagnose and ascertain the cause of cases of ehrlichiosis. RESULTS: On testing, four cases of ehrlichiosis in Minnesota or Wisconsin were found not to be from E. chaffeensis or E. ewingii and instead to be caused by a newly discovered ehrlichia species. All patients had fever, malaise, headache, and lymphopenia; three had thrombocytopenia; and two had elevated liver-enzyme levels. All recovered after receiving doxycycline treatment. At least 17 of 697 Ixodes scapularis ticks collected in Minnesota or Wisconsin were positive for the same ehrlichia species on polymerase-chain-reaction testing. Genetic analyses revealed that this new ehrlichia species is closely related to E. muris. CONCLUSIONS: We report a new ehrlichia species in Minnesota and Wisconsin and provide supportive clinical, epidemiologic, culture, DNA-sequence, and vector data. Physicians need to be aware of this newly discovered close relative of E. muris to ensure appropriate testing, treatment, and regional surveillance. (Funded by the National Institutes of Health and the Centers for Disease Control and Prevention.).

Utility of next-generation sequencing for the etiological diagnosis of Orientia tsutsugamushi infection.

Background: Scrub typhus, an acute febrile disease caused by Orientia tsutsugamushi, is transmitted to humans through infected chigger mites. We present a case of scrub typhus in a previously healthy man from Shandong Province diagnosed using next-generation sequencing (NGS) and PCR and review recent literature on NGS for scrub typhus diagnosis. Methods: NGS was utilized for testing whole blood collected on admission. Confirmatory testing was done by detecting IgM and IgG antibodies to Orientia in acute and convalescent sera by ELISA. Orientia 47-kDa protein gene TaqMan and standard PCR of the 56-kDa protein gene and Sanger sequencing were performed on eschar scab DNA. Results: The NGS diagnosis was confirmed by 47-kDa protein gene TaqMan and sequencing of a fragment of the O. tsutsugamushi 56-kDa protein gene from the eschar scab. Analysis of this sequence and the NGS data indicated O. tsutsugamushi strain Cheeloo2020 is a novel genotype. Mapping of the NGS data against the O. tsutsugamushi Gilliam strain genome sequence identified 304 reads with high similarity. Conclusions: NGS is not only useful for multiplex diagnosis of scrub typhus, but also provides insight into the genetic diversity of O. tsutsugamushi. The common failure to submit sequences to databases makes it difficult to determine the minimal quantity and quality of NGS data being used for the positive identification of Orientia DNA in clinical specimens.

History and Current Status of Mediterranean Spotted Fever (MSF) in the Crimean Peninsula and Neighboring Regions along the Black Sea Coast.

Mediterranean spotted fever (MSF) is a tick-borne rickettsiosis caused by Rickettsia conorii subspecies conorii and transmitted to humans by Rhipicephalus sanguineus ticks. The disease was first discovered in Tunisia in 1910 and was subsequently reported from other Mediterranean countries. The first cases of MSF in the former Soviet Union were detected in 1936 on the Crimean Peninsula. This review summarizes the historic information and main features of MSF in that region and contemporary surveillance and control efforts for this rickettsiosis. Current data pertinent to the epidemiology of the disease, circulation of the ticks and distribution of animal hosts are discussed and compared for each of the countries in the Black Sea basin where MSF occurs.

Use of eschar swab DNA to diagnose Rickettsia conorii subspecies conorii infection in Crimea: A case report.

Mediterranean spotted fever (MSF) has been diagnosed clinically in the Crimean Peninsula since the 1930s. We describe the recent illness of an elderly patient from Crimea who had developed a classic triad of MSF symptoms consisting of fever, maculopapular rash, and eschar. Clinical diagnosis of rickettsiosis was confirmed using real-time PCR and sequencing of 4 Rickettsia protein genes. The strain causing clinical illness was characterized as Rickettsia conorii subspecies conorii Malish 7. This report corroborates the utility of eschar swab material as a source of DNA for PCR-based diagnostics that enables timely patient treatment and management.

Two pathogens and one disease: detection and identification of flea-borne Rickettsiae in areas endemic for murine typhus in California.

