African tick-bite fever: a new entity in the differential diagnosis of multiple eschars in travelers. Description of five cases imported from South Africa to Switzerland

Molecular screening reveals non-uniform malaria transmission in western Kenya and absence of Rickettsia africae and selected arboviruses in hospital patients

Background

In sub-Saharan Africa, malaria is the common diagnosis for febrile illness and related clinical features, resulting in the under-diagnosis of other aetiologies, such as arboviruses and Rickettsia. While these may not be significant causes of mortality in malaria-endemic areas, they affect the daily life and performance of affected individuals. It is, therefore, important to have a clear picture of these other aetiologies to institute correct diagnoses at hospitals and improve patient outcomes.

Methods

Blood samples were collected from patients with fever and other clinical features associated with febrile illness at selected hospitals in the malaria-endemic counties of Busia, Bungoma, and Kakamega, and screened for Crimean-Congo haemorrhagic fever, Sindbis, dengue and chikungunya viruses, Rickettsia africae, and Plasmodium spp. using high-throughput real-time PCR techniques. A logistic regression was performed on the results to explore the effect of demographic and socio-economic independent variables on malaria infection.

Results

A total of 336 blood samples collected from hospital patients between January 2018 and February 2019 were screened, of which 17.6% (59/336) were positive for Plasmodium falciparum and 1.5% (5/336) for Plasmodium malariae. Two patients had dual P. falciparum/P. malariae infections. The most common clinical features reported by the patients who tested positive for malaria were fever and headache. None of the patients were positive for the arboviruses of interest or R. africae. Patients living in Busia (OR 5.2; 95% CI 2.46–11.79; p < 0.001) and Bungoma counties (OR 2.7; 95% CI 1.27–6.16; p = 0.013) had higher odds of being infected with malaria, compared to those living in Kakamega County.

Conclusions

The reported malaria prevalence is in line with previous studies. The absence of arboviral and R. africae cases in this study may have been due to the limited number of samples screened, low-level circulation of arboviruses during inter-epidemic periods, and/or the use of PCR alone as a detection method. Other sero-surveys confirming their circulation in the area indicate that further investigations are warranted.

Unraveling the epidemiological relationship between ticks and rickettsial infection in Africa

Tick-borne rickettsioses are emerging and re-emerging diseases of public health concern caused by over 30 species of Rickettsia. Ticks are obligate hematophagous arthropods with over 700 species of Ixodid ticks known worldwide. The escalating geographical dispersal of tick vectors and concomitant increase in the incidences of tick-borne diseases have fueled interest in the ecology of tick-borne pathogens. This review focuses on aspects of the Rickettsia pathogen, including biology, taxonomy, phylogeny, genetic diversity, epidemiology of the disease, and the role of vertebrate host in the perpetuation of rickettsioses in Africa. Our review also highlights some of the species of Rickettsia that are responsible for disease, the role of tick vectors (both hard and soft ticks) and the species of Rickettsia associated with diverse tick species across the continent. Additionally, this article emphasizes the evolutionary perspective of rickettsiae perpetuation and the possible role of amplifying vertebrate host and other small mammals, domestic animals and wildlife in the epidemiology of Rickettsia species. We also specifically, discussed the role of avian population in the epidemiology of SFG rickettsiae. Furthermore, we highlighted tick-borne rickettsioses among travelers due to African tick-bite fever (ATBF) and the challenges to surveillance of rickettsial infection, and research on rickettsiology in Africa. Our review canvasses the need for more rickettsiologists of African origin based within the continent to further research towards understanding the biology, characterization, and species distribution, including the competent tick vectors involved in their transmission of rickettsiae across the continent in collaboration with established researchers in western countries. We further highlighted the need for proper funding to encourage research despite competing demands for resources across the various sectors. We finalize by discussing the similarities between rickettsial diseases around the world and which steps need to be taken to help foster our understanding on the eco-epidemiology of rickettsioses by bridging the gap between the growing epidemiological data and the molecular characterization of Rickettsia species.

