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

Orientia and Rickettsia: different flowers from the same garden

Recent discoveries of basal extracellular Rickettsiales have illuminated divergent evolutionary paths to host dependency in later-evolving lineages. Family Rickettsiaceae, primarily comprised of numerous protist- and invertebrate-associated species, also includes human pathogens from two genera, Orientia and Rickettsia. Once considered sister taxa, these bacteria form distinct lineages with newly appreciated lifestyles and morphological traits. Contrasting other rickettsial human pathogens in Family Anaplasmataceae, Orientia and Rickettsia species do not reside in host-derived vacuoles and lack glycolytic potential. With only a few described mechanisms, strategies for commandeering host glycolysis to support cytosolic growth remain to be discovered. While regulatory systems for this unique mode of intracellular parasitism are unclear, conjugative transposons unique to Orientia and Rickettsia species provide insights that are critical for determining how these obligate intracellular pathogens overtake eukaryotic cytosol.

Mediterranean Spotted Fever: Current Knowledge and Recent Advances

Mediterranean spotted fever (MSF) is an emerging tick-borne rickettsiosis of the spotted fever group (SFG), endemic in the Mediterranean basin. By virtue of technological innovations in molecular genetics, it has been determined that the causative agent of MSF is Rickettsia conorii subspecies conorii. The arthropod vector of this bacterium is the brown dog tick Rhipicephalus sanguineus. The true nature of the reservoir of R. conorii conorii has not been completely deciphered yet, although many authors theorize that the canine population, other mammals, and the ticks themselves could potentially contribute as reservoirs. Typical symptoms of MSF include fever, maculopapular rash, and a characteristic eschar (“tache noire”). Atypical clinical features and severe multi-organ complications may also be present. All of these manifestations arise from the disseminated infection of the endothelium by R. conorii conorii. Several methods exist for the diagnosis of MSF. Serological tests are widely used and molecular techniques have become increasingly available. Doxycycline remains the treatment of choice, while preventive measures are focused on modification of human behavior and vector control strategies. The purpose of this review is to summarize the current knowledge on the epidemiology, pathogenesis, clinical features, diagnosis, and treatment of MSF.

Vaccine Design and Vaccination Strategies against Rickettsiae

Rickettsioses are febrile, potentially lethal infectious diseases that are a serious health threat, especially in poor income countries. The causative agents are small obligate intracellular bacteria, rickettsiae. Rickettsial infections are emerging worldwide with increasing incidence and geographic distribution. Nonetheless, these infections are clearly underdiagnosed because methods of diagnosis are still limited and often not available. Another problem is that the bacteria respond to only a few antibiotics, so delayed or wrong antibiotic treatment often leads to a more severe outcome of the disease. In addition to that, the development of antibiotic resistance is a serious threat because alternative antibiotics are missing. For these reasons, prophylactic vaccines against rickettsiae are urgently needed. In the past years, knowledge about protective immunity against rickettsiae and immunogenic determinants has been increasing and provides a basis for vaccine development against these bacterial pathogens. This review provides an overview of experimental vaccination approaches against rickettsial infections and perspectives on vaccination strategies.

Neglected human Rickettsia felis infection in Taiwan: A retrospective seroepidemiological survey of patients with suspected rickettsioses

BACKGROUND

Current knowledge on Rickettsia felis infection in humans is based on sporadic case reports. Here we conducted a retrospective seroepidemiological survey of R. felis infection among febrile patients visiting a medical center in Taipei.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 122 patients with suspected rickettsioses presenting with fever of unknown origin (FUO) but tested negative for scrub typhus, murine typhus, or Q fever were retrospectively identified during 2009 to 2010. The archived serum samples were examined for the presence of antibodies against R. felis, Rickettsia japonica, and Rickettsia typhi using microimmunofluorescence (MIF) assay. Serological evidence of Rickettsia exposure was found in 23 (19%, 23/122) patients. Eight patients had antibodies reactive to R. felis, including four with current infection (a ≥4-fold increase in IgG titer between acute and convalescent sera). The clinical presentations of these four patients included fever, skin rash, lymphadenopathy, as well as more severe conditions such as pancytopenia, hepatomegaly, elevated liver enzymes/bilirubin, and life-threatening acute respiratory distress syndrome. One of the patients died after doxycycline was stopped after being tested negative for scrub typhus, Q fever, and murine typhus.

