Orientia tsutsugamushi in human scrub typhus eschars shows tropism for dendritic cells and monocytes rather than endothelium

Scrub typhus is a common and underdiagnosed cause of febrile illness in Southeast Asia, caused by infection with Orientia tsutsugamushi. Inoculation of the organism at a cutaneous mite bite site commonly results in formation of a localized pathological skin reaction termed an eschar. The site of development of the obligate intracellular bacteria within the eschar and the mechanisms of dissemination to cause systemic infection are unclear. Previous postmortem and in vitro reports demonstrated infection of endothelial cells, but recent pathophysiological investigations of typhus patients using surrogate markers of endothelial cell and leucocyte activation indicated a more prevalent host leucocyte than endothelial cell response in vivo. We therefore examined eschar skin biopsies from patients with scrub typhus to determine and characterize the phenotypes of host cells in vivo with intracellular infection by O. tsutsugamushi, using histology, immunohistochemistry, double immunofluorescence confocal laser scanning microscopy and electron microscopy. Immunophenotyping of host leucocytes infected with O. tsutsugamushi showed a tropism for host monocytes and dendritic cells, which were spatially related to different histological zones of the eschar. Infected leucocyte subsets were characterized by expression of HLADR+, with an "inflammatory" monocyte phenotype of CD14/LSP-1/CD68 positive or dendritic cell phenotype of CD1a/DCSIGN/S100/FXIIIa and CD163 positive staining, or occasional CD3 positive T-cells. Endothelial cell infection was rare, and histology did not indicate a widespread inflammatory vasculitis as the cause of the eschar. Infection of dendritic cells and activated inflammatory monocytes offers a potential route for dissemination of O. tsutsugamushi from the initial eschar site. This newly described cellular tropism for O. tsutsugamushi may influence its interaction with local host immune responses.

[Sequence analysis subtyping of the 56-kDa protein-encoding gene of Karp-type Orientia tsutsugamushi isolated in scrub typhus cases]

To determine the Karp-type Orientia tsutsugamushi subtype in northern Japan, i.e., Yamagata, Niigata, and Akita Prefectures, we analyzed the partial nucleotide sequence of the 56-kDa protein-encoding gene of 30 isolates from scrub typhus cases. Based on sequencing results, we classified isolates into two groups of 27 and 3 isolates. Nucleotide sequences of 27 isolates were homologous to the yeo-joo strain, classified as a JP-1 subtype. The three isolates were each homologous to a stain of CMM1, KNP1, or KNP2, classified as JP-2 subtypes. Phylogenetic tree analysis showed the 27 isolates forming a cluster with the yeo-joo strain and the three isolates with the CMM, KNP1, and KNP2 strains and therefore belonging to these subtypes. The Karp-type O. tsutsugamushi JP-2 subtype predominates in Japan, the JP-1 subtype probably the predominates in the area investigated. O. tsutsugamushi JP-1 subtype strains must therefore be isolated from subjects in this area and comprehensively studied.

Chest radiographic presentation in patients with scrub typhus

We conducted a retrospective study of the adult patients (age ≥18 years) with serologically confirmed scrub typhus admitted between January 1998 and December 2009 at Kaohsiung Chang Gung Memorial Hospital. There were 63 adult scrub typhus patients with chest radiographic examinations. A total of 147 chest radiographs were obtained and reviewed. The most frequent abnormal findings in this study were parenchymal infiltration with bilateral and lower lung predilection. The distribution of abnormal chest radiographs was observed more than 50% during the first week. Furthermore, the progressive change was frequently observed during the first week. There is a significant correlation among laboratory findings, clinical course, and outcome. Chest radiography may be a complementary tool to evaluate the clinical course of scrub typhus and chest radiographic examinations should be taken during the first week after the onset of illness.

Diagnostic accuracy of a loop-mediated isothermal PCR assay for detection of Orientia tsutsugamushi during acute Scrub Typhus infection

Background

There is an urgent need to develop rapid and accurate point-of-care (POC) technologies for acute scrub typhus diagnosis in low-resource, primary health care settings to guide clinical therapy.