Epidemiology of Ticks and Tick-Borne Pathogens in Domestic Ruminants across Southern African Development Community (SADC) Region from 1980 until 2021: A Systematic Review and Meta-Analysis

Ticks are hematophagous ectoparasites that are capable of infesting a wide range of mammals, including domestic animals, ruminants, wildlife, and humans across the world, and they transmit disease-causing pathogens. Numerous individual epidemiological studies have been conducted on the distribution and prevalence of ticks and tick-borne diseases (TBDs) in the Southern African Developing Community (SADC) region, but no effort has been undertaken to synchronize findings, which would be helpful in the implementation of consolidated tick control measures. With the aim of generating consolidated pooled prevalence estimates of ticks and TBDs in the SADC region, we performed a systematic review and meta-analysis of published articles using the PRISMA 2020 guidelines. A deep search was performed on five electronic databases, namely, PubMed, ScienceDirect, Google Scholar, AJOL, and Springer Link. Of the 347 articles identified, only 61 of the articles were eligible for inclusion. In total, 18,355 tick specimens were collected, belonging to the genera Amblyomma, Haemaphysalis, Hyalomma, and Rhipicephalus (including Boophilus) across several countries, including South Africa (n = 8), Tanzania (n = 3), Zambia (n = 2), Zimbabwe (n = 2), Madagascar (n = 2), Angola (n = 2), Mozambique (n = 1), and Comoros (n = 1). The overall pooled prevalence estimate (PPE) of TBPs in livestock was 52.2%, with the highest PPE in cattle [51.2%], followed by sheep [45.4%], and goats [29.9%]. For bacteria-like and rickettsial TBPs, Anaplasma marginale had the highest PPE of 45.9%, followed by A. centrale [14.7%], A. phagocytophilum [2.52%], and A. bovis [0.88%], whilst Ehrlichia ruminantium had a PPE of 4.2%. For piroplasmids, Babesia bigemina and B. bovis had PPEs of 20.8% and 20.3%, respectively. Theileria velifera had the highest PPE of 43.0%, followed by T. mutans [29.1%], T. parva [25.0%], and other Theileria spp. [14.06%]. Findings from this study suggest the need for a consolidated scientific approach in the investigation of ticks, TBPs, and TBDs in the whole SADC region, as most of the TBDs are transboundary and require a regional control strategy.

Clinical, epidemiological, and laboratory features of Rickettsia africae infection, African tick-bite fever: A systematic review

African tick-bite fever (ATBF), caused by Rickettsia africae, is the main tick-borne rickettsiosis and the second most frequent cause of fever after malaria in travelers returning from sub-Saharan Africa. General descriptions on ATBF were made in the first two decades after recognized as a new infectious entity, and since then, many authors have contributed to the knowledge of the disease by reporting clinical cases in scientific literature. We developed a systematic review that evaluated all available evidence in the literature regarding clinical, epidemiological, and laboratory features of confirmed R. africae rickettsiosis cases. We followed the recommendations made by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guide. A total of 48 scientific publications (108 confirmed cases) were analyzed in order to extract data for developing this review. Overall, our results show that R. africae rickettsiosis is more frequent in males in the age group of 18-64 years, more than 80% of the cases occurred in European travelers, South Africa was the country where most infections were acquired, and almost 40% of cases occurred in clusters. Clinically, more than 80% of the cases had fever and eschar (55% developed multiple eschars), rash was present in less than the half of cases, and lymphangitis was not a common sign (11%). Headache, myalgia and regional lymphadenopathy were predominant nonspecific clinical manifestation (mean of 60%, 49% and 51%, respectively). Our results show that at least 70% of R. africae cases had altered laboratory parameters, most often showing an increase in transaminases and C-reactive protein. Tetracycline-class antibiotics, as monotherapy, were used in most (>90%) of the patients. Overall, only 4% of cases had complications, 12% required hospitalization, and there was a 100% rate of clinical recovery.

