Rickettsioses of the spotted fever group around the world

Discovery of a novel spotted fever group Rickettsia, "Candidatus Rickettsia kedanie," in unfed larval chigger mites, Leptotrombidium scutellare

Spotted fever group (SFG) rickettsia, the causative agent of SFG rickettsiosis, is predominantly carried by ticks, whereas Orientia tsutusgamushi, the causative agent of scrub typhus, is primarily transmitted by chigger mites in Japan. In this study, we attempted to isolate intracellular eubacteria from Leptotrombidium scutellare, a major vector of O. tsutsugamushi; moreover, we isolated an SFG rickettsia using a mosquito-derived cell line. Draft genome sequences of this unique isolate, by applying criteria for species delimitation, classified this isolate as a novel strain, proposed as "Rickettsia kedanie." Further genetic analysis identified conserved virulence factors, and the isolate successfully propagated in mammalian cells, suggesting its ability to cause diseases in humans. The presence of SFG rickettsia in unfed larvae implies potential dual-pathogen carriage and reflects a symbiotic relationship similar to that between the mites and O. tsutsugamushi, indicating possibility of its transovarial transmission from female adults. Furthermore, conserved genomic similarity of the novel isolate to known SFG rickettsia suggests potential multiple hosts, including chiggers and ticks. In the natural environment, ticks, chigger mites, and wild animals may carry new isolates, complicating the infection cycle and increasing the transmission risks to humans. This discovery challenges the conventional association of SFG rickettsia with ticks, emphasizing its implications for research and disease control. However, this study was confined to a particular species of chigger mites and geographic area, underscoring the necessity for additional studies to comprehend the ecological dynamics, host interactions, and health implications linked to this newly identified SFG rickettsia.

Rickettsia sp. and Anaplasma spp. in Haemaphysalis longicornis from Shandong province of China, with evidence of a novel species "Candidatus Anaplasma Shandongensis"

Haemaphysalis longicornis is one of the most dominant and widespread tick species in China. This species mainly infests wild animals and occasionally attacks humans, and has been associated with the transmission of a variety of zoonotic pathogens including spotted fever group Rickettsia (SFGR), severe fever with thrombocytopenia syndrome virus (SFTSV), Anaplasma phagocytophilum, Babesia spp. and Theileria spp.. Although there are increasing reports of various pathogens associated with H. longicornis, some neglected pathogens in certain areas still need to be studied. In this study, a total of 171 H. longicornis ticks were collected from goats in three locations of Shandong Province, Eastern China (Zibo, Linyi, and Qingdao cities), and subsequently screened for the presence of Rickettsia, Anaplasma, and Ehrlichia bacteria. A total of four bacterial species were identified and characterized. "Candidatus Rickettsia jingxinensis" was detected in one tick specimen from Zibo city. Of 98 ticks from Linyi city, 63.27% (62/98) were tested positive for Anaplasma capra and 5.10% (5/98) were positive for Anaplasma bovis. Interestingly, a novel Anaplasma species was detected and characterized in one tick specimen from Zibo and one other from Linyi, respectively. Genetic and phylogenetic analysis based on the 16S, gltA, groEL, and msp4 genes indicated that it was divergent from all known Anaplasma species but mostly related to A. phagocytophilum and "Cadidatus Anaplasma boleense". Based on where it was first detected, we named it "Candidatus Anaplasma shandongensis".

Mapping potential risks for the transmission of spotted fever rickettsiosis: The case study from the Rio de Janeiro state, Brazil

Spotted fever rickettsiosis is a zoonosis transmitted by ticks, having a varied clinical course that can lead to death if not managed properly. In Brazil it is more commonly observed in the Southeast, being an emerging public health problem. Hazard mapping models are common in different areas of knowledge, including public health, as a way of inferring reality and seeking to reduce or prevent damage. The aim of this study is to offer a spatial heuristic methodology for assessing the potential risk of transmission of spotted fever in the Rio de Janeiro state, located in the southeastern region of Brazil. For this, we used geospatial tools associated with eco-epidemiological data related to the clinical profile of the disease. The results achieved were substantially encouraging, considering that there are territories with greater or lesser expectation of risk for spotted fever in the study area. We observed that there are important distinctions between the two rickettsiosis scenarios in the same geographic space and that the areas where there is a greater potential risk of contracting rickettsiosis coincide with the administrative regions that concentrated the cases of hospitalization and deaths from the disease, concluding that the scenery found are relevant to the case series for the disease and that the planning of surveillance actions can gain in quality if the use of this spatial analysis tool is incorporated into the routine of local health management.