Methodology/Principal Findings

In this study we present the clinical evaluation of loop-mediated isothermal PCR assay (LAMP) in the context of a prospective fever study, including 161 patients from scrub typhus-endemic Chiang Rai, northern Thailand.

A robust reference comparator set comprising following ‘scrub typhus infection criteria’ (STIC) was used: a) positive cell culture isolate and/or b) an admission IgM titer ≥1∶12,800 using the ‘gold standard’ indirect immunofluorescence assay (IFA) and/or c) a 4-fold rising IFA IgM titer and/or d) a positive result in at least two out of three PCR assays.

Compared to the STIC criteria, all PCR assays (including LAMP) demonstrated high specificity ranging from 96–99%, with sensitivities varying from 40% to 56%, similar to the antibody based rapid test, which had a sensitivity of 47% and a specificity of 95%.

Conclusions/Significance

The diagnostic accuracy of the LAMP assay was similar to realtime and nested conventional PCR assays, but superior to the antibody-based rapid test in the early disease course. The combination of DNA- and antibody-based detection methods increased sensitivity with minimal reduction of specificity, and expanded the timeframe of adequate diagnostic coverage throughout the acute phase of scrub typhus.

There is an urgent need for alternative diagnostic methods for scrub typhus, but evaluation of these is hampered because the current serological gold standard (IFA) is imperfect. In a study from Thailand, 3 of 20 (15%) patients with fever had a positive Orientia tsutsugamushi PCR result despite negative serology. These findings could reflect potential benefits of the PCR assay in detecting rickettsaemia before antibody responses set in and/or a diagnostic advantage in endemic areas with high background levels of antibody in the population. Serology is complicated by the heterogeneity of strains present in Southeast Asia, but high resource costs and training make realtime PCR assays impractical for many areas where scrub typhus is endemic. This is where the new LAMP methodology has potential: it is inexpensive, simple to perform and requires only a waterbath or simple heating block instead of a thermocycler. In the context of a prospective fever study in a scrub typhus-endemic area in Thailand, the results support the validity of LAMP methodology for the diagnosis of scrub typhus, highlight the difficulties in comparing antibody- with DNA-based methods and also contribute towards understanding the dynamics of bacteraemia in this under recognised and under studied disease.

Differences in clinical features according to Boryoung and Karp genotypes of Orientia tsutsugamushi

Background

Scrub typhus is an infectious disease caused by Orientia tsutsugamushi. The differences in virulence of O. tsutsugamushi prototypes in humans are still unknown. We investigated whether there are any differences in the clinical features of the Boryoung and Karp genotypes.

Methodology/Principal Findings

Patients infected with O. tsutsugamushi, as Boryoung and Karp clusters, who had visited 6 different hospitals in southwestern Korea were prospectively compared for clinical features, complications, laboratory parameters, and treatment responses. Infected patients in the Boryoung cluster had significantly more generalized weakness, eschars, skin rashes, conjunctival injection, high albumin levels, and greater ESR and fibrinogen levels compared to the Karp cluster. The treatment response to current antibiotics was significantly slower in the Karp cluster as compared to the Boryoung cluster.

Conclusion

The frequency of occurrence of eschars and rashes may depend on the genotype of O. tsutsugamushi.

Lack of effect of dexamethasone on growth of Orientia tsutsugamushi Gilliam in mouse L929 cells

PURPOSE

Previous studies and our own clinical experience suggest that concurrent corticosteroid treatment for severe rickettsial disease with multiorgan failure may improve the clinical course or reduce mortality. However, the use of corticosteroids as adjunctive treatment for rickettsial diseases is controversial. We attempted to determine the influences of corticosteroid on the growth of Orientia tsutsugamushi in vitro to justify and evaluate the clinical applicability of corticosteroid in rickettsial disease.

MATERIALS AND METHODS

L929 cells were infected with Orientia tsutsugamushi Gilliam. Dexamethasone was added to the cells at final concentrations of 10¹ and 10⁷ pg/mL. Cultures were incubated at 35°C and processed for flow cytometry on the 6th day after addition of dexamethasone.