CONCLUSIONS

Rickettsia felis is a neglected flea-borne pathogen in Taiwan, and its infection can be life-threatening. Further prospective studies of the prevalence of R. felis among patients with FUO and compatible clinical manifestations are warranted.

The neglected challenge: Vaccination against rickettsiae

Over the last decades, rickettsioses are emerging worldwide. These diseases are caused by intracellular bacteria. Although rickettsioses can be treated with antibiotics, a vaccine against rickettsiae is highly desired for several reasons. Rickettsioses are highly prevalent, especially in poor countries, and there are indications of the development of antibiotic resistance. In addition, some rickettsiae can persist and cause recurrent disease. The development of a vaccine requires the understanding of the immune mechanisms that are involved in protection as well as in immunopathology. Knowledge about these immune responses is accumulating, and efforts have been undertaken to identify antigenic components of rickettsiae that may be useful as a vaccine. This review provides an overview on current knowledge of adaptive immunity against rickettsiae, which is essential for defense, rickettsial antigens that have been identified so far, and on vaccination strategies that have been used in animal models of rickettsial infections.

Clinically-diagnosed Mediterranean Spotted Fever in Malta

BACKGROUND

Mediterranean Spotted Fever (MSF) is a tick-borne zoonosis caused by Rickettsia conorii which is endemic in Malta, an island in the South Mediterranean that is a popular tourist destination. Diagnosis is frequently based on clinical manifestations as laboratory results are often limited to a retrospective diagnosis. We describe the clinical presentation, diagnosis and treatment of children <16 years who presented with MSF from 2011 to 2016.

METHOD

The demographics, clinical findings, laboratory results, management and outcome of all children hospitalised with suspected MSF based on the presence of fever and an eschar, were retrieved from their case notes.

RESULTS

Over the five-year study period six children, aged between 17 months and 15 years, were diagnosed with MSF. All children had contact with ticks and the majority presented in summer. Laboratory results were non-specific and included elevated inflammatory markers, lymphocytosis/lymphopenia and hyponatraemia. Serological and molecular techniques were used for diagnosis. Response to clarithromycin or doxycycline was immediate.

CONCLUSION

MSF should be included in the differential diagnosis of fever, rash and an eschar in children who travel to Malta. Despite advances in molecular diagnostics, clinical diagnosis remains important in the management of children with suspected MSF.

Guidelines for the Detection of Rickettsia spp

The genus Rickettsia (Rickettsiales: Rickettsiaceae) includes Gram-negative, small, obligate intracellular, nonmotile, pleomorphic coccobacilli bacteria transmitted by arthropods. Some of them cause human and probably also animal disease (life threatening in some patients). In these guidelines, we give clinical practice advices (microscopy, serology, molecular tools, and culture) for the microbiological study of these microorganisms in clinical samples. Since in our environment rickettsioses are mainly transmitted by ticks, practical information for the identification of these arthropods and for the study of Rickettsia infections in ticks has also been added.

Novel Rickettsia raoultii strain isolated and propagated from Austrian Dermacentor reticulatus ticks

Background

Continuous culture of tick cell lines has proven a valuable asset in isolating and propagating several different vector-borne pathogens, making it possible to study these microorganisms under laboratory conditions and develop serological tests to benefit public health. We describe a method for effective, cost- and labor-efficient isolation and propagation of Rickettsia raoultii using generally available laboratory equipment and Rhipicephalus microplus cells, further demonstrating the usefulness of continuous tick cell lines. R. raoultii is one of the causative agents of tick-borne lymphadenopathy (TIBOLA) and is, together with its vector Dermacentor reticulatus, emerging in novel regions of Europe, giving rise to an increased threat to general public health.