Molecular Detection of Coxiella burnetii, Rickettsia africae and Anaplasma Species in Ticks from Domestic Animals in Lesotho

Tick-borne diseases (TBDs) hamper the growth of the livestock sector and impose major constraints for the health and management of domestic animals in the tropic and subtropical regions globally. Currently, there is no scientific report on the presence of zoonotic pathogens transmitted by tick species in Lesotho. This study aimed to identify zoonotic tick-borne pathogens of economic importance from ticks infesting domestic animals in Lesotho using molecular techniques. A total of 322 tick DNA pools were subjected to PCR screening for the presence of zoonotic pathogens and sequenced. The overall prevalence of Anaplasma spp. was 35% (113/322), with a 100% infection rate in Rhipicephalus microplus, followed by R. evertsi evertsi (92%), Hyalomma rufipes and Otobius megnini sharing 50% and the lowest infection rate was observed in R. decoloratus with 40%. The prevalence of Coxiella burnetii, a gram-negative pleomorphic etiological agent of Query fever (Q fever), was 1% (2/322) for all screened samples, with 20% of R. decoloratus and 1% of R. e. evertsi infected. Rickettsia africae was detected from Hyalomma rufipes with a 70% prevalence. This study provides a baseline knowledge of tick-borne pathogens of medical and veterinary importance in Lesotho and raises awareness of the prevalence of such diseases within the tourism sector as they are mostly affected.

Molecular Detection and Characterization of Rickettsia Species in Ixodid Ticks Collected From Cattle in Southern Zambia

Tick-borne zoonotic pathogens are increasingly becoming important across the world. In sub-Saharan Africa, tick-borne pathogens identified include viruses, bacteria and protozoa, with Rickettsia being the most frequently reported. This study was conducted to screen and identify Rickettsia species in ticks (Family Ixodidae) infesting livestock in selected districts of southern Zambia. A total of 236 ticks from three different genera (Amblyomma, Hyalomma, and Rhipicephalus) were collected over 14 months (May 2018-July 2019) and were subsequently screened for the presence of Rickettsia pathogens based on PCR amplification targeting the outer membrane protein B (ompB). An overall Rickettsia prevalence of 18.6% (44/236) was recorded. Multi-locus sequencing and phylogenetic characterization based on the ompB, ompA, 16S rRNA and citrate synthase (gltA) genes revealed the presence of Rickettsia africae (R. africae), R. aeschlimannii-like species and unidentified Rickettsia species. While R. aeschlimannii-like species are being reported for the first time in Zambia, R. africae has been reported previously, with our results showing a wider distribution of the bacteria in the country. Our study reveals the potential risk of human infection by zoonotic Rickettsia species and highlights the need for increased awareness of these infections in Zambia's public health systems.

Development of a practical framework for sustainable surveillance and control of ticks and tick-borne diseases in Africa

A workshop on ticks and tick-borne diseases (T&TBDs) was held on June 25 and 26, 2019, at the Tropical Pesticides Research Institute, Division of Livestock and Human Diseases Vector Control, Arusha, Tanzania. The objectives of the workshop were to discuss the current situation and to formulate actionable strategies to improve surveillance and control of T&TBDs in Africa. The workshop was funded by the National Research Foundation and the Cape Peninsula University of Technology and attended by livestock health providers, farmers, and researchers from East, West, and Southern African countries. During the workshop, experts presented recent surveillance data focused on T&TBDs; participants discussed research opportunities and community engagement. The primary outcome of the workshop was the creation of a new research consortium known as The African Consortium for T&TBDs. The consortium is intended to function as a community for researchers, students, farmers, policymakers, extension workers, and community members who are interested in the advancement of T&TBD control. The consortium will engage in research activities that focus on comprehensive surveillance of T&TBDs, developing tick acaricide resistance, alternative tick control programs, and policy development and education. These areas were identified as top priorities to be developed to improve T&TBD control on the continent.

Amblyomma hebraeum is the predominant tick species on goats in the Mnisi Community Area of Mpumalanga Province South Africa and is co-infected with Ehrlichia ruminantium and Rickettsia africae

Background

In sub-Saharan Africa, Amblyomma ticks are vectors of heartwater disease in domestic ruminants, caused by the rickettsial pathogen Ehrlichia ruminantium. Immature tick stages often bite humans, whereby they act as vectors of tick-bite fever caused by Rickettsia africae. Moreover, Amblyomma ticks cause damage to livestock due to their feeding behaviour. In South Africa, we studied the abundance of Amblyomma hebraeum ticks on goats of emerging farmers in Mpumalanga Province. A selected number of A. hebraeum nymphs and adult ticks was tested for co-infection with E. ruminantium and R. africae.