RESULTS

Observation on the 6th day after treatment with dexamethasone in infected cultures revealed that there was no difference in fluorescence intensity among the treatment wells. Treatment of the cells with dexamethasone at concentrations of 10¹ and 10⁷ pg/mL showed no influence on the growth of Orientia tsutsugamushi.

CONCLUSION

Our results to show that isolated corticosteroid does not enhance the replication of Orientia tsutsugamushi in vitro. Concurrent use of anti-inflammatory or immunosuppressive doses of corticosteroids in conjunction with antibiotics may not have detrimental effects on the course of scrub typhus.

Orientia tsutsugamushi stimulates an original gene expression program in monocytes: relationship with gene expression in patients with scrub typhus

Orientia tsutsugamushi is the causal agent of scrub typhus, a public health problem in the Asia-Pacific region and a life-threatening disease. O. tsutsugamushi is an obligate intracellular bacterium that mainly infects endothelial cells. We demonstrated here that O. tsutsugamushi also replicated in monocytes isolated from healthy donors. In addition, O. tsutsugamushi altered the expression of more than 4,500 genes, as demonstrated by microarray analysis. The expression of type I interferon, interferon-stimulated genes and genes associated with the M1 polarization of macrophages was significantly upregulated. O. tsutsugamushi also induced the expression of apoptosis-related genes and promoted cell death in a small percentage of monocytes. Live organisms were indispensable to the type I interferon response and apoptosis and enhanced the expression of M1-associated cytokines. These data were related to the transcriptional changes detected in mononuclear cells isolated from patients with scrub typhus. Here, the microarray analyses revealed the upregulation of 613 genes, which included interferon-related genes, and some features of M1 polarization were observed in these patients, similar to what was observed in O. tsutsugamushi-stimulated monocytes in vitro. This is the first report demonstrating that monocytes are clearly polarized in vitro and ex vivo following exposure to O. tsutsugamushi. These results would improve our understanding of the pathogenesis of scrub typhus, during which interferon-mediated activation of monocytes and their subsequent polarization into an M1 phenotype appear critical. This study may give us a clue of new tools for the diagnosis of patients with scrub typhus.

Genome comparison and phylogenetic analysis of Orientia tsutsugamushi strains

Orientia tsutsugamushi (OT) is an obligate intracellular bacterium belonging to the family Rickettsiaceae and is the causative agent of scrub typhus, or Tsutsugamushi disease. The complete genome sequences of two OT strains (Boryong and Ikeda) have recently been determined. In the present study, we performed a fine genome sequence comparison of these strains. Our results indicate that although the core gene set of the family Rickettsiaceae is highly conserved between the two strains, a common set of repetitive sequences have been explosively amplified in both genomes. These amplified repetitive sequences have induced extensive genome shuffling and duplications and deletions of many genes. On the basis of the results of the genome sequence comparison, we selected 11 housekeeping genes and carried out multilocus sequence analysis of OT strains using the nucleotide sequences of these genes. This analysis revealed for the first time the phylogenetic relationships of representative OT strains. Furthermore, the results suggest the presence of an OT lineage with higher potential for virulence, which may explain the clinical and epidemiological differences between 'classic' and 'new' types of Tsutsugamushi disease in Japan.

Serosurveillance of scrub typhus in small mammals collected from military training sites near the DMZ, Northern Gyeonggi-do, Korea, and analysis of the relative abundance of chiggers from mammals examined