Results of an environmental assessment conducted in a newly emergent focus of murine typhus in southern California are described. Opossums, Didelphis virginiana Kerr, infested with cat fleas, Ctenocephalides felis Buché, in the suburban area were abundant. Animal and flea specimens were tested for the DNA of two flea-borne rickettsiae, Rickettsia typhi and Rickettsia felis. R. felis was commonly detected in fleas collected throughout this area while R. typhi was found at a much lower prevalence in the vicinity of just 7 of 14 case-patient homes identified. DNA of R. felis, but not R. typhi, was detected in renal, hepatic, and pulmonary tissues of opossums. In contrast, there were no hematologic polymerase chain reaction findings of R. felis or R. typhi in opossums, rats, and cats within the endemic area studied. Our data suggest a significant probability of human exposure to R. felis in the area studied; however, disease caused by this agent is not recognized by the medical community and may be misdiagnosed as murine typhus using nondiscriminatory serologic methods.

Genetic typing of isolates of Rickettsia typhi.

Murine typhus, which is caused by Rickettsia typhi, has a wide range of clinical manifestations. It has a low mortality rate but may result in meningoencephalitis and interstitial pneumonia in severe cases. Comparisons of complete genome sequences of R. typhi isolates from North Carolina, USA (Wilmington), Myanmar (B9991PP), and Thailand (TH1527) identified only 26 single nucleotide polymorphism (SNP) and 7 insertion-deletion (INDEL) sites in these highly syntenic genomes. Assays were developed to further define the distribution of these variant sites among 15 additional isolates of R. typhi with different histories from Asia, the USA, and Africa. Mismatch amplification mutation assays (MAMA) were validated for 22 SNP sites, while the 7 INDEL sites were analyzed directly on agarose gels. Six SNP types, 9 INDEL types, 11 total types were identified among these 18 isolates. Replicate DNA samples as well as comparisons of isolates with different passage and source histories gave consistent genetic typing profiles. Comparison of the SNP and INDEL markers to R. typhi's nearest neighbor Rickettsia prowazekii demonstrated that the majority of the SNPs represent intra-species variation that arose post divergence of these two species while several INDEL sites also exhibited intraspecies variability among the R. prowazekii genomes that have been completely sequenced. The assays for the presence of these SNP and INDEL sites, particularly the latter, comprise a low technology gel method for consistently distinguishing R. typhi and R. prowazekii as well as for differentiating genetic types of R. typhi.

Molecular Characterization of Rickettsial Agents in Ticks (Acari: Ixodidae) from Sri Lanka.

Because the majority of spotted fever group rickettsiae are transmitted to humans by tick bites, it is important to understand which ticks might play a role in transmission of rickettsial pathogens in Sri Lanka. The purpose of our study was to conduct molecular surveillance of 847 ticks collected in different locations in central Sri Lanka to determine which were infected with Rickettsia and Anaplasmataceae. Molecular methods were used to identify the ticks and the agents detected. Most ticks (Amblyomma, Haemaphysalis, and Rhipicephalus) were collected by flagging, and lower number was collected from dogs, cattle, pigs, a pangolin, and tortoises. Five spotted fever genotypes were identified: a Rickettsia africae-like agent in Amblyomma larvae, Rhipicephalus massiliae and a related genotype identified in association with the tropical type of Rhipicephalus sanguineus from dogs and Rhipicephalus haemaphysaloides from dogs and cattle, and Candidatus R. kellyi and another novel genotype (SL94) in R. haemaphysaloides. Twenty-three ticks were positive for Anaplasmataceae, including one Anaplasma and two Ehrlichia genotypes. Because the sequence database for both ticks and rickettsial agents from Sri Lanka and southern India is not extensive, additional molecular characterization of the tick species of Sri Lanka and their rickettsial agents is required to understand their pathogenic potential more completely. However, several of the agents we identified in this survey may well be pathogenic for humans and domestic animals, and should be considered as a part of epidemiological surveillance and patient management.

Beta interferon-mediated activation of signal transducer and activator of transcription protein 1 interferes with Rickettsia conorii replication in human endothelial cells.