Clinicopathological study on rickettsial spotted fever from south India

In a prospective study conducted between November 2006 and April 2008 of 35 patients (male:female ratio 2:1) with proven rickettsial spotted fever, a generalised rash with involvement of palms and soles were seen in 80% of patients. Vasculitis on histopathology of rash was seen in 54%.

Comparative value of blood and skin samples for diagnosis of spotted fever group rickettsial infection in model animals

The definitive diagnosis of spotted fever group (SFG) rickettsioses in humans is challenging due to the retrospective nature and cross reactivity of the serological methods and the absence of reliable and consistent samples for molecular diagnostics. Existing data indicate the transient character of bacteremia in experimentally infected animals. The ability of arthropod vectors to acquire rickettsial infection from the laboratory animals in the absence of systemic infection and known tropism of rickettsial agents to endothelial cells of peripheral blood vessels underline the importance of local infection and consequently the diagnostic potential of skin samples. In order to evaluate the diagnostic sensitivity of rickettsial DNA detection in blood and skin samples, we compared results of PCR testing in parallel samples collected from model laboratory animals infected with Rickettsia rickettsii, Rickettsia parkeri and Rickettsia slovaca-like agent at different time points after infection. Skin samples were collected from ears - away from the site of tick placement and without eschars. Overall, testing of skin samples resulted in a higher proportion of positive results than testing of blood samples. Presented data from model animals demonstrates that testing of skin samples from sites of rickettsial proliferation can provide definitive molecular diagnosis of up to 60-70% of tick-borne SFG rickettsial infections during the acute stage of illness. Detection of pathogen DNA in cutaneous samples is a valuable alternative to blood-PCR at least in model animals.

Failure of a heterologous recombinant Sca5/OmpB protein-based vaccine to elicit effective protective immunity against Rickettsia rickettsii infections in C3H/HeN mice

Spotted fever group (SFG) rickettsial species are obligate intracellular tick-borne pathogens that are responsible for important human diseases. Previous reports have demonstrated the feasibility of using recombinant surface cell antigen Sca5/OmpB to elicit protective immunity against homologous challenges using murine models of Mediterranean spotted fever and Rocky Mountain spotted fever. In addition, the feasibility of generating cross-protective immunity against related rickettsial species has also been established, but the molecular basis for these phenomena was not explored. Here, we demonstrate that vaccination of C3H/HeN mice with a recombinant OmpB domain derived from Rickettsia conorii induced high titer humoral immune responses that are capable of recognizing the native OmpB protein at the R. rickettsii outer membrane, but this immunization was not sufficient to induce effective protective immunity. In contrast, animals vaccinated with a corresponding OmpB domain derived from R. rickettsii protected animals from fatal outcomes. These results demonstrate that vaccination with nearly identical antigens may not be an effective strategy to induce wide-ranging protective immunity against related SFG Rickettsia species.

Rickettsiae induce microvascular hyperpermeability via phosphorylation of VE-cadherins: evidence from atomic force microscopy and biochemical studies

