[Neoehrlichiosis has entered the Stockholm region]. / Ovanlig fästingsjukdom har gjort sitt intåg i Stockholmsregionen.

The number of cases diagnosed with neoehrlichiosis in Stockholm has increased over the last years. PCR analysis is needed for the detection of the intracellular bacterium Neoehrlichia mikurensis. The real number of cases in the area is unknown since the specific PCR for N mikurensis is not routinely included in the workup for unknown fever in Stockholm. By describing three cases, we want to increase the awareness of neoehrlichiosis among clinicians. Symptoms of prolonged fever, myalgia and thrombosis among immunocompromised patients should raise the suspicion of neoehrlichiosis and the specific PCR analysis should be performed. The diagnosed patients were all treated with doxycycline; the fever disappeared within a few days, and clinical improvement was observed. After treatment no relapses were noticed, despite immunological deficiencies in the patients.

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.

Infection with Neoehrlichia mikurensis promotes the development of malignant B-cell lymphomas.

The tick-borne pathogen Neoehrlichia (N.) mikurensis is implicated in persistent infection of the vascular endothelium. B cells are crucial for the host defence to this infection. Chronic stimulation of B cells may result in B-cell transformation and lymphoma. Five patients with malignant B-cell lymphoma and concomitant N. mikurensis infection were investigated regarding clinical picture, lymphoma subtype, B-cell lymphoma immunophenotype and IGHV (variable region of the immunoglobulin heavy) gene repertoire. Three of the five patients improved markedly and ceased lymphoma treatment after doxycycline treatment to eliminate N. mikurensis. Sequencing the B-cell lymphoma IGHV genes revealed preferred usage of the IGHV1 (IGHV1-2, and -69) and IGHV3 (IGHV3-15, -21, -23) families. In conclusion, N. mikurensis infection may drive the development of malignant B-cell lymphomas. Eradication of the pathogen appears to induce remission with apparent curing of the lymphoma in some cases.

Case report: first symptomatic Candidatus Neoehrlichia mikurensis infection in Slovenia.

BACKGROUND: Candidatus Neoehrlichia mikurensis (CNM) is an emerging tick-born pathogen and usually causes symptomatic infection only in immunocompromised patients. Apart from one described case found in the literature where cultivation was successful, all cases so far were diagnosed by using broad-range 16S rDNA PCR. CASE PRESENTATION: Our patient presented with a prolonged febrile state of unknown origin. Clinical presentation, extensive medical workup and classic microbiologic testing were non-conclusive. Several infectious agents and other causes for the febrile state were excluded. In the end, a broad-range 16S rDNA PCR was to be performed to confirm the diagnosis of CNM infection. Treatment was successful with doxycycline. CONCLUSIONS: Due to the obscurity of the pathogen, diagnostic workup in CNM is prolonged and challenging. More awareness is need about this emerging infectious disease in countries with high prevalence of tick-borne diseases as standard microbiological methods are not successful in confirming the diagnosis.

[Fever of unknown origin in a multiple sclerosis patient on immunomodulatory therapy was due to neoehrlichiosis]. / Oklar feber hos patient med MS och rituximab­behandling var neoehrlichios - Ny fästingburen infektion som är svår att diagnostisera.

Fever of unknown origin in a multiple sclerosis patient on immunomodulatory therapy was due to neoehrlichiosis The emerging tick-borne bacterium Candidatus Neoehrlichia mikurensis is the etiologic agent of neoehrlichiosis, a febrile illness that may be accompanied by vascular complications. Severe cases of neoehrlichiosis have been described in patients with hematologic malignancies and systemic rheumatic diseases. We present the first case of neoehrlichiosis in a patient with multiple sclerosis undergoing rituximab therapy.

Anaplasmataceae-Specific PCR for Diagnosis and Therapeutic Guidance for Symptomatic Neoehrlichiosis in Immunocompetent Host.

Candidatus Neoehrlichia is increasingly being recognized worldwide as a tickborne pathogen. We report a case of symptomatic neoehrlichiosis in an immunocompetent Austria resident who had recently returned from travel in Tanzania. The use of Anaplasmataceae-specific PCR to determine the duration of antimicrobial therapy seems reasonable to avert recrudescence.

Neoehrlichiosis - a new tick-borne disease - is there a threat in Poland?

