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.

Isolation of Rickettsia parkeri and identification of a novel spotted fever group Rickettsia sp. from Gulf Coast ticks (Amblyomma maculatum) in the United States.

Until recently, Amblyomma maculatum (the Gulf Coast tick) had garnered little attention compared to other species of human-biting ticks in the United States. A. maculatum is now recognized as the principal vector of Rickettsia parkeri, a pathogenic spotted fever group rickettsia (SFGR) that causes an eschar-associated illness in humans that resembles Rocky Mountain spotted fever. A novel SFGR, distinct from other recognized Rickettsia spp., has also been detected recently in A. maculatum specimens collected in several regions of the southeastern United States. In this study, 198 questing adult Gulf Coast ticks were collected at 4 locations in Florida and Mississippi; 28% of these ticks were infected with R. parkeri, and 2% of these were infected with a novel SFGR. Seventeen isolates of R. parkeri from individual specimens of A. maculatum were cultivated in Vero E6 cells; however, all attempts to isolate the novel SFGR were unsuccessful. Partial genetic characterization of the novel SFGR revealed identity with several recently described, incompletely characterized, and noncultivated SFGR, including "Candidatus Rickettsia andeanae" and Rickettsia sp. Argentina detected in several species of Neotropical ticks from Argentina and Peru. These findings suggest that each of these "novel" rickettsiae represent the same species. This study considerably expanded the number of low-passage, A. maculatum-derived isolates of R. parkeri and characterized a second, sympatric Rickettsia sp. found in Gulf Coast ticks.

New approaches to detection and identification of Rickettsia africae and Ehrlichia ruminantium in Amblyomma variegatum (Acari: Ixodidae) ticks from the Caribbean.

Imported from Africa in the 1700s and despite frequent modern eradication efforts, Amblyomma variegatum (F.) spread through the Caribbean by cattle transport, small ruminants, and migrating birds. A. variegatum is a vector for Rickettsia africae, the causative agent of African tick bite fever, and Ehrlichia ruminantium, the causative agent of heartwater. We examined 95 A. variegatum and six Rhipicephalus (Boophilus) microplus (Canestrini) collected from cattle at an abattoir in Antigua. Engorged tick extracts adsorbed on Nobotu filter paper strips and new nested polymerase chain reaction (PCR) assays for E. ruminantium and Dermatophilus congolensis were used to evaluate these ticks for the presence of these pathogenic bacteria. Amblyomma ticks (62.4%) contained R. africae DNA by PCR/restriction fragment length polymorphism analysis and DNA sequencing of the OmpA and 17-kDa antigen genes. Twenty Amblyomma and two Rh. microplus contained E. ruminantium DNA. No E. chaffeensis, Anaplasma phagocytophilum, Coxiella burnetii, or D. congolensis DNA was detected in these ticks. The continued presence of Am. variegatum in the Caribbean poses a significant risk of infection in cattle with E. ruminantium and in humans by R. africae. Eradication efforts are essential to prevent the further spread of Am. variegatum.

Ehrlichia ewingii in an immunocompetent adult.

The third Ehrlichia infection described in humans in the United States is reviewed. This rare zoonosis was first published in 1999. This case report that expands the clinical paradigm is described. A 57-year-old immunocompetent adult, unlike previously published reports, did not cross react with Ehrlichia chaffeensis.

Rickettsia parkeri rickettsiosis and its clinical distinction from Rocky Mountain spotted fever.

BACKGROUND: Rickettsia parkeri rickettsiosis, a recently identified spotted fever transmitted by the Gulf Coast tick (Amblyomma maculatum), was first described in 2004. We summarize the clinical and epidemiological features of 12 patients in the United States with confirmed or probable disease attributable to R. parkeri and comment on distinctions between R. parkeri rickettsiosis and other United States rickettsioses. METHODS: Clinical specimens from patients in the United States who reside within the range of A. maculatum for whom an eschar or vesicular rash was described were evaluated by > or =1 laboratory assays at the Centers for Disease Control and Prevention (Atlanta, GA) to identify probable or confirmed infection with R. parkeri. RESULTS: During 1998-2007, clinical samples from 12 patients with illnesses epidemiologically and clinically compatible with R. parkeri rickettsiosis were submitted for diagnostic evaluation. Using indirect immunofluorescence antibody assays, immunohistochemistry, polymerase chain reaction assays, and cell culture isolation, we identified 6 confirmed and 6 probable cases of infection with R. parkeri. The aggregate clinical characteristics of these patients revealed a disease similar to but less severe than classically described Rocky Mountain spotted fever. CONCLUSIONS: Closer attention to the distinct clinical features of the various spotted fever syndromes that exist in the United States and other countries of the Western hemisphere, coupled with more frequent use of specific confirmatory assays, may unveil several unique diseases that have been identified collectively as Rocky Mountain spotted fever during the past century. Accurate assessments of these distinct infections will ultimately provide a more valid description of the currently recognized distribution, incidence, and case-fatality rate of Rocky Mountain spotted fever.