The most prominent pathophysiological effect of spotted fever group (SFG) rickettsial infection of microvascular endothelial cells (ECs) is an enhanced vascular permeability, promoting vasogenic cerebral edema and non-cardiogenic pulmonary edema, which are responsible for most of the morbidity and mortality in severe cases. To date, the cellular and molecular mechanisms by which SFG Rickettsia increase EC permeability are largely unknown. In the present study we used atomic force microscopy (AFM) to study the interactive forces between vascular endothelial (VE)-cadherin and human cerebral microvascular EC infected with R. montanensis, which is genetically similar to R. rickettsii and R. conorii, and displays a similar ability to invade cells, but is non-pathogenic and can be experimentally manipulated under Biosafety Level 2 (BSL2) conditions. We found that infected ECs show a significant decrease in VE-cadherin-EC interactions. In addition, we applied immunofluorescent staining, immunoprecipitation phosphorylation assay, and an in vitro endothelial permeability assay to study the biochemical mechanisms that may participate in the enhanced vascular permeability as an underlying pathologic alteration of SFG rickettsial infection. A major finding is that infection of R. montanensis significantly activated tyrosine phosphorylation of VE-cadherin beginning at 48 hr and reaching a peak at 72 hr p.i. In vitro permeability assay showed an enhanced microvascular permeability at 72 hr p.i. On the other hand, AFM experiments showed a dramatic reduction in VE-cadherin-EC interactive forces at 48 hr p.i. We conclude that upon infection by SFG rickettsiae, phosphorylation of VE-cadherin directly attenuates homophilic protein-protein interactions at the endothelial adherens junctions, and may lead to endothelial paracellular barrier dysfunction causing microvascular hyperpermeability. These new approaches should prove useful in characterizing the antigenically related SFG rickettsiae R. conorii and R. rickettsii in a BSL3 environment. Future studies may lead to the development of new therapeutic strategies to inhibit the VE-cadherin-associated microvascular hyperpermeability in SFG rickettsioses.

Molecular Pathology of Rickettsial Lung Infections

Rickettsial infections of humans comprise a diverse group of infections caused by pathogens that are obligate intracellular bacteria with a genetic relationship, including the genera Rickettsia, Orientia, Ehrlichia, and Anaplasma. The host cells of these pathogens largely belie the systemic clinical manifestations, because Rickettsia and Orientia infect endothelial cells, and Ehrlichia and Anaplasma infect circulating leukocytes (monocytes and neutrophils, respectively). Thus, the predominant manifestations (fever, headache, myalgia, with or without rash) do not usually focus attention on the respiratory system; however, the underlying pathogenesis of these infections involves degrees of vascular compromise either by direct injury and inflammation or by the action of vasoactive proinflammatory molecules such as cytokines, chemokines, and prostaglandins. Given that the lung possesses the largest vascular bed in the human body, it is not surprising that pulmonary involvement is periodically identified and, when severely affected, is considered a potentially life-threatening complication.1,2

Rickettsial infections around the world, part 1: pathophysiology and the spotted fever group

BACKGROUND

The rickettsial diseases are an important group of infectious agents that have dermatological manifestations. These diseases are important to consider in endemic areas, but in certain suspicious cases, possible acts of bioterrorism should warrant prompt notification of the appropriate authorities.

OBJECTIVE

In this two part review article, we review these diverse diseases by examining established and up-to-date information about the pathophysiology, epidemiology, clinical manifestations, and treatment of the ricksettsiae.

METHODS

Using PubMed to search for relevant articles, we browsed over 500 articles to compose a clinically based review article.

RESULTS

Part one focuses on pathophysiology of the rickettsial diseases and the clinical aspects of the spotted fever group.

CONCLUSIONS

At the completion of part one of this learning activity, participants should be able to discuss all of the clinical manifestations and treatments of the sported fever group. Participants should also be familiar with the pathophysiology of the rickettsial diseases.

Rickettsial Infections around the World, Part 1: Pathophysiology and the Spotted Fever Group

Background:

The rickettsial diseases are an important group of infectious agents that have dermatological manifestations. These diseases are important to consider in endemic areas, but in certain suspicious cases, possible acts of bioterrorism should warrant prompt notification of the appropriate authorities.

Objective:

In this two part review article, we review these diverse diseases by examining established and up-to-date information about the pathophysiology, epidemiology, clinical manifestations, and treatment of the ricksettsiae.

Methods:

Using PubMed to search for relevant articles, we browsed over 500 articles to compose a clinically based review article.

Results:

Part one focuses on pathophysiology of the rickettsial diseases and the clinical aspects of the spotted fever group.

Conclusions:

At the completion of part one of this learning activity, participants should be able to discuss all of the clinical manifestations and treatments of the sported fever group. Participants should also be familiar with the pathophysiology of the rickettsial diseases.

