The case of Mediterranean spotted fever of the traveler returned from Zambia.

We report the case of a traveler who returned from Zambia and was diagnosed with Mediterranean spotted fever (MSF), an infectious disease caused by Rickettsia conorii conorii. The patient presented to Sapporo City General Hospital with symptoms of fever, malaise, headache, and rash. The pathogen was identified by Polymerase Chain Reaction assays and subsequent analyses. The patient improved with 10-day treatment of oral doxycycline. Although some cases of MSF have been reported in sub-Saharan Africa, none have been reported in Zambia. Rhipicephalus sanguineus sensu lato, the vector of the Rickettsia conorii conorii, has been found in various areas of Zambia. Our case report highlights the potential threat of Mediterranean spotted fever in urban areas of Zambia.

Cervids as Sentinels for Rickettsia spp. in Portugal.

Cervids are highly exposed to ticks, however, their role in the life cycle of these rickettsiae has not been fully elucidated. Given the expanding distribution and growing population of deer species in Portugal, coupled with their direct and indirect interactions with humans during hunting, it becomes crucial to explore their role as sentinels and potential reservoirs of Rickettsia. The present investigation aimed to detect and evaluate exposure to Rickettsia in free-living deer from Portugal. Blood samples (n = 77) were collected from hunted game animals (red deer and fallow deer) from different areas throughout Portugal (Idanha-a-Nova, Monte Fidalgo, Montalvão and Arraiolos) and sera were tested by immunofluorescence assay, to detect antibodies. Additionally, blood DNA samples were screened for SFGR by nested-polymerase chain reaction targeting a fragment of the outer membrane protein B (ompB) gene, as well as for Anaplasma and Ehrlichia spp. targeting the 16S rRNA gene. Thirty-five per cent (25 deer and two fallow deer) tested positive (sera with a titer ≥1:64) for IgG antibodies against Rickettsia conorii. No rickettsial DNA was detected by PCR for the ompB gene, and all DNA samples tested negative for Anaplasma and Ehrlichia. As far as we know, this study is the first screening of cervid species in Portugal for Rickettsia antibodies. The findings suggest that these animals serve as useful sentinel indicators for the circulation of rickettsiae, offering a complementary perspective to studies focused on ticks. The increasing numbers of hunted deer in Portugal and the potential zoonotic features of Rickettsia spp. highlight the importance of continued surveillance directed at tick-borne diseases, especially those involving wild animals.

Rhipicephalus sanguineus from Hungarian dogs: Tick identification and detection of tick-borne pathogens.

The brown dog tick, Rhipicephalus sanguineus is a complex of tick species with an unsettled species concept. In Europe, R. sanguineus is considered mainly a Mediterranean tick with sporadic findings in central and northern Europe. R. sanguineus is known as a vector of a range of pathogens of medical and veterinary importance, most of which not yet reported as autochthonous in Hungary. A total of 1839 ticks collected by veterinarians from dogs and cats were obtained in Hungary. The study aims at precise determination of ticks identified as R. sanguineus and detection of pathogens in collected ticks. All ticks were morphologically determined and 169 individuals were identified as R. sanguineus. A subset of 15 ticks was selected for molecular analysis (16S rDNA, 12S rDNA, COI). Phylogenetic analyses invariably placed sequences of all three markers into a single haplotype identified as R. sanguineus sensu stricto. All 169 brown dog ticks were tested for the presence of A. platys, E. canis, R. conorii, B. vogeli and H. canis. None of the investigated ticks was positive for the screened pathogens, though A. phagocytophilum sequence was detected in a single tick.

Concomitant Mediterranean spotted fever and systemic lupus erythematosus: a rare case report.

Infections are an important cause of morbidity and mortality in Systemic Lupus Erythematosus (SLE). Mediterranean spotted fever (MSF) is a tick-borne disease caused by Rickettsia conorii. This infection is endemic in Tunisia with summer seasonality. Herein, the case of a 45 years old woman, admitted to hospital with fever and erythema nodosum. On examination, she had a diffuse skin rash, malar rash, and polyarthritis. Serology demonstrated Rickettsia Conoriiinfection. The diagnosis of MSF was made and the patient had a course of doxycycline for 5 days with a prompt improvement of the fever, the skin lesions but she had a persistent malar rash, polyarthritis, and lymphopenia. The immunological profile was positive for antinuclear antibodies (ANA), anti-DNA antibodies, anti-nucleosomes antibodies, and anti-citrullinated protein antibodies (ACPA). The diagnosis of SLE was established. We report the first case of SLE associated with MSF and with erythema nodosum as the initial presentation.