Rickettsia parkeri in Argentina.

Clinical reports of an eschar-associated rickettsiosis in the Paraná River Delta of Argentina prompted an evaluation of Amblyomma triste ticks in this region. When evaluated by PCR, 17 (7.6%) of 223 questing adult A. triste ticks, collected from 2 sites in the lower Paraná River Delta, contained DNA of Rickettsia parkeri.

Isolation of Rickettsia akari from eschars of patients with rickettsialpox.

Rickettsialpox is a cosmopolitan, mite-borne, spotted fever rickettsiosis caused by Rickettsia akari. The disease is characterized by a primary eschar, fever, and a papulovesicular rash. Rickettsialpox was first identified in New York City in 1946 and the preponderance of recognized cases in the United States continues to originate from this large metropolitan center. The most recently isolated U.S. strain of R. akari was obtained more than a half century ago. We describe the culture and initial characterization of five contemporaneous isolates of R. akari obtained from eschar biopsy specimens from New York City patients with rickettsialpox. This work emphasizes the importance and utility of culture-and molecular-based methods for the diagnosis of rickettsialpox and other eschar-associated illnesses.

Phylogenetic analysis of a novel molecular isolate of spotted fever group Rickettsiae from northern Peru: Candidatus Rickettsia andeanae.

Phylogenetic analysis of five rickettsial genes (17-kDa gene, gltA, ompB, ompA, and sca4) from two molecular isolates of Candidatus Rickettsia andeanae from two ticks (Amblyomma maculatum and Ixodes boliviensis) collected from two domestic horses living in two separate locations in northern Peru (Coletas and Naranjo) was conducted to more clearly characterize this recently reported novel spotted fever group (SFG) rickettsia. Following nested polymerase chain reaction (PCR) amplification of the 17-kDa gene, gltA, ompB, ompA, and sca4, amplicons were purified, sequenced, and compared to those downloaded from GenBank. Phylogenetic analyses of the Candidatus Rickettsia andeanae sequences generated from 17-kDa gene (483 bp), gltA (1185 bp), ompA (1598 bp), ompB (4839 bp), and sca4 (2634 bp) demonstrated that they aligned strongly with those of SFG rickettsiae. Moreover, the sequences of these five genes most closely aligned with the following rickettsiae: ompA: Rickettsia sp RpA4 (98.03%), R. sp DnS28 (97.90%), and R. rhipicephali and R. massiliae (97.11%); ompB: R. aeschlimannii (97.22%), R. rhipicephali (97.20%), and R. sp Bar 29 (97.10%); and sca4: R. massiliae (97.8%), R. rhipicephali, and R. slovaca (97.7%). These results from the additional phylogenetic analyses of Candidatus Rickettsia andeanae confirm its inclusion within, and distance and uniqueness from, other known SFG rickettsiae.

Reinfection with Ehrlichia chaffeensis in a liver transplant recipient.

Human monocytic ehrlichiosis is an emerging infection caused by Ehrlichia chaffeensis, but reinfection with this agent has not been described. We report a case of reinfection with E. chaffeensis after a 2-year interval in a 56-year-old liver transplant recipient with frequent tick attachments.

Rickettsia parkeri: a newly recognized cause of spotted fever rickettsiosis in the United States.

Ticks, including many that bite humans, are hosts to several obligate intracellular bacteria in the spotted fever group (SFG) of the genus Rickettsia. Only Rickettsia rickettsii, the agent of Rocky Mountain spotted fever, has been definitively associated with disease in humans in the United States. Herein we describe disease in a human caused by Rickettsia parkeri, an SFG rickettsia first identified >60 years ago in Gulf Coast ticks (Amblyomma maculatum) collected from the southern United States. Confirmation of the infection was accomplished using serological testing, immunohistochemical staining, cell culture isolation, and molecular methods. Application of specific laboratory assays to clinical specimens obtained from patients with febrile, eschar-associated illnesses following a tick bite may identify additional cases of R. parkeri rickettsiosis and possibly other novel SFG rickettsioses in the United States.