Methods

Dermacentor reticulatus ticks were collected in the Donau-Auen (Lobau) national park in Vienna, Austria. The hemolymph of ten collected ticks was screened by PCR-reverse line blot for the presence of rickettsial DNA. A single tick tested positive for R. raoultii DNA and was used to infect Rhipicephalus microplus BME/CTVM2 cells.

Results

Sixty-five days after infection of the tick-cell line with an extract from a R. raoultii-infected tick, we observed intracellular bacteria in the cultured cells. On the basis of microscopy we suspected that the intracellular bacteria were a species of Rickettsia; this was confirmed by several PCRs targeting different genes. Subsequent sequencing showed 99–100 % identity with R. raoultii. Cryopreservation and resuscitation of R. raoultii was successful. After 28 days identical intracellular bacteria were microscopically observed.

Conclusions

R. raoultii was successfully isolated and propagated from D. reticulatus ticks using R. microplus BME/CTVM2 cells. The isolated strain shows significant molecular variation compared to currently known sequences. Furthermore we show for the first time the successful cryopreservation and resuscitation of R. raoultii.

Strategies for detecting rickettsiae and diagnosing rickettsial diseases

Rickettsial diseases and scrub typhus constitute a group of the oldest known vector-borne diseases. The cosmopolitan distribution of the vectors that transmit rickettsiae and orientiae leads to a worldwide prevalence of these diseases. Despite their significant historical status, detection and diagnosis of these diseases are still evolving today. Serological methods remain among the most prevalent techniques used for the detection/diagnosis of rickettsial diseases and scrub typhus. Molecular techniques have been instrumental in increasing the sensitivity/specificity of diagnosis, identifying new Rickettsia and Orientia species and have enhanced epidemiological capabilities when used in combination with serological methods. In this review, we discuss these techniques and their associated pros and cons.

Antibodies to Rickettsia spp. and Borrelia burgdorferi in Spanish Wild Red Foxes (Vulpes vulpes)

We examined 314 red foxes (Vulpes vulpes) from the province of Soria, Spain, for Rickettsia typhi, Rickettsia slovaca, and Borrelia burgdorferi infection. Immunofluorescence assays showed 1.9% had antibodies to R. typhi, 6.7% had antibodies to R. slovaca, and 8.3% had antibodies to B. burgdorferi. Serostatus was not correlated with sex or age. Because red foxes can be infected by Rickettsiae and B. burgdorferi, presence of red foxes may be and indicator for the presence of these pathogens.

Survival of rat cerebrocortical neurons after rickettsial infection

Neuroinvasive microorganisms are suspected to play an important role in the etiopathogenesis of neurological diseases. However, direct evidence for the pathogenic function is still missing. The main aim of this study was to investigate biochemical and morphological changes that may occur as a result of an in vitro infection of rat cerebrocortical neurons by selected members of the genus Rickettsia. Our results showed that survival of the neurons is significantly reduced after the infection. Intracellular level of ATP is gradually decreased and inversely correlates with the load of rickettsiae. Immunofluorescence revealed that rickettsiae can enter the neurons and are localized in perinuclear space and also in neuronal processes. Data obtained in this study correspond to the idea of possible involvement of rickettsiae in the etiopathogenesis of various neuropathies.

Serological differentiation of antibodies against Rickettsia helvetica, R. raoultii, R. slovaca, R. monacensis and R. felis in dogs from Germany by a micro-immunofluorescent antibody test

Background

Spotted Fever Group (SFG) Rickettsiae can cause febrile diseases with or without rash in humans worldwide. In Germany only limited data are available about their medical significance. Serological screening tests for antibodies against rickettsiae usually only distinguish between SFG and Typhus Group (TG) Rickettsiae due to the strong cross reactivities within the groups. Seroprevalence rates in