Methods

A total of 630 indigenous goats, belonging to farmers in the Mnisi Community area, were examined for ticks in 2013 and 2014. All ticks were identified, and a selected number was tested by PCR with reverse line blot hybridisation.

Results

In total, 13,132 ticks were collected from goats distributed over 17 different households. Amblyomma hebraeum was the predominant species, followed by R. microplus. Rhipicephalus appendiculatus, R. simus and R. zambeziensis were also identified. Amblyomma hebraeum was present throughout the year, with peak activity of adults in summer (November) and nymphs in winter (July). The ratio between adults and nymphs ranged from 1:2.7 in summer to 1:55.1 in winter. The mean prevalence of infection for E. ruminantium by PCR/RLB in adult ticks was 17.4% (31/178), whereas 15.7% (28/178) were infected with R. africae. In pooled nymphs, 28.4% were infected with E. ruminantium and 38.8% carried R. africae infection. Co-infections of E. ruminantium and R. africae in adult and pooled nymphal ticks were 3.9% (7/178) and 10% (14.9), respectively. Lameness of goats due to predilection of ticks for the interdigital space of their feet was observed in 89% of the households.

Conclusions

Goats act as important alternative hosts for cattle ticks, which underscored the necessity to include goats in control programs. It is suggested to use acaricide-impregnated leg-bands as a sustainable method to kill ticks and prevent lameness in goats. The challenge of goats by considerable numbers of E. ruminantium-infected ticks is a major obstacle for upgrading the indigenous goat breeds. Humans may be at risk to contract tick-bite fever in this area.

Rickettsioses: Cutaneous findings frequently lead to diagnosis - a review

While epidemic typhus caused by Rickettsia prowazekii posed a significant threat in Europe before and throughout World War II due to its high mortality, the condition fortunately no longer plays a significant role. Nevertheless, rickettsioses, such as African tick bite fever, have been increasingly diagnosed in travelers returning from sub-Saharan Africa. Caused by Rickettsia africae, African tick bite fever presents with characteristic cutaneous findings such as eschar (tache noir) and a rash. Similar findings are also observed in Mediterranean spotted fever caused by Rickettsia conorii. On the other hand, Rocky Mountain spotted fever - caused by Rickettsia rickettsii - is characterized by a rash without an eschar, in combination with distinctly more severe general symptoms. The objective of the present CME article is to familiarize dermatologists with the spectrum of the most common types of rickettsiosis in humans, including their epidemiology, clinical presentation, diagnostic workup, and treatment. Recognition of characteristic cutaneous manifestations and their correct interpretation facilitate early diagnosis. Prompt initiation of treatment usually results in recovery without sequelae.

First report of African tick-bite fever in a South American traveler

We report a clinical case of African tick-bite fever in a Brazilian traveler right after his return from South Africa. Definitive diagnosis was supported by seroconversion between acute-phase and convalescent-phase serum samples, detection of rickettsial DNA in skin lesions, and in vitro culture of Rickettsia africae from the patient's skin. Most of the previous reported cases of African tick-bite fever were confirmed solely by serological or/and molecular methods. Through this first confirmed case of African tick-bite fever in Brazil, it is quite possible that other cases are occurring unnoticed by the health authorities, requiring a greater vigilance in traveler's medicine in South America.

Rickettsia sibirica mongolitimonae infection in a woman travelling from Cameroon: a case report and review of the literature

Rickettsia sibirica mongolitimonae is now a well-known cause of human rickettsial infection, with 52 reported cases, including 47 in southern Europe and one in South Africa. We report the first case of R. sibirica mongolitimonae in Central Africa, likely a sentinel case for a more common disease than originally suspected.