Rickettsialpox in New York City: a persistent urban zoonosis.

Rickettsialpox, a spotted fever rickettsiosis, was first identified in New York City (NYC) in 1946. During the next five years, approximately 540 additional cases were identified in NYC. However, during the subsequent five decades, rickettsialpox received relatively little attention from clinicians and public health professionals, and reporting of the disease diminished markedly. During February 2001 through August 2002, 34 cases of rickettsialpox in NYC were confirmed at CDC from cutaneous biopsy specimens tested by using immunohistochemical (IHC) staining, PCR analysis, and isolation of Rickettsia akari in cell culture, as well as an indirect immunofluorescence assay of serum specimens. Samples were collected from patients with febrile illnesses accompanied by an eschar, a papulovesicular rash, or both. Patients originated predominantly from two boroughs (Manhattan and the Bronx). Only 8 (24%) of the cases were identified prior to the reports of bioterrorism-associated anthrax in the United States during October 2001, and lesions of several patients evaluated during and subsequent to this episode were suspected initially to be cutaneous anthrax. IHC staining of biopsy specimens of eschars and papular lesions were positive for spotted fever group rickettsiae for 32 patients. Of the eleven patients for whom paired serum samples were obtained, all demonstrated fourfold or greater increases in antibody titers reactive with R. akari. The 17-kDa protein gene sequence of R. akari was amplified from eschars of five patients. Four isolates of R. akari were obtained from cutaneous lesions. Possible factors responsible for the increase in clinical samples evaluated for rickettsialpox during this interval include renewed clinical interest in the disease, improved diagnostic methods, epizootiological influences, and factors associated with the recent specter of bioterrorism.

Evidence of rickettsial and leptospira infections in Andean northern Peru.

Between May and October 2002, a cluster of acute febrile illnesses occurred in the subtropical Andean foothills of Peru. Serologic evidence in villages where disease had been documented showed that the prevalence of IgM antibody to Leptospira ranged from 6% to 52%, that of IgM antibody to spotted fever group (SFG) rickettsia ranged from 10% to 19%, and that of IgM antibody to Coxiella burnetii from 1% to 15%. Measurement of IgG antibodies for SFG rickettsiae suggested that this disease was endemic. In contrast, IgG antibodies against C. burnetii were largely absent. In humans, microagglutination tests identified pathogenic variants of Leptospira. The presence of an SFG rickettsial infection was confirmed in four febrile patients following polymerase chain reaction and sequencing of the conserved 17-kD common antigen gene (htrA). Collectively, these analyses indicated that Rickettsia sp., C. burnetii, and Leptospira sp. were circulating in the region during the time of disease outbreak and implicate the involvement of an as yet undetermined SFG rickettsia in northwestern Peru.

Comparison of the reservoir competence of medium-sized mammals and Peromyscus leucopus for Anaplasma phagocytophilum in Connecticut.

In the northeastern United States, Anaplasma phagocytophilum, the agent of human granulocytic ehrlichiosis (HGE), is transmitted by the tick vector Ixodes scapularis. The white-footed mouse Peromyscus leucopus is a competent reservoir for this agent, but the reservoir competence of non-Peromyscus hosts of I. scapularis has not been studied. Here, we report data confirming reservoir competence of medium-sized mammals for A. phagocytophilum. Raccoons, Virginia opossums, gray squirrels, and striped skunks were live-trapped in June-August of 1998-1999 at two locations in Connecticut. Captured animals were kept for several days at the laboratory in wire-mesh cages over water to allow naturally attached ticks to drop off. Samples of blood and serum were taken from each animal prior to its release at the site of capture. Engorged ticks collected from each animal were allowed to molt. Resulting I. scapularis nymphs and adults were tested for the presence of A. phagocytophilum DNA by polymerase chain reaction, as were the blood samples from the animals. A. phagocytophilum DNA was detected in the blood of >10% of the raccoons tested. Raccoons, opossums, squirrels, and skunks produced adult I. scapularis infected with the agent of HGE. Prevalence of infection was the highest in adult ticks fed as nymphs upon raccoons (23%) and the lowest in those fed upon skunks and opossums (5-7%). The agent was present in nymphal I. scapularis fed as larvae upon raccoons and squirrels, but not in ticks fed upon skunks or opossums. We also tested the ability of I. scapularis to transmit A. phagocytophilum to laboratory-reared white-footed mice after acquiring it from medium-sized mammals. Ticks that acquired the agent from raccoons and squirrels successfully transmitted it to mice. Thus, raccoons and gray squirrels are reservoir-competent for the agent of HGE-they become naturally infected, and are capable of transmitting the infection to feeding ticks.