Recently in a few European countries a new pathogen transmitted by ticks Ixodes ricinus - Candidatus Neoehrlichia mikurensis was identified. It is a Gram negative intracellular bacterium belonging to the Anaplasmataceae family. Worldwide 23 cases were described, among which 16 in Europe. Infection with Candidatus Neoehrlichia mikurensis in humans runs mainly with fever, headache, nausea, arthralgia, thrombotic or haemorrhagic lesions, subcutaneous haemorrhages, haemorrhagic rash, general malaise, weight loss. The course of infection may be acute or chronic. The diagnosis is based on TaqMan real-time PCR, which allows for the detection of the gene coding for 16S rRNA and a blood smear. The drug of choice is doxycycline. Due to the fact that the Ixodes ricinus ticks are common in Poland, there is a probability of infection with Candidatus Neoehrlichia mikurensis among patients bitten by ticks. The possibility of non-symptomatic human infection Candidatus Neoehrlichia mikurensis in north-eastern Poland was shown, confirming the necessity to conduct research on a larger scale. Moreover, awareness of physicians about the possibility of infection in patients with non-specific symptoms after tick bite should be increased.

Infections with the tick-borne bacterium "Candidatus Neoehrlichia mikurensis" mimic noninfectious conditions in patients with B cell malignancies or autoimmune diseases.

BACKGROUND: Candidatus Neoehrlichia mikurensis is a newly discovered noncultivatable bacterium spread among ticks and rodents in Europe and Asia that can infect humans, particularly immunocompromised patients. METHODS: We compiled clinical and laboratory data from 11 patients with hematological malignances or autoimmune diseases who were diagnosed with Candidatus N. mikurensis infection in Europe 2010-2013. Both published (6) and unpublished cases (5) were included. RESULTS: The patients had a median age of 67, were mostly male (8/11), and resided in Sweden, Switzerland, Germany, and the Czech Republic. All but one had ongoing or recent immune suppressive treatment and a majority were splenectomized (8/11). Less than half of them recalled tick exposure. The most frequent symptoms were fever (11/11), localized pain afflicting muscles and/or joints (8/11), vascular and thromboembolic events (6/11), that is, deep vein thrombosis (4), transitory ischemic attacks (2), pulmonary embolism (1), and arterial aneurysm (1). Typical laboratory findings were elevated C-reactive protein, leukocytosis with neutrophilia, and anemia. Median time from onset of symptoms to correct diagnosis was 2 months. In at least 4 cases, the condition was interpreted to be due to the underlying disease, and immunosuppressive therapy was scheduled. All patients recovered completely when doxycycline was administered. CONCLUSIONS: Candidatus N. mikurensis is an emerging tick-borne pathogen that may give rise to a systemic inflammatory syndrome in persons with hematologic or autoimmune diseases that could be mistaken for recurrence of the underlying disease and/or unrelated arteriosclerotic vascular events. Awareness of this new pathogen is warranted among rheumatologists, hematologists, oncologists, and infectious disease specialists.

Diagnosis of rickettsial diseases in dogs and cats.

Rickettsial agents, including those in the genera Anaplasma, Ehrlichia, Neorickettsia, and Rickettsia, are important and common vector-borne pathogens of dogs and cats. Disease induced by these organisms ranges from clinically inapparent to severe and potentially fatal. However, laboratory confirmation of a rickettsial etiology can be complicated by a number of factors, including the wide spectrum of disease induced by these organisms, an often low and widely fluctuating level of organism present in infected animals, cross-reactions on serologic and molecular assays, and the presence of co-infections. Correct diagnosis is most likely to be reached when multiple diagnostic strategies, including careful microscopic examination of stained blood films or tissues, both specific and broad serologic tests, and a suite of molecular detection assays, are used in concert. Accurate interpretation of diagnostic tests requires awareness of the likelihood for multiple agents, including novel organisms, to be responsible for the results seen in a given patient. This review provides an overview of current strategies used to diagnose rickettsial infections in dogs and cats.

Detection of "Candidatus Neoehrlichia mikurensis" in two patients with severe febrile illnesses: evidence for a European sequence variant.

Recently, a new genus of Anaplasmataceae termed "Candidatus Neoehrlichia" was discovered in ticks and rodents. Here, we report on two patients who suffered from febrile bacteremia due to "Candidatus Neoehrlichia mikurensis" associated with thrombotic or hemorrhagic events. 16S rRNA and groEL gene sequencing provided evidence of three groups of sequence variants.

Sennetsu neorickettsiosis: a probable fish-borne cause of fever rediscovered in Laos.

Neorickettsia sennetsu has been described from Japan and Malaysia, causing a largely forgotten infectious mononucleosis-like disease. Because it is believed to be contracted from eating raw fish, frequently consumed in the Lao PDR, we looked for evidence of N. sennetsu among Lao patients and fish. A buffy coat from 1 of 91 patients with undifferentiated fever was positive by 16S rRNA amplification and sequencing and real-time polymerase chain reactions (PCR) targeting two N. sennetsu genes. Lao blood donors and patients with fever, hepatitis, or jaundice (N = 1,132) had a high prevalence (17%) of immunofluorescence assay IgG anti-N. sennetsu antibodies compared with 4% and 0% from febrile patients (N = 848) in Thailand and Malaysia, respectively. We found N. sennetsu DNA by PCR, for the first time, in a fish (Anabas testudineus). These data suggest that sennetsu may be an under-recognized cause of fever and are consistent with the hypothesis that it may be contracted from eating raw fish.