Rickettsia diversity in southern Africa: A small mammal perspective

Worldwide, including Africa, rickettsioses are recognized as emerging or re-emerging infections. To date, little is known about the diversity of Rickettsia species that are naturally associated with small mammals in southern Africa. The aim of the study was to screen a diversity of small mammals for the presence of rickettsial DNA. Animals were trapped at 38 localities in South Africa and Namibia. In total, 1616 ear-tissue samples from 23 species representing 17 genera were tested using real-time (rt)PCR and multi-locus sequence typing (MLST). Of the 1616 samples 251 (15.5%) were positive in an initial rtPCR. In 16 of the 23 investigated animal species rickettsial DNA was detected with an average prevalence of 15.7%. We herein describe for the first time four Rickettsia (R.) species known to be pathogenic for humans in rodents from South Africa, R. conorii, R. massiliae, R. felis and R. helvetica. In addition, by MLST and subsequent phylogenetic analyses so far undescribed Rickettsia species, Candidatus Rickettsia africaustralis, Candidatus Rickettsia rhabdomydis, and Candidatus Rickettsia muridii were confirmed. Further four new genotypes, genotype Rickettsia hofmannii, genotype Rickettsia stutterheimensis, genotype Rickettsia hogsbackensis and genotype Rickettsia kaalplaasensis, respectively, are described. The data indicate a surprisingly high diversity of Rickettsia in small mammals in South Africa and might indicate their possible role as reservoirs for Rickettsia. Ecological questions concerning their natural hosts such as small mammals, but also the role of livestock or pet animals, require further investigation. Particularly, data on the relevance of these rickettsiae for diseases in humans are of further interest.

Molecular detection of pathogens in ticks infesting cattle in Nampula province, Mozambique

Ticks are ectoparasites that can act as vectors of a large number of pathogens in wild and domestic animals, pets, and occasionally humans. The global threat of emerging or re-emerging tick-borne diseases supports the need for research focused in the zoonotic transmission, especially in countries like Mozambique where rural populations are in close contact with domestic animals. The present study aims to: (1) identify tick species infesting cattle from Monapo and Nacala Porto, districts of Nampula province, Mozambique; and (2) investigate the presence of pathogens in the collected ticks. A total of 646 ticks were collected from cattle and morphologically identified as Amblyomma variegatum, Rhipicephalus microplus, and R. evertsi evertsi. For convenience, 72 A. variegatum and 15 R. microplus from Monapo, and 30 A. variegatum from Nacala Porto were screened for the presence of the selected pathogens: Rickettsia spp. (A. variegatum), and Babesia/Theileria spp. and Anaplasma/Ehrlichia spp. (R. microplus). Rickettsia africae was detected in four of the 72 A. variegatum collected in Monapo (5.6%). Additionally, one R. microplus tick (6.7%) was positive for Theileria velifera, one positive for Colpodella spp., one positive for Candidatus Midichloria mitochondrii, and another one positive for Anaplasma ovis. Using the present approach, no microorganisms were detected in tick samples from Nacala Porto. These findings expand our knowledge about the repertoire of tick-borne microorganisms in ticks in Nampula province, Mozambique.

Rickettsia sibirica mongolitimonae Infection, France, 2010-2014

To further characterize human infections caused by Rickettsia sibirica mongolitimonae, we tested skin biopsy and swab samples and analyzed clinical, epidemiologic, and diagnostic characteristics of patients with a rickettsiosis. The most common (38%) indigenous species was R. sibirica mongolitimonae. Significantly more cases of R. sibirica mongolitimonae infection occurred during spring and summer.