Detection of Ehrlichia chaffeensis in adult and nymphal Amblyomma americanum (Acari: Ixodidae) ticks from Long Island, New York.

The lone star tick, Amblyomma americanum (L.), has increased in abundance in several regions of the northeastern United States, including areas of Long Island, NY. Adult and nymphal stage A. americanum collected from several sites on Long Island were evaluated for infection with Ehrlichia chaffeensis, the causative agent of human monocytic ehrlichiosis (HME), by using a nested polymerase chain reaction assay. Fifty-nine (12.5%) of 473 adults and eight of 113 pools of five nymphs each (estimated minimum prevalence of infection 1.4%) contained DNA of E. chaffeensis. These data, coupled with the documented expansion of lone star tick populations in the northeastern United States, confirm that E. chaffeensis is endemic to many areas of Long Island and that HME should be considered among the differential diagnoses of the many distinct tick-borne diseases that occur in this region.

Infection with Anaplasma phagocytophila in cervids from Slovenia: evidence of two genotypic lineages.

OBJECTIVE: Human granulocytic ehrlichiosis (HGE) was recently recognized as an emerging tick-borne infection in Europe. The disease is caused by Anaplasma (previously Ehrlichia) phagocytophila. The first confirmed acute human disease caused by A. phagocytophila was reported from Slovenia in 1998. The tick Ixodes ricinus was identified as the likely vector for this pathogen of humans and animals in Europe. In order to assess the possibility that roe and red deer in Slovenia serve as potential reservoir hosts for A. phagocytophila, materials from both species were examined. METHODS: Samples were obtained from 32 red deer (Cervus elaphus) and 56 roe deer (Capreolus capreolus). Polyvalent antibodies to the USG3 isolate of Anaplasma phagocytophila were detected by indirect immunofluorescence assay (IFA). DNA was extracted from spleen tissue. The 16S rRNA gene and a portion of the groESL heat shock operon were used for PCR detection and subsequent direct sequencing of amplified products. RESULTS: Serological and PCR results indicated that high proportions of roe and red deer were infected with A. phagocytophila. Infection was confirmed in 74% of the animals by IFA and in 86% of animals by PCR. While similar prevalences by PCR were seen in the two species (approximately 86%), the prevalence of antibodies was much higher in roe deer (94% vs. 35% in red deer). Sequence analysis of a 1256-bp fragment of the groESL operon revealed genetic diversity among collected samples. Identity of sequences ranging from 98% to 100%. None of the A. phagocytophila groESL and 16S rRNA gene sequences from red or roe deer were identical to the sequences previously obtained from human patients with ehrlichiosis from Slovenia or elsewhere in the world. All red deer sequences clustered with those obtained from humans, whereas all but two sequences from roe deer clustered separately. CONCLUSIONS: The results of our study indicate that a high percentage of red deer and roe deer in Slovenia are infected with A. phagocytophila. Analysis of groESL and 16S rRNA gene sequences revealed two distinct genetic lineages. Among deer, one variant was primarily associated with roe deer. Although none of the sequences from red deer was identical to those found in humans, they were more closely related.

Survey of ticks collected in Mississippi for Rickettsia, Ehrlichia, and Borrelia species.