Infection of the endothelial cell lining of blood vessels with Rickettsia conorii, the causative agent of Mediterranean spotted fever, results in endothelial activation. We investigated the effects of R. conorii infection on the status of the Janus kinase (JAK)-signal transducer and activator of transcription protein (STAT) signaling pathway in human microvascular endothelial cells (HMECs), the most relevant host cell type, in light of rickettsial tropism for microvascular endothelium in vivo. R. conorii infection induced phosphorylation of STAT1 on tyrosine 701 and serine 727 at 24, 48, and 72 h postinfection in HMECs. Employing transcription profile analysis and neutralizing antibodies, we further determined that beta interferon (IFN-ß) production and secretion are critical for STAT1 activation. Secreted IFN-ß further amplified its own expression via a positive-feedback mechanism, while expression of transcription factors interferon regulatory factor 7 (IRF7) and IRF9, implicated in the IFN-ß-STAT1 feedback loop, was also induced. Metabolic activity of rickettsiae was essential for the IFN-ß-mediated response(s) because tetracycline treatment inhibited R. conorii replication, IFN-ß expression, and STAT1 phosphorylation. Inclusion of IFN-ß-neutralizing antibody during infection resulted in significantly enhanced R. conorii replication, whereas addition of exogenous IFN-ß had the opposite inhibitory effect. Finally, small interfering RNA-mediated knockdown further confirmed a protective role for STAT1 against intracellular R. conorii replication. In concert, these findings implicate an important role for IFN-ß-mediated STAT1 activation in innate immune responses of vascular endothelium to R. conorii infection.

Eschar-associated spotted fever rickettsiosis, Bahia, Brazil.

In Brazil, Brazilian spotted fever was once considered the only tick-borne rickettsial disease. We report eschar-associated rickettsial disease that occurred after a tick bite. The etiologic agent is most related to Rickettsia parkeri, R. africae, and R. sibirica and probably widely distributed from Sao Paulo to Bahia in the Atlantic Forest.

Rickettsia rickettsii in Rhipicephalus ticks, Mexicali, Mexico.

Circulation of a unique genetic type of Rickettsia rickettsii in ticks of the Rhipicephalus sanguineus complex was detected in Mexicali, Baja California, Mexico. The Mexican R. rickettsii differed from all isolates previously characterized from the endemic regions of Rocky Mountain spotted fever in northern, central, and southern Americas. Rhipicephalus ticks in Mexicali are genetically different from Rh. sanguineus found in the United States.

Fleas (Siphonaptera) Parasitizing Peridomestic and Indigenous Mammals in Panamá and Screening of Selected Fleas for Vector-Borne Bacterial Pathogens.

In total, 341 fleas belonging to 16 species were collected from 78 host mammals belonging to 10 species in Panamá from 2010 to 2016. The cat flea, Ctenocephalides felis (Bouché) predominated on domestic dogs and was also recorded from domestic cats, the raccoon, Procyon lotor (Linnaeus) and the common opossum, Didelphis marsupialis Linnaeus. The largest number of flea species (7) was recorded from D. marsupialis and the most common flea on that host was the ctenophthalmid, Adoratopsylla intermedia copha Jordan. One Oriental rat flea, Xenopsylla cheopis (Rothschild), was collected from D. marsupialis. Native rodents were parasitized by indigenous ceratophyllid, rhopalopsyllid, and stephanocircid fleas. The Mexican deermouse, Peromyscus mexicanus (Saussure), was parasitized by six species of ceratophyllids belonging to the mostly Central American genera, Baculomeris, Jellisonia, Kohlsia and Plusaetis. The long-tailed singing mouse, Scotinomys xerampelinus (Bangs), was parasitized by Plocopsylla scotinomi Tipton and Méndez, the only species of stephanocircid flea known from Central America. Twenty-six pools of extracted flea DNA representing 5 flea species (C. felis, Pulex echidnophagoides (Wagner), Pulex simulans Baker, A. intermedia copha, and P. scotinomi) and 79 individual fleas were all real-time polymerase chain reaction negative for Rickettsia felis, Rickettsia typhi, and Bartonella henselae.

Rickettsia 364D: a newly recognized cause of eschar-associated illness in California.