Lymph node aspirate from a California wine-country dog.

A 4-year-old, male Golden Retriever was presented to the Veterinary Medical Teaching Hospital at the University of California-Davis with a history of lethargy, inappetance, and vomiting. The patient had generalized lymphadenomegaly, marked thrombocytopenia, mild anemia, and moderate hypoalbuminemia. Moderate to marked histiocytic inflammation and lymphocytic-plasmacytic reactivity of the mesenteric, left popliteal, and right mandibular lymph nodes were diagnosed cytologically. Many macrophages contained granular to amorphous material of a uniform blue color, occasionally in morula formation, suggestive of rickettsial organisms. Exposure to raw trout was subsequently documented, leading to a presumptive diagnosis of salmon poisoning disease (SPD). The patient responded quickly to doxycycline therapy for the causative agent of SPD (Neorickettsia helminthoeca). SPD should be considered as a differential diagnosis for a canine patient with clinical signs of vomiting, diarrhea, lethargy, and lymphadenomegaly; laboratory findings of thrombocytopenia and hypoalbuminemia; and potential exposure to raw fish from an endemic area. The cytologic finding of rickettsial inclusions within lymph node macrophages is reportedly seen within a majority of SPD cases and can be valuable in supporting a clinical suspicion of SPD, as it was in this case.

Use of enrofloxacin for treatment of large-form Haemobartonella felis in experimentally infected cats.

OBJECTIVE: To compare treatment with enrofloxacin and doxycycline with no treatment in cats experimentally infected with Haemobartonella felis. DESIGN: Prospective case-control study. ANIMALS: 16 cats. PROCEDURE: Cats were inoculated with large-form H. felis from a chronically infected donor. Cats were assigned to 1 of 4 treatment groups: doxycycline (5 mg/kg [2.3 mg/lb], p.o., q 12 h), low-dose enrofloxacin (5 mg/kg, p.o., q 24 h), high-dose enrofloxacin (10 mg/kg [4.5 mg/lb], p.o., q 24 h), and an untreated control group. Clinical signs, Hct, blood smears, and a polymerase chain reaction (PCR) assay were used to monitor progression of the infection. RESULTS: All cats were confirmed to be infected with H. felis via blood smear evaluations and PCR assay results. Treatment had no effect on Hct during the intratreatment period, but Hct values were significantly greater in the low-dose enrofloxacin group, compared with the control group, during the posttreatment period. During the intratreatment period, H. felis organism counts per 1,000 RBC in the doxycycline treatment and the high-dose enrofloxacin treatment groups decreased at a significantly faster rate than those in the control group. In the posttreatment period, organism counts in the doxycycline treatment group and the low- and high-dose enrofloxacin groups decreased at significantly faster rates than counts in the control group. There was no significant effect of treatment on the number of positive PCR assay results. Two cats treated with enrofloxacin and 1 cat treated with doxycycline completely cleared the H. fe is organism despite presumed immunosuppression caused by glucocorticoids. CONCLUSIONS AND CLINICAL RELEVANCE: Results support the hypothesis that enrofloxacin has anti-H. felis effects.

Oesophageal stricture in a cat due to oral administration of tetracyclines.

A three-year-old, male neutered domestic shorthair cat was presented with dysphagia and regurgitation following treatment with oral doxycycline and oxytetracycline for Haemobartonella felis infection. Fluoroscopy confirmed the presence of multiple strictures along the entire length of the oesophagus. Balloon dilatation was performed successfully on two occasions and the symptoms resolved. To the authors' knowledge, this is the first report of oesophageal strictures associated with oral administration of tetracyclines in a cat in the UK.

Effects of imidocarb dipropionate in cats with chronic haemobartonellosis.

The objective of this study was to evaluate the safety and efficacy of imidocarb dipropionate administered to cats for clearing chronic Haemobartonella felis infections. Imidocarb dipropionate was administered twice at 5.0 mg/kg by intramuscular injection 14 days apart to eight cats with chronic, subclinical haemobartonellosis. Clinical signs and laboratory parameters were monitored throughout the study. Polymerase chain reaction (PCR) for the detection of Mycoplasma haemofelis (large form of H. felis) and Mycoplasma haemominutum (small form of H. felis) was performed to assess for parasitologic cure. Four of the eight cats treated with imidocarb dipropionate became transiently PCR-negative after treatment; untreated control cats (n = 2) were persistently PCR-positive. Two persistently PCR-negative cats were given one dose of methylprednisolone acetate; one was PCR-positive 10 days later. There was no evidence of significant toxicity associated with this imidocarb treatment protocol.