From November 1999 through October 2000, we tested ticks collected from vegetation as well as from deer, dogs, and humans for spotted fever group (SFG) rickettsiae, Ehrlichia chaffeensis, and Borrelia spp. spirochetes. A total of 149 adult ticks representing four species was collected from 11 collection sites from southwestern to northern Mississippi. Amblyomma americanum was most commonly collected (n=68), followed by Ixodes scapularis (n=53). The bird tick, Ixodes brunneus (usually rare), was the third most commonly collected tick (n=17). Eleven Dermacentor variabilis were also collected. Ticks were cut longitudinally to make smears on three microscope slides. The remaining body parts were frozen at -65 degrees C for additional testing. Tick smears were stained by direct immunofluorescence assays (DFA) for Rickettsia spp. and Borrelia spp., while indirect immunofluorescence assays (IFA) were used for Ehrlichia spp. The corresponding tick for each positive smear was evaluated using PCR analysis. None of the 149 ticks tested was DFA positive for Borrelia spp. However, smears of 30 (20%) and 32 (22%) ticks reacted with anti-E. chaffeensis sera and anti-R. rickettsii conjugate (known to react with several members of the spotted fever group), respectively. None of the ticks staining with the IFA for Ehrlichia was positive for E. chaffeensis using PCR. However, 23 (72%) of 32 FA-positive ticks for SFG rickettsiae yielded amplicons of the appropriate size when tested using a PCR assay for SFG rickettsiae, corresponding to an overall infection rate with SFG rickettsiae among the collected ticks of 15%. Smears of 12 (71%) of 17 I. brunneus revealed abundant bacilliform bacteria. PCR amplification of DNA from a single I. brunneus containing these bacteria was performed using universal primers for the 16S rRNA gene as well as Borrelia-specific primers. The predominant sequence obtained using the universal primers did not match any sequence in GenBank, but it showed 91% identity with an endosymbiont of Acanthoamoeba. Other sequences represented in the top 50 Basic Local Alignment Search (BLAST) scores were primarily from soil bacteria, although some similarity to several Anaplasma species and Ehrlichia risticii was indicated. The significance of this finding remains undetermined.

Rocky Mountain spotted fever in Argentina.

We describe the first molecular confirmation of Rickettsia rickettsii, the cause of Rocky Mountain spotted fever (RMSF), from a tick vector, Amblyomma cajennense, and from a cluster of fatal spotted fever cases in Argentina. Questing A. cajennense ticks were collected at or near sites of presumed or confirmed cases of spotted fever rickettsiosis in Jujuy Province and evaluated by polymerase chain reaction assays for spotted fever group rickettsiae. DNA of R. rickettsii was amplified from a pool of A. cajennense ticks and from tissues of one of four patients who died during 2003-2004 after illnesses characterized by high fever, severe headache, myalgias, and petechial rash. The diagnosis of spotted fever rickettsiosis was confirmed in the other patients by indirect immunofluorescence antibody and immunohistochemical staining techniques. These findings show the existence of RMSF in Argentina and emphasize the need for clinicians throughout the Americas to consider RMSF in patients with febrile rash illnesses.

Gulf Coast ticks (Amblyomma maculatum) and Rickettsia parkeri, United States.

Geographic distribution of Rickettsia parkeri in its US tick vector, Amblyomma maculatum, was evaluated by PCR. R. parkeri was detected in ticks from Florida, Georgia, Kentucky, Mississippi, Oklahoma, and South Carolina, which suggests that A. maculatum may be responsible for additional cases of R. parkeri rickettsiosis throughout much of its US range.

PCR detection and serological evidence of granulocytic ehrlichial infection in roe deer (Capreolus capreolus) and chamois (Rupicapra rupicapra).

The role of wild mammals, such as roe deer (Capreolus capreolus) and chamois (Rupicapra rupicapra), in the epidemiology of granulocytic ehrlichiae in Switzerland was investigated. We tested blood samples for Ehrlichia phagocytophila genogroup 16S rRNA gene sequences by PCR and for immunoglobulin G antibodies against granulocytic ehrlichiae by indirect fluorescent-antibody assay (IFA). Overall means of 60.9% of 133 roe deer serum samples and 28.2% of 39 chamois serum samples were seroreactive by IFA. PCR results were positive for 18.4% of 103 roe deer serum samples as well. None of the 24 chamois blood samples tested were positive by PCR. Partial 16S rRNA gene and groESL heat shock operon sequences of three roe deer samples tested showed strong degrees of homology (> or =99.7 and > or =98.6%, respectively) with the sequences of granulocytic ehrlichiae isolated from humans. These results confirm that chamois, and particularly roe deer, are commonly infected with granulocytic ehrlichiae and provide evidence that these wild mammals are potential reservoirs for granulocytic ehrlichiae in Switzerland.