Characterization of spotted fever group rickettsiae in flea and tick specimens from northern Peru

Evidence of spotted fever group (SFG) rickettsiae was obtained from flea pools and individual ticks collected at three sites in northwestern Peru within the focus of an outbreak of febrile disease in humans attributed, in part, to SFG rickettsia infections. Molecular identification of the etiologic agents from these samples was determined after partial sequencing of the 17-kDa common antigen gene (htrA) as well as pairwise nucleotide sequence homology with one or more of the following genes: gltA, ompA, and ompB. Amplification and sequencing of portions of the htrA and ompA genes in pooled samples (2 of 59) taken from fleas identified the pathogen Rickettsia felis. Four tick samples yielded molecular evidence of SFG rickettsiae. Fragments of the ompA (540-bp) and ompB (2,484-bp) genes were amplified from a single Amblyomma maculatum tick (tick 124) and an Ixodes boliviensis tick (tick 163). The phylogenetic relationships between the rickettsiae in these samples and other rickettsiae were determined after comparison of their ompB sequences by the neighbor-joining method. The dendrograms generated showed that the isolates exhibited close homology (97%) to R. aeschlimannii and R. rhipicephali. Significant bootstrap values supported clustering adjacent to this nodule of the SFG rickettsiae. While the agents identified in the flea and tick samples have not been linked to human cases in the area, these results demonstrate for the first time that at least two SFG rickettsia agents were circulating in northern Peru at the time of the outbreak. Furthermore, molecular analysis of sequences derived from the two separate species of hard ticks identified a possibly novel member of the SFG rickettsiae.

The past and present threat of rickettsial diseases to military medicine and international public health

Morbidity and mortality caused by rickettsioses have had a major influence on military activities and public health for >2000 years. The threat posed by the rickettsioses is reviewed, focusing on the impact and epidemiology of those that have adversely influenced wartime operations and the current challenges posed by these diseases. With their uneven worldwide distribution, the discovery of drug-refractory strains of Orientia tsutsugamushi, the increased threat of their use in acts of bioterrorism, frequent deployment of troops to regions of endemicity, and exposures due to increased humanitarian missions, these diseases continue to be a threat to military personnel in the field. Effective strategies to reduce the impact of these diseases include development of effective vaccines, enhanced surveillance, and development of new safe, effective, and odorless repellants. The continuation of a proven, highly productive military infectious disease research program is essential for providing solutions to these daunting tasks.

Tick-borne diseases in transfusion medicine

Ticks are effective vectors of viral, bacterial, rickettsial and parasitic diseases. Many of the tick-borne diseases (TBDs) are of significance to transfusion medicine, either because of the risks they pose to the blood supply or the necessity for blood products required in their treatment. The transmission of tick-borne pathogens via blood transfusion is of global concern. However, among transfusion medicine practitioners, experience with most of these microorganisms is limited. Transfusion transmission of TBDs has been documented largely by means of single case reports. A better understanding of the epidemiology, biology and management of this group of diseases is necessary in order to assess the risks they pose to the blood supply and to help guide effective prevention strategies to reduce this risk. Unique methods are required to focus on donor selection, predonation questioning, mass screening and inactivation or eradication procedures. The role of the transfusion medicine service in their treatment also needs to be better defined. This article reviews the growing body of literature pertaining to this emerging field of transfusion medicine and offers some recommendations for transfusionists in dealing with TBDs.

Imported skin diseases in dermatology

Millions of afflicted people suffer from conditions which Japanese dermatologists may rarely encounter. Many of our patients travel extensively either as part of work-related business trips or during vacationing. From three to ten percent of travelers experience skin, hair or nail disorders. With worldwide travel heightening exposure to the causative agents, there is an increasing likelihood that a patient with leishmaniasis, Boutonneuse fever, onchocerciasis, loaiasis, dengue fever, cutaneous larva migrans or other recently acquired skin conditions from a far away land will visit your office for diagnosis and treatment. The clinical characteristics, diagnostic tests and therapeutic options for such imported tropical diseases will be discussed.