BACKGROUND: Four spotted fever group rickettsiae (SFGR) are known to infect humans in the United States. A member of the SFGR designated 364D and detected in Dermacentor occidentalis ticks has not previously been identified as a human pathogen. METHODS: An 80-year-old man from a rural northern California community presented with an eschar on his forearm. A skin punch biopsy of the lesion was evaluated by immunohistochemistry and molecular analysis. Serum specimens obtained from the patient and 3 other area residents with similar illnesses were tested by immunofluorescence and Western immunoblot for antibodies to SFGR. Ticks were collected near the patient's residence and tested for SFGR. RESULTS: Abundant intracellular rickettsiae and fragmented rickettsial antigens were observed in the mononuclear inflammatory infiltrates of the biopsy. Nucleotide sequences of DNA fragments amplified from the biopsy were identical to those of 364D. Convalescent sera from all four patients exhibited high immunoglobulin G titers to Rickettsia rickettsii, Rickettsia rhipicephali, and 364D antigens. Three adult D. occidentalis were positive for 364D, R. rhipicephali, and an unidentified Rickettsia species. CONCLUSIONS: This is the first confirmation of human disease associated with the SFGR 364D, which was likely transmitted by D. occidentalis. Although the patients described here presented with a single cutaneous eschar as the principal manifestation, the full spectrum of illness associated with 364D has yet to be determined. Possible infection with 364D or other SFGR should be confirmed through molecular techniques in patients who present with "spotless" Rocky Mountain spotted fever or have serum antibodies to R. rickettsii with group-specific assays.

Murine typhus in Austin, Texas, USA, 2008.

In August 2008, Texas authorities and the Centers for Disease Control and Prevention investigated reports of increased numbers of febrile rash illnesses in Austin to confirm the causative agent as Rickettsia typhi, to assess the outbreak magnitude and illness severity, and to identify potential animal reservoirs and peridomestic factors that may have contributed to disease emergence. Thirty-three human cases of confirmed murine typhus were identified. Illness onset was reported from March to October. No patients died, but 23 (70%) were hospitalized. The case-patients clustered geographically in central Austin; 12 (36%) resided in a single ZIP code area. Specimens from wildlife and domestic animals near case-patient homes were assessed; 18% of cats, 44% of dogs, and 71% of opossums had antibodies reactive to R. typhi. No evidence of R. typhi was detected in the whole blood, tissue, or arthropod specimens tested. These findings suggest that an R. typhi cycle involving opossums and domestic animals may be present in Austin.

Bacteremia, fever, and splenomegaly caused by a newly recognized bartonella species.

Bartonella species cause serious human infections globally, including bacillary angiomatosis, Oroya fever, trench fever, and endocarditis. We describe a patient who had fever and splenomegaly after traveling to Peru and also had bacteremia from an organism that resembled Bartonella bacilliformis, the causative agent of Oroya fever, which is endemic to Peru. However, genetic analyses revealed that this fastidious bacterium represented a previously uncultured and unnamed bartonella species, closely related to B. clarridgeiae and more distantly related to B. bacilliformis. We characterized this isolate, including its ability to cause fever and sustained bacteremia in a rhesus macaque. The route of infection and burden of human disease associated with this newly described pathogen are currently unknown.

Detection of Rickettsia asembonensis in Fleas (Siphonaptera: Pulicidae, Ceratophyllidae) Collected in Five Counties in Georgia, United States.

We conducted a molecular survey of Rickettsia in fleas collected from opossums, road-killed and live-trapped in peridomestic and rural settings, state parks, and from pet cats and dogs in Georgia, United States during 1992-2014. The cat flea, Ctenocephalides felis (Bouché) was the predominant species collected from cats and among the archival specimens from opossums found in peridomestic settings. Polygenis gwyni (Fox) was more prevalent on opossums and a single cotton rat trapped in sylvatic settings. Trapped animals were infested infrequently with the squirrel flea, Orchopeas howardi (Baker) and C. felis. TaqMan assays targeting the BioB gene of Rickettsia felis and the OmpB gene of Rickettsia typhi were used to test 291 flea DNAs for Rickettsia. A subset of 53 C. felis collected from a cat in 2011 was tested in 18 pools which were all bioB TaqMan positive (34% minimum infection prevalence). Of 238 fleas tested individually, 140 (58.8%, 95% confidence interval [CI]: 52.5-64.9%) DNAs were bioB positive. Detection of bioB was more prevalent in individual C. felis (91%) compared to P. gwyni (13.4%). Twenty-one (7.2%) were ompB TaqMan positive, including 18 C. felis (9.5%) and 3 P. gwyni (3.2%). Most of these fleas were also positive with bioB TaqMan; however, sequencing of gltA amplicons detected only DNA of Rickettsia asembonensis. Furthermore, only the R. asembonensis genotype was identified based on NlaIV restriction analysis of a larger ompB fragment. These findings contribute to understanding the diversity of Rickettsia associated with fleas in Georgia and emphasize the need for development of more specific molecular tools for detection and field research on rickettsial pathogens.