The Eco-epidemiology of Pacific Coast Tick Fever in California

Rickettsia philipii (type strain “Rickettsia 364D”), the etiologic agent of Pacific Coast tick fever (PCTF), is transmitted to people by the Pacific Coast tick, Dermacentor occidentalis. Following the first confirmed human case of PCTF in 2008, 13 additional human cases have been reported in California, more than half of which were pediatric cases. The most common features of PCTF are the presence of at least one necrotic lesion known as an eschar (100%), fever (85%), and headache (79%); four case-patients required hospitalization and four had multiple eschars. Findings presented here implicate the nymphal or larval stages of D. occidentalis as the primary vectors of R. philipii to people. Peak transmission risk from ticks to people occurs in late summer. Rickettsia philipii DNA was detected in D. occidentalis ticks from 15 of 37 California counties. Similarly, non-pathogenic Rickettsia rhipicephali DNA was detected in D. occidentalis in 29 of 38 counties with an average prevalence of 12.0% in adult ticks. In total, 5,601 ticks tested from 2009 through 2015 yielded an overall R. philipii infection prevalence of 2.1% in adults, 0.9% in nymphs and a minimum infection prevalence of 0.4% in larval pools. Although most human cases of PCTF have been reported from northern California, acarological surveillance suggests that R. philipii may occur throughout the distribution range of D. occidentalis.

Rickettsia philipii, a spotted fever group rickettsia, is the etiologic agent of Pacific Coast tick fever, an emerging tick-borne disease transmitted by the Pacific Coast tick (Dermacentor occidentalis). The Pacific Coast tick’s range, and thus potential for exposure to R. philipii, includes most of California, southern Oregon, and northern Baja California, Mexico. This study describes the clinical manifestations of the 14 human cases reported to date in California and the known acarological risk factors for encountering PCTF. While Rickettsia rickettsii, the agent of Rocky Mountain spotted fever (RMSF) is genetically similar to R. philipii, PCTF is a milder disease than RMSF; the two diseases share key clinical features such as headache and fever but differ in that PCTF presents with a localized eschar (necrotic wound) but without a petechial rash. Most case-patients have illness onset dates in the summer (peak: July and August) which is coincident with the activity period of immature D. occidentalis. Results from this study support the premise that larval and nymphal D. occidentalis are the vectors of PCTF to humans in California. While only three ticks have tested positive for R. rickettsii over decades of surveillance in California, the prevalence of R. philipii in D. occidentalis ticks averages 0.4% in larvae, 0.9% in nymphs, and 2.1% in adult ticks, indicating a higher risk of acquiring PCTF than RMSF statewide.

High prevalence of Rickettsia africae variants in Amblyomma variegatum ticks from domestic mammals in rural western Kenya: implications for human health

Tick-borne spotted fever group (SFG) rickettsioses are emerging human diseases caused by obligate intracellular Gram-negative bacteria of the genus Rickettsia. Despite being important causes of systemic febrile illnesses in travelers returning from sub-Saharan Africa, little is known about the reservoir hosts of these pathogens. We conducted surveys for rickettsiae in domestic animals and ticks in a rural setting in western Kenya. Of the 100 serum specimens tested from each species of domestic ruminant 43% of goats, 23% of sheep, and 1% of cattle had immunoglobulin G (IgG) antibodies to the SFG rickettsiae. None of these sera were positive for IgG against typhus group rickettsiae. We detected Rickettsia africae-genotype DNA in 92.6% of adult Amblyomma variegatum ticks collected from domestic ruminants, but found no evidence of the pathogen in blood specimens from cattle, goats, or sheep. Sequencing of a subset of 21 rickettsia-positive ticks revealed R. africae variants in 95.2% (20/21) of ticks tested. Our findings show a high prevalence of R. africae variants in A. variegatum ticks in western Kenya, which may represent a low disease risk for humans. This may provide a possible explanation for the lack of African tick-bite fever cases among febrile patients in Kenya.

Evaluation of a new serological test for the detection of anti-Coxiella and anti-Rickettsia antibodies