Use of a polymerase chain reaction assay for detection of Haemobartonella canis in a dog.

A polymerase chain reaction (PCR) originally developed for detection of Haemobartonella felis in cats was successfully used for detection of H canis in an 8-year-old spayed Great Dane. The dog had been splenectomized and was undergoing immunosuppressive chemotherapy at the time of diagnosis. Sequence analysis of the 16S ribosomal RNA gene revealed that the Haemobartonella spp infecting this dog was 97% homologous to the sequence previously reported for the Ohio strain of H felis. Clinical and hematologic abnormalities as well as identification of the organisms by use of light and electron microscopy supported the diagnosis of H canis. The PCR assay used for detection of H felis may be useful for the detection of H canis in dogs prior to blood donation, splenectomy, or treatment with immunosuppressive drugs.

Inoculation of two genotypes of Hemobartonella felis (California and Ohio variants) to induce infection in cats and the response to treatment with azithromycin.

OBJECTIVES: To describe clinical and laboratory findings associated with cats experimentally infected by inoculation with the 2 recognized genotypes of Hemobartonella felis (small variant, Hfsm; large variant, Hflg) and to determine the response of cats to treatment with azithromycin. ANIMALS: 18 young adult domestic shorthair cats of both sexes. PROCEDURES: Cats were inoculated with H felis and monitored weekly, using CBC counts and a polymerase chain reaction (PCR) designed to detect both genetic variants of H felis. Beginning 26 days after inoculation, 11 cats were administered azithromycin (15 mg/kg of body weight, PO, q 12 h, for 7 days). RESULTS: Inoculation resulted in coinfection with Hflg and Hfsm, and both variants were detected by PCR. Clinical abnormalities and anemia were most severe in Hflg- and dual-infected cats. Results of PCR and CBC were positive for H felis in 112/112 (100%) and 42/112 (37.5%), respectively, samples collected after inoculation. Administration of azithromycin had little effect on clinical variables, including anemia. All cats, regardless of treatment with azithromycin, had positive results for the PCR at the end of the study period. CONCLUSIONS AND CLINICAL RELEVANCE: In these cats, Hflg was more pathogenic than Hfsm, and coinfection with both variants was detected. Results of the PCR were superior to results of CBC for detecting infection with H felis. Azithromycin administered at the dose and duration reported here was not efficacious for the treatment of cats with hemobartonellosis.

Chemotherapy of haemobartonellosis in squirrel monkeys (Saimiri sciureus).

Splenectomised Saimiri sciureus squirrel monkeys are being used increasingly as an experimental host for human malarial studies, notably for the assessment of candidate vaccines against Plasmodium falciparum blood-stage infection. Recently, we have reported that colony-reared S. sciureus monkeys are asymptomatic carriers of Haemobartonella sp. and that patent Haemobartonella infection, activated following splenectomy, may interfere with the course of P. falciparum parasitaemia in these animals. For several years, splenectomised S. sciureus monkeys were routinely submitted to oxytetracycline therapy before their use in malarial studies in order to prevent a possible spontaneous Heamobartonella infection. However, we report here that such antibiotic therapy is often ineffective and that neoarsphenamine chemotherapy may be considered as an alternative to cure both latent and patent haemobartonellosis in S. sciureus monkeys.

Detection of Haemobartonella felis in cats with experimentally induced acute and chronic infections, using a polymerase chain reaction assay.

OBJECTIVE: To develop a test for detection of Haemobartonella felis, using a polymerase chain reaction (PCR) assay. ANIMALS: 4 adult cats seronegative for FeLV and feline immunodeficiency virus. PROCEDURE: Cats were infected with H felis by i.v. administration of 1 ml of blood obtained from an infected cat. Rectal temperature, PCV, and microscopic examination of blood smears for organisms were monitored daily. At peak of infection, doxycycline treatment was initiated for 21 days. Blood samples were collected at weekly intervals. Six months after treatment, 2 cats were given methylprednisolone (14 mg/kg of body weight, i.m.). Daily blood samples were collected for CBC, detection of organisms, and PCR evaluation. On the basis of the 16S rRNA gene sequence of H felis, specific PCR primers were created for a 393-basepair internal fragment. RESULTS: The 393-basepair product was consistently amplified from blood samples obtained during peak parasitemia but not during the last week of or immediately after completion of doxycycline treatment. After treatment, PCV returned to the reference range, and organisms were not observed in blood samples; however, the PCR product could be consistently amplified. After administration of methylprednisolone, organisms were only rarely observed in blood smears but were consistently detected by PCR analysis. CLINICAL RELEVANCE: Using PCR analysis, it was possible to detect H felis in blood samples obtained from cats during peak parasitemia, during most of the carrier phase, and after challenge with immunosuppressive drugs. During and immediately after antibiotic treatment, this test may fail to detect the organisms.