Tick-borne pulmonary disease: update on diagnosis and management

Ticks are capable of transmitting viruses, bacteria, protozoa, and rickettsiae to man. Several of these tick-borne pathogens can lead to pulmonary disease. Characteristic clinical features, such as erythema migrans in Lyme disease, or spotted rash in a spotted fever group disease, may serve as important diagnostic clues. Successful management of tick-borne diseases depends on a high index of suspicion and recognition of their clinical features. Patients at risk for tick bites may be coinfected with two or more tick-borne pathogens. A Lyme vaccine has recently become available for use in the United States. Disease prevention depends on the avoidance of tick bites. When patients present with respiratory symptoms and a history of a recent tick bite or a characteristic skin rash, a differential diagnosis of a tick-borne pulmonary disease should be considered. Early diagnosis and appropriate antibiotic therapy for these disorders lead to greatly improved outcomes.

Skin problems in the traveler

Skin lesions are common in travelers and include a mix of mundane dermatologic problems and rare diseases acquired only in remote or tropical regions. The morphology, distribution, and progression of the lesions are useful in assessing possible causes. Early in the evaluation it is important to determine whether the patient might have a process that is rapidly progressive, treatable, or transmissible. In addition to routine laboratory studies, biopsy and serologic tests are often necessary to confirm a specific diagnosis.

Antibodies to spotted fever group rickettsiae in dogs in Croatia

The prevalence of IgG antibodies to spotted fever group rickettsiae was studied by the indirect immunofluorescent antibody assay in a sample of 194 canine sera from different parts of Croatia. Dogs (n = 141) from urban and suburban-semirural environs from the middle part of the eastern coast of Adriatic sea, and dogs (n = 53) from Zagreb, the capital of Croatia located in the northern continental part of Croatia, were tested. The total of 88 (62.4%) dogs from southern coastal Croatia had antibodies to Rickettsia conorii, with a significantly higher prevalence (69.9%) in suburban-semirural areas. The prevalence rate of antibodies to Rickettsia conorii in canine sera from urban environment in the north of Croatia was 20.7%. The results show that the members of spotted fever group rickettsiae are present in both coastal and continental Croatia.

Fatal rickettsial meningitis in Hong Kong: a need for rapid laboratory diagnosis

A 22-year-old Chinese male, investigated elsewhere for fever and myalgia, was transferred to our hospital drowsy, unresponsive to commands and with a petechial rash. Partially treated meningococcal meningitis was suspected and high-dose antibiotics were immediately started. Rising Weil-Felix titres occurred too late for anti-rickettsial therapy to prevent a fatal outcome. Subsequent specific serology showed rising titres against Rickettsia conori. The desirability of more rapid and reliable methods of laboratory diagnosis of rickettsial infection is evident.

[Tick-borne diseases]

Due to their worldwide distribution, from hottest to coldest climates, and due to their behaviour, ticks are capable of transmitting numerous human and animal bacterial viral or parasitous diseases. Depending on the disease, they play the role of biological vector or intermediate host. In France, six tick borne diseases are of epidemiologic importance. Q fever (not often tick-borne), Mediterranean Spotted Fever, Lyme disease, Turalemia (human and animal), Babesiosis and Tick-borne Viral Encephalitis.

Comparison of Western immunoblotting and microimmunofluorescence for diagnosis of Mediterranean spotted fever

One-hundred serum samples from 41 patients suffering from Mediterranean spotted fever (MSF) were tested by microimmunofluorescence (MIF) and Western blot (WB; immunoblot). Immunoglobulin G (IgG), IgM, and IgA antibody-specific responses to the high-molecular-mass species-specific protein antigens (115 kDa and 135 kDa) of Rickettsia conorii, as well as to cross-reactive lipopolysaccharide (LPS) antigens, were observed. The WB assay detected IgM-type antibodies earlier than did the MIF assay. These antibodies were often directed against nonspecific LPS and may have a questionable positive predictive value. In addition, an IgG reaction to a 60-kDa protein was observed in four cases of malignant forms of MSF but was never observed in cases of mild forms. This reaction could be correlated with a marker of the severity of the development of MSF. From a previous MIF survey of blood donors, 9 negative, 11 IgG-positive, and 6 IgM-positive serum samples were selected for comparison by WB. Sera negative by MIF were also negative by WB. MIF IgG-positive sera showed a specific response to R. conorii in the WB assay, but the six serum samples from this seroepidemiological study positive for IgM by MIF were almost all negative by the WB assay. One was positive for IgM against the LPS but was considered a false positive. The WB is shown to provide a new tool for serodiagnosis.