Coxiella burnetii and members of the genus Rickettsia are obligate intracellular bacteria. Since cultivation of these organisms requires dedicated techniques, their diagnosis usually relies on serological or molecular biology methods. Immunofluorescence is considered the gold standard to detect antibody-reactivity towards these organisms. Here, we assessed the performance of a new automated epifluorescence immunoassay (InoDiag) to detect IgM and IgG against C. burnetii, Rickettsia typhi and Rickettsia conorii. Samples were tested with the InoDiag assay. A total of 213 sera were tested, of which 63 samples from Q fever, 20 from spotted fever rickettsiosis, 6 from murine typhus and 124 controls. InoDiag results were compared to micro-immunofluorescence. For acute Q fever, the sensitivity of phase 2 IgG was only of 30% with a cutoff of 1 arbitrary unit (AU). In patients with acute Q fever with positive IF IgM, sensitivity reached 83% with the same cutoff. Sensitivity for chronic Q fever was 100% whereas sensitivity for past Q fever was 65%. Sensitivity for spotted Mediterranean fever and murine typhus were 91% and 100%, respectively. Both assays exhibited a good specificity in control groups, ranging from 79% in sera from patients with unrelated diseases or EBV positivity to 100% in sera from healthy patients. In conclusion, the InoDiag assay exhibits an excellent performance for the diagnosis of chronic Q fever but a very low IgG sensitivity for acute Q fever likely due to low reactivity of phase 2 antigens present on the glass slide. This defect is partially compensated by the detection of IgM. Because it exhibits a good negative predictive value, the InoDiag assay is valuable to rule out a chronic Q fever. For the diagnosis of rickettsial diseases, the sensitivity of the InoDiag method is similar to conventional immunofluorescence.

Molecular detection of zoonotic tick-borne pathogens from ticks collected from ruminants in four South African provinces

Ticks carry and transmit a remarkable array of pathogens including bacteria, protozoa and viruses, which may be of veterinary and/or of medical significance. With little to no information regarding the presence of tick-borne zoonotic pathogens or their known vectors in southern Africa, the aim of our study was to screen for Anaplasma phagocytophilum, Borrelia burgdorferi, Coxiella burnetii, Rickettsia species and Ehrlichia ruminantium in ticks collected and identified from ruminants in the Eastern Cape, Free State, KwaZulu-Natal and Mpumalanga Provinces of South Africa. The most abundant tick species identified in this study were Rhipicephalus evertsi evertsi (40%), Rhipicephalus species (35%), Amblyomma hebraeum (10%) and Rhipicephalus decoloratus (14%). A total of 1634 ticks were collected. DNA was extracted, and samples were subjected to PCR amplification and sequencing. The overall infection rates of ticks with the target pathogens in the four Provinces were as follows: A. phagocytophilum, 7%; C. burnetii, 7%; E. ruminantium, 28%; and Rickettsia spp., 27%. The presence of B. burgdorferi could not be confirmed. The findings of this study show that zoonotic pathogens are present in ticks in the studied South African provinces. This information will aid in the epidemiology of tick-borne zoonotic diseases in the country as well as in raising awareness about such diseases in the veterinary, medical and tourism sectors, as they may be the most affected.

Rickettsioses and Q fever in travelers (2004-2013)

Rickettsioses (also called typhus) are associated with arthropods, including ticks, mites, fleas, and lice, although Q fever is more frequently acquired through the inhalation of contaminated aerosols or the consumption of milk. These zoonoses first emerged in the field of travel medicine 20 years ago. Here, we review rickettsioses and Q fever in travelers, highlighting cases reported in the past decade. African tick bite fever and Mediterranean spotted fever are the two most frequent spotted fevers. While the presentation of these fevers is typically benign, cardiac and neurological complications due to African tick bite fever have been reported, and Mediterranean spotted fever has been complicated by multi-organ failure and death in a few cases. Murine typhus and Q fever remain difficult to recognize and diagnose because these illnesses often present with only fever. New molecular tools, particularly when deployed with samples obtained from eschar swabs, might be easily implemented in laboratories with PCR facilities. Doxycycline must be introduced upon clinical suspicion of rickettsioses or Q fever and should be considered in cases of fever of unknown origin in travelers who are returning from at-risk geographic areas.

Tick-borne pathogens of potential zoonotic importance in the southern African Region

The aim of this communication is to provide preliminary information on the tick-borne pathogens of potential zoonotic importance present in southern Africa, mainly focusing on their geographical distribution and host range, and to identify research gaps. The following tick-borne zoonoses have been reported to occur in southern Africa based mainly on case reports: Crimean-Congo haemorrhagic fever caused by Crimean-Congo haemorrhagic fever virus; ehrlichiosis caused by Ehrlichia ruminantium, Ehrlichia canis and Anaplasma phagocytophilum; babesiosis caused by Babesia microti; relapsing fever caused by Borrelia duttonii and rickettsioses caused by Rickettsia africae, Rickettsia aeschlimannii and Rickettsia conorii. The epidemiological factors influencing their occurrence are briefly reviewed.