Comprehensive quarterly serosurveillance on scrub typhus in small mammals collected from military training sites located near the Demilitarized Zone (DMZ), northern Gyeonggi-do (Province), ROK was conducted to determine the potential rodent-borne and associated ectoparasite disease risks to military personnel. A total of 1,196 rodents and insectivores representing 8 species, Apodemus agrarius (87.3%, n = 1,044), Mus musculus (5.4%, n = 65), Crocidura lasiura (3.3%, n = 40), Microtus fortis (2.6%, n = 31), Micromys minutus (0.3%, n = 4), Tscherskia triton (0.3%, n = 4), Rattus norvegicus (0.3%, n = 4), and Myodes regulus (0.3%, n = 4) were assayed for the presence of antibodies to Orientia tsutsugamushi. O. tsutsugamushi antibodies were detected in 6 of 8 species and seroprevalence determined; A. agrarius (45.6%), M. musculus (23.1%), M. fortis (48.4%), M. minutus (50.0%), T. triton (50.0%), and R. norvegicus (25.0%). A total of 31,184 chigger mites collected from 508 rodents and insectivores were slide-mounted and 10 species belonging to 4 genera were identified. Leptotrombidium pallidum (53.4%) was the most frequently collected, followed by L. palpale (15.7%), Neotrombicula tamiyai (14.3%), L. orientale (10.7%), L. zetum (3.1%), Walchia fragilis (2.1%), and L. gemiticulum (0.8%), while the remaining 3 species, L. subintermedium, N. gardellai, and Euschoengastia koreaensis were rarely observed (prevalence < 10%). In contrast to previous surveys, higher chigger indices of the primary scrub typhus vectors, L. pallidum (165.4), L. orientale (45.0), and L. palpale (21.4), were observed during the spring season.

High rates of homologous recombination in the mite endosymbiont and opportunistic human pathogen Orientia tsutsugamushi

Orientia tsutsugamushi is an intracellular alpha-proteobacterium which resides in trombiculid mites, and is the causative agent of scrub typhus in East Asia. The genome sequence of this species has revealed an unprecedented number of repeat sequences, most notably of the genes encoding the conjugative properties of a type IV secretion system (T4SS). Although this observation is consistent with frequent intragenomic recombination, the extent of homologous recombination (gene conversion) in this species is unknown. To address this question, and to provide a protocol for the epidemiological surveillance of this important pathogen, we have developed a multilocus sequence typing (MLST) scheme based on 7 housekeeping genes (gpsA, mdh, nrdB, nuoF, ppdK, sucD, sucB). We applied this scheme to the two published genomes, and to DNA extracted from blood taken from 84 Thai scrub typhus patients, from 20 cultured Thai patient isolates, 1 Australian patient sample, and from 3 cultured type strains. These data demonstrated that the O. tsutsugamushi population was both highly diverse [Simpson's index (95% CI) = 0.95 (0.92-0.98)], and highly recombinogenic. These results are surprising given the intracellular life-style of this species, but are broadly consistent with results obtained for Wolbachia, which is an alpha-proteobacterial reproductive parasite of arthropods. We also compared the MLST data with ompA sequence data and noted low levels of consistency and much higher discrimination by MLST. Finally, twenty-five percent of patients in this study were simultaneously infected with multiple sequence types, suggesting multiple infection caused by either multiple mite bites, or multiple strains co-existing within individual mites.

[Occurrence of Tsutsugamushi disease infection by Orientia tsutsugamushi, Kawasaki serotype, in Yamagata Prefecture, Japan]

Of 95 Tsutsugamushi disease case occurring in Yamagata prefecture from 1999 to 2006, four-all women-involved the O. tsutsugamushi Kawasaki serotype. The three major symptoms were fever, exanthema, and eschar present from mid-October to early November. Serodiagnosis by indirect immunofluoresence assay showed elevated IgG and IgM antibody titers against the Kawasaki serotype antigen, with IgM higher than IgG. Nested PCR detected 56-kDa DNA in three of the cases. DNA was amplified in Kawasaki-specific PCR. Two cases for which sequencing was done using nested PCR-amplified DNA showed an identity of 99.8% for the Kawasaki strain (Accession number: M63383). These results confirmed the occurrence of Tsutsugamushi disease infection involving Kawasaki serotype in Yamagata prefecture.

Rickettsial diseases in Haryana: not an uncommon entity

Rickettsioses have not been reported from the plains of North India and Haryana in particular. Here we are reporting three cases of scrub typhus and one cases of Indian tick typhus in the state of Haryana, all of which presented with fever and multi organ dysfunction, rash and without eschar. All were successfully treated with doxycycline.

Electron-microscopic observation of mouse spleen tissue infected with Orientia tsutsugamushi isolated from Shandong, China

Low-virulent Orientia tsutsugamushi (Ot) were successfully isolated from scrub typhus patients in Shandong, China, and the isolates were similar to the Kawasaki type identified by nested polymerase chain reaction (PCR). To identify the morphological characterization of the low-virulent Ot, and elucidate the pathological changes on host cells, mouse spleen tissue infected with the Ot isolated from Shandong was used for the ultrastructural study. Transmission electron microscopy showed that the Ot parasitized in the spleen were different in size, shape and electron density and many significant changes occurred in cytoplasmic organelles of the inoculated mouse spleen cells. Swollen perinuclear cisterna was observed in the nuclear membranes of mononuclear cells and a multivesicular body was found in the intracytoplasm of the macrophage. In the phagosome of the macrophage, many Ot enveloped with an additional membrane were found to push the phagosomal membrane outward from inside. The results indicated that the low-virulent Ot and the spleen cells suffered various damages.

An application of duplex PCR for detection of Leptospira spp. and Orientia tsutsugamushi from wild rodents

Duplex PCR is useful for detecting two different agents from the same specimen. Kidney specimens are the most suitable for detection of Leptospira spp. For Orientia tsutsugamushi, blood clots, spleen, and liver specimens are considered the most suitable. For this study, kidney tissues were the only specimens obtainable for the PCR. Blood clots, spleen, and liver specimens were not available. However, by using the PCR for scrub typhus, O. tsutsugamushi was detected in the kidney of one rodent. This result shows that kidney specimens can be used to detect O. tsutsugamushi using PCR. Further studies will be necessary in order to be able to compare the detection ratio of O. tsutsugamushi using kidney specimens and blood clots, spleen, and liver specimens.

Comparative analysis of nucleotide sequences of Orientia tsutsugamushi in different epidemic areas of scrub typhus in Shandong, China

Scrub typhus, caused by Orientia tsutsugamushi, is a zoonosis that spreads rapidly in Shandong, China. To investigate the molecular characterization of O. tsutsugamushi in new and old epidemic areas in Shandong Province, we compared the genetic relationships of O. tsutsugamushi between Linyi and Tai'an districts, typical old and new epidemic areas in Shandong, respectively. O. tsutsugamushi was detected in blood from 12 of 16 patients in Linyi and in eschar from 3 of 4 patients in Tai'an; 17 of 128 rodents were found to be infected with O. tsutsugamushi in Linyi, and 4 of 68 rodents were found to be O. tsutsugamushi-positive in Tai'an. The results indicated less genetic variation in O. tsutsugamushi between the new and old epidemic areas, and the Sdu-1 type, similar to Japan Kawasaki, was the main genotype of O. tsutsugamushi in Shandong Province.

Acute renal failure due to acute tubular necrosis caused by direct invasion of Orientia tsutsugamushi

We describe a scrub typhus patient with acute renal failure for whom a diagnosis was made based on serology as well as immunohistochemical (IHC) staining and an electron microscopic examination (EM) of a renal biopsy specimen. For our case, we demonstrated by IHC staining and EM that renal failure was caused by acute tubular necrosis due to a direct invasion of Orientia tsutsugamushi.

[Contribution of I.V. Tarasevich to the study of tsutsugamushi disease]

This article summarizes the results of study of tsutsugamushi disease in the Primorye and Tadzhikistan, in its epidemiology, diagnosis and biology of the Rickettsia tsutsugamushi. There is also information on the vectors of the disease, rickettsial infection within chiggers and transtadial transmission from larva to nymph, hosts of trombiculids and natural infection with R. tsutsugamushi.

Guillain-Barré syndrome associated with scrub typhus

We report a 42-y-old female with Guillain-Barré syndrome (GBS) who presented with scrub typhus for a duration of 2 weeks. Subsequently, ascending paralysis and facial diplegia developed. GBS was confirmed with nerve conduction studies and cerebrospinal fluid examinations. After administration of intravenous immunoglobulin, symptoms gradually disappeared.