Renal Involvement in Mediterranean Spotted Fever: Clinical and Histopathological Data.

OBJECTIVE: Mediterranean spotted fever (MSF) is a tick-borne rickettsial infection endemic to the Mediterranean coastline countries. As a result of growing tourism, imported cases have been registered in many nonendemic countries and regions. We present clinical laboratory parameters and histopathological data on renal impairment in patients with MSF. The study meets our goal of identifying kidney involvement and detecting renal damage in people with MSF. SUBJECTS AND METHODS: Three hundred fifty patients with MSF with a diagnosis confirmed by immunofluorescence analysis were tested for serum urea, creatinine, and albumin. Fifty-five patients with malignant form of MSF were divided into 2 groups: 19 fatalities and 36 survivors. The percentage of patients with acute renal failure (ARF) was compared in both groups. RESULTS: Subjects with elevated urea and creatinine levels increased from 5.21 to 3.47% in mild to 48.78 and 29.26% in severe MSF, respectively. Loss of serum albumin also increased from mild to severe MSF. Renal impairment comprised 60% of the cohort of 55 patients with malignant MSF: 89.4% in the group of deaths and almost twice less in the survivors. ARF developed in 84.2% of fatal cases and was >2 times less in survivors. Postmortem light microscopy of renal samples of 9 fatal cases revealed perivascular mononuclear inflammatory infiltrates, vasculitis with fibrinoid necrosis, acute tubular necrosis, interstitial edema, hemorrhage, and thrombosis. CONCLUSION: Renal pathology associated with MSF rickettsial infection consists of systemic small vessel vasculitis and vascular injury, leading to ARF in the most severe cases.

Molecular confirmation & characterization of Rickettsia conorii in north India: A report of three cases.

Background & objectives: In India, spotted fever group rickettsiae (SFGR) are an underdiagnosed cause of acute febrile illness (AFI). The non-specific Weil-Felix test is the first diagnostic modality for the diagnosis of SFGR in many laboratories due to the lack of advanced diagnostic facilities in developing countries. The aim of this study was to detect SFGR using molecular methods in the patients, presenting with AFI in a tertiary care centre in north India. Methods: Consecutive patients (>14 yr of age) with AFI were enrolled over a six month period. Standard investigations for common pathogens causing AFI in India (malaria, dengue, scrub typhus, leptospirosis and enteric fever) were carried out. In patients who were negative for all of the above investigations, blood was subjected to polymerase chain reaction (PCR) targeting outer membrane protein A (ompA) gene of Rickettsia. Results: Of the 51 patients with an undiagnosed aetiology, three were positive by ompA PCR. Two of the PCR products produced good sequences and BLAST identification confirmed them as Rickettsia conorii. The sequences of R. conorii reported from south India clustered with two previously reported novel rickettsial genotypes. The study sequences clustered in a group different from that of Rickettsia spp. of the south Indian sequences reported earlier. Interpretation & conclusions: This study showed the existence of R. conorii in north India. Testing for SFGR may be included in the diagnostic workup of AFI for better disease management.

Detection of Rickettsia conorii israelensis DNA in the Blood of a Cat and a Dog From Southern Portugal.

Vector-borne rickettsioses represent emerging threats to public health worldwide. The aim of this work was the screening for the presence of Rickettsia spp. in the blood of dogs and cats from southern Portugal. A PCR product of the expected size was amplified from DNA extracts obtained from blood samples of 29 out of 225 (12.9%) cats and in 2 out of 375 (.5%) dogs using genus-specific primers targeting Rickettsia gltA. Rickettsia conorii israelensis was identified by phylogenetical analysis of partial ompB sequences, amplified from blood samples taken from both a cat and a dog. The obtained results reinforce the idea that domestic animals may act as sentinels for the presence of vector-borne Rickettsia spp. in a given geographical area. In addition, rickettsioses should be included in the differential diagnosis of canine and feline vector-borne diseases.

Seroprevalences of Rickettsia conorii, Ehrlichia canis and Coxiella burnetii in Dogs from Montenegro.

PURPOSE: The incidence of vector-borne zoonoses has been increasing in Europe as a result of global climate change, and rickettsioses are a significant etiologic entity among these infections. The objective of this study was to investigate the seroprevalences of Rickettsia conorii, Ehrlichia canis and Coxiella burnetii in dogs in Montenegro. METHODS: The seroepidemiological study covered 259 dogs, of which 155 were owned dogs suspected of infection with agents of rickettsial aetiology from the continental (Podgorica) or five coastal municipalities of Montenegro (Budva, Herceg Novi, Kotor, Ulcinj and Bar), and 104 dogs were from a public shelter in Podgorica. The presence of specific IgG antibodies against R. conorii was analysed using a commercial indirect enzyme-linked immunosorbent assay (ELISA) test, and the presence of antibodies against E. canis and C. burnetii was analysed using commercial indirect immunofluorescence tests (IFAT). RESULTS: Seroprevalences of 73.36, 19.3 and 1.16% were determined for R. conorii, E. canis and C. burnetii, respectively. R. conorii was significantly more prevalent (χ2 = 14.53; p < 0.001) in owned dogs (81.93%) than in dogs from the public shelter (60.6%), while E. canis was more prevalent (χ2 = 12.31; p < 0.001) in dogs from the public shelter (29.81%) than in owned dogs (12.26%). Coinfection with two pathogens was determined in 40 (15.44%) dogs, and the prevalence of R. conorii/E. canis (χ2 = 4.23; p < 0.05) was greater in dogs from the public shelter (20.19%) than in owned dogs (10.97%). CONCLUSION: The prevailing evidence from this study shows that dogs from Montenegro are exposed to pathogens of veterinary and public health importance. This calls for the One Health approach to sensitise the public on the risks of zoonoses from dogs and to formulate policies and strategies to mitigate their spread and safeguard public health.

Spotted fever rickettsioses causing myocarditis and ARDS: a case from Sri Lanka.

BACKGROUND: Spotted fever group of rickettsial infections are emerging in Sri Lanka. We describe a patient with rapidly progressing ARDS and myocarditis secondary to spotted fever caused by Rickettsia conorii. ARDS and myocarditis are rare complications of Rickettsia conorii infections and only a few cases are reported to date. CASE PRESENTATION: A 53 years old manual worker presented with fever for 5 days and a skin rash. He was in circulatory failure on admission and developed severe hypoxaemia with gross changes in chest radiograph by next day requiring assisted ventilation. He had myocarditis causing left ventricular failure and acute respiratory distress syndrome. He was confirmed to have spotted fever rickettsial infection with rising titre of indirect immunofluorescence antibodies to Ricketssia conorii and made a complete recovery with appropriate antibiotic therapy and supportive care. CONCLUSION: Rickettsial infections can present with diverse manifestations. Even the patients with severe organ involvements such as myocarditis and ARDS can be completely cured if timely identified and treated.

Ocular manifestations of Rickettsia conorii in South India.

PURPOSE: Among the major groups of rickettsiosis, the commonly reported diseases in India are: (a) Typhus group induced-scrub typhus, murine flea-borne typhus; (b) Spotted fever group induced-Indian tick typhus; and (c) Q fever. Though many scrub typhus outbreaks have been reported from India, only one outbreak of spotted fever-serologically proven Indian tick typhus (Rickettsia conorii)-has been reported. We report for the first time ocular manifestations of serologically proven R. conorii infection in a cluster of patients. METHODS: In this retrospective study, case records patients with serologically proven Indian tick typhus (Rickettsia conorii) were reviewed for clinical manifestations and treatment outcomes. RESULTS:: In the months of February to April 2016, a cluster of 12 patients (23 eyes) visited us with defective vision. Examination showed multifocal retinitis; mostly bilateral; patients had a history of fever approximately 4 weeks prior to onset of symptoms. After excluding other causes of multifocal retinitis, a diagnosis of rickettsial retinitis was made after Weil-Felix test (WFT) was significantly positive, and enzyme-linked immunosorbent assay was positive for R. conorii. Course of the disease, visual outcome, and investigations are discussed. Doxycycline along with oral corticosteroids was effective in treating the condition. CONCLUSION:: Systematic fundus examination should be part of the routine evaluation of any patient who presents with fever and/or skin rash living in or returning from a specific endemic area. Clinical clues to diagnosing ocular rickettsiosis could be multifocal retinitis predominantly involving the posterior pole and macular involvement in the form of serous macular detachment or macular hard exudates. A positive WFT still serves as a useful and cheap diagnostic tool for laboratory diagnosis of rickettsial disease. Doxycycline along with oral corticosteroids was effective in treating the condition.

[Haemophagocytic syndrome secondary to Mediterranean spotted fever]. / Syndrome d'activation macrophagique secondaire à une fièvre boutonneuse méditerranéenne.

INTRODUCTION: Haemophagocytic syndrome (HS) is a rare disease with a severe prognosis that is defined by clinical, laboratory and histopathological criteria. Infections represent the classical cause of HS. HS secondary to Mediterranean spotted fever (MSF) is rare with only a few cases being reported in the literature. OBSERVATIONS: We report two cases of HS secondary to MSF in 2 men aged 77 and 63 years presenting a febrile maculo-purpuric eruption with inoculation ulcer associated with laboratory abnormalities (cytopenia, elevated ferritin, hypertriglyceridaemia). Haemophagocytosis was present in 2 cases. Serology and PCR for Rickettsia conorii were positive and militated in favour of recent infection responsible for the diagnosis of MSF. DISCUSSION: The first case of HS was described in 1979. Sixteen cases of HS secondary to MSF are described in the literature. Cytopenia associated with hyperferritinaemia and hypertriglyceridaemia strongly suggests MSF complicated by HS. The prognosis depends on the time elapsed since diagnosis and host-specific factors. Immunosuppressants and antibiotics may be necessary to ensure healing. CONCLUSION: Rickettsioses can induce HS, and this potential complication with a severe prognosis must be known.

Detection of Rickettsia massiliae/Bar29 and Rickettsia conorii in red foxes (Vulpes vulpes) and their Rhipicephalus sanguineus complex ticks.

To determine the prevalence of exposure to Rickettsia massiliae/Bar29 and Rickettsia conorii in wild red foxes, we collected blood samples and ticks from 135 foxes shot in different game reserve areas in Catalonia. To detect SFG rickettsia in Rhipicephalus sanguineus complex ticks collected from the foxes, we used real-time polymerase chain reaction (PCR) to screen for ompA gene and a tick-borne bacteria flow chip technique based on multiplex PCR. Serum samples were positive for antibodies against spotted fever group (SFG) rickettsiae in 68 (50.3%). Molecular techniques identified R. massiliae in 107 ticks, R. aeschlimannii in 3 ticks, and R. slovaca in one tick; no R. conorii was identified in any of the ticks analyzed. We conclude that red foxes can carry ticks with SFG rickettsia.

First detection of Rickettsia conorii ssp. caspia in Rhipicephalus sanguineus in Zambia.

Ticks are important vectors for Rickettsia spp. of the spotted fever group all around the world. Rickettsia conorii is the etiological agent of boutonneuse fever in the Mediterranean region and Africa. Tick identification was based on morphological features and further characterized using the 16S rRNA gene. The ticks were individually tested using pan-Rickettsia real-time-PCR for screening, and 23S-5S intergenic spacer region, 16S rDNA, gltA, sca4, ompB, and ompA genes were used to analyze the Rickettsia positive samples. Rickettsia conorii ssp. caspia was detected in tick collected in Zambia for the first time, thus demonstrating the possibility of the occurrence of human disease, namely Astrakhan fever, due to this Rickettsia ssp. in this region of Africa. The prevalence of R. conorii ssp. caspia was 0.06% (one positive tick out of 1465 tested ticks) and 0.07% (one positive tick out of 1254 tested Rh. sanguineus).

[Rickettsiosis associated with cerebral infarction: a new case study]. / Association rickettsiose et infarctus cérébral: une nouvelle observation.

Mediterranean spotted fever (MSF) is a rickettsiosis of the spotted fever group caused by rickettsia conorii. This zoonosis is benign but it can be complicated by severe neurological impairment (hence its severity). We report the case of a 49-year old patient hospitalized in the Department of Dermatology for rickettsiosis, who suffered from right massive hemiplegia of brutal onset. Magnetic resonance angiography (MRA) of the brain showed deep left sylvian fissure ischemic stroke. The diagnosis of conorii-type rickettsiosis has been retained based on the aspect of skin lesions and on positive sierologic testing with the indirect immunofluorescence method. Evolution was favorable under anti-biotherapy (Doxycycline and fluoroquinolone). Cerebral infarction, exceptionally reported in the framework of neurological manifestations of rickettsioses, is a complication that shouldn't be underestimated especially when etiologic assessment (cardiovascular in particular) is negative.

Epidemiological evaluation of Mediterranean spotted fever in children of the Karak province in south Jordan.

INTRODUCTION: The aim of this study was to describe the epidemiological patterns of Mediterranean spotted fever (MSF) as well as its treatment and outcomes in children in south Jordan. METHODOLOGY: A retrospective observational study was conducted from June 2013 to December 2015. Data regarding demographics, clinical presentation, laboratory findings, treatment, and outcomes were collected. RESULTS: In total, 35 male and 20 female patients (mean age: 6 years ± 3.6) were included. The incidence of MSF was 7.9 cases/100,000 inhabitants/year; MSF affected 89% of individuals in the summer, 74.5% of those living in a rural area with tent housing, and 100% of those who had contact with animals. All cases presented with fever, and 94.5% had a skin rash. Serological tests were positive in 87.2% of cases, and Rickettsia conorii (the Moroccan strain) was present in all positive cases. All cases had thrombocytopenia, but none had leukocytosis. Hyponatremia was present in 71% of cases, and 49%, 61.8%, and 72.7% had increased urea, alanine transaminase, and aspartate aminotransferase levels, respectively. Doxycycline was administered to all patients, with a cure rate of 96.4% and mortality rate of 3.6%. CONCLUSIONS: MSF caused by R. conorii (the Moroccan strain) is prevalent in Jordan, and contact with animals is the route of transmission. The patients' responses to doxycycline were excellent. A high index of suspicion, early diagnosis, and specific treatment considerably decrease mortality. MSF should be considered as a possible cause of febrile disease in those with a rash and in those living in rural areas.

Widespread subcutaneous necrosis in spotted fever group Rickettsioses from the coastal belt of Sri Lanka- a case report.

BACKGROUND: Spotted fever group rickettsioses (SFGR) transmitted mostly by ticks are increasingly discovered around the World and some of them are either re-emerging or emerging in Sri Lanka. Accidental human infections caused by these vector borne zoonotic diseases generally give rise to nonspecific acute febrile illnesses which can be complicated by multi organ involvement carrying high morbidity and mortality. Nonspecific clinical features and non-availability of early diagnostic facilities are known to result in delay in the diagnosis of rickettsial infections. Therefore, awareness of their prevalence and more importantly their clinical features would be help in the early diagnosis and institution of appropriate therapy. CASE PRESENTATION: A 39-year-old otherwise healthy female presented with an acute febrile illness complicated by severe small joint and large joint arthritis, jaundice, acute kidney injury and disseminated intravascular coagulation (DIC) mimicking palindromic rheumatism or severe sepsis. She later developed a widespread fern-leaf pattern necrotic skin rash with evidence of vasculitis on the palms and soles, aiding the clinical diagnosis of SFGR. She had very high antibody titres against R. conorii antigen confirming the diagnosis and recovered completely with anti-rickettsial therapy. CONCLUSION: We feel that clinicians should be aware of the unusual clinical presentations such as purpura fulminans and 'fern-leaf' pattern necrotic skin rash of SFGR infection. Such knowledge would not only benefit those who practice in tropics with limited diagnostic facilities but also would improve the management of acute febrile illness in returning travelers who visit endemic areas.