Rickettsia africae and Candidatus Rickettsia barbariae in ticks in Israel

DNA of several spotted fever group rickettsiae was found in ticks in Israel. The findings include evidence for the existence of Rickettsia africae and Candidatus Rickettsia barbariae in ticks in Israel. The DNA of R. africae was detected in a Hyalomma detritum tick from a wild boar and DNA of C. Rickettsia barbariae was detected in Rhipicephalus turanicus and Rhipicephalus sanguineus collected from vegetation. The DNA of Rickettsia massiliae was found in Rh. sanguineus and Haemaphysalis erinacei, whereas DNA of Rickettsia sibirica mongolitimonae was detected in a Rhipicephalus (Boophilus) annulatus. Clinicians should be aware that diseases caused by a variety of rickettsiae previously thought to be present only in other countries outside of the Middle East may infect residents of Israel who have not necessarily traveled overseas. Furthermore, this study reveals again that the epidemiology of the spotted fever group rickettsiae may not only involve Rickettsia conorii but may include other rickettsiae.

Case report of African tick-bite fever from Poland

A confirmed case of rickettsiosis acquired in South Africa and recognized in Poland was described. The patient fulfilled clinical criteria highly suggestive of African tick bite fever, such as eschars, regional lymphadenitis, cutaneous rash within 10 days after his return from sub-Saharan Africa. Infection with Rickettsia africae was confirmed by polymerase chain reaction and sequencing.

Update on tick-borne rickettsioses around the world: a geographic approach

Tick-borne rickettsioses are caused by obligate intracellular bacteria belonging to the spotted fever group of the genus Rickettsia. These zoonoses are among the oldest known vector-borne diseases. However, in the past 25 years, the scope and importance of the recognized tick-associated rickettsial pathogens have increased dramatically, making this complex of diseases an ideal paradigm for the understanding of emerging and reemerging infections. Several species of tick-borne rickettsiae that were considered nonpathogenic for decades are now associated with human infections, and novel Rickettsia species of undetermined pathogenicity continue to be detected in or isolated from ticks around the world. This remarkable expansion of information has been driven largely by the use of molecular techniques that have facilitated the identification of novel and previously recognized rickettsiae in ticks. New approaches, such as swabbing of eschars to obtain material to be tested by PCR, have emerged in recent years and have played a role in describing emerging tick-borne rickettsioses. Here, we present the current knowledge on tick-borne rickettsiae and rickettsioses using a geographic approach toward the epidemiology of these diseases.

Molecular diagnostics of Rickettsia africae infection in travelers returning from South Africa to The Netherlands

BACKGROUND

African tick-bite fever (ATBF) is frequently diagnosed in The Netherlands in travelers returning from South Africa. It is caused by Rickettsia africae and diagnosis is based on travel history and clinical presentation and usually confirmed by detecting serum antibodies against rickettsiae of the spotted fever group. However, these typically occur late in the course of the disease, and a mild clinical course or early antibiotic treatment can diminish antibody production.

METHODS AND RESULTS

Four travelers presented with (sub)febrile temperatures and eschar(s), several days after returning from South Africa. R. africae DNA was amplified and sequenced from skin biopsies of the eschars of all patients. Initial immunofluorescence assays yielded no immunoglobulin M (IgM)/IgG antibodies directed against spotted fever group rickettsiae; however, serology in the convalescent phase-several weeks after the patients had fully recovered-was positive.

CONCLUSIONS

ATBF should be considered in travelers returning from South Africa to The Netherlands with febrile illness and (multiple) skin lesions. The diagnosis can be confirmed by (paired) serology; however, polymerase chain reaction and sequencing on skin biopsies could be a (faster and more accurate) confirmatory test. Advantages of molecular methods over serology are species identification and high sensitivity early in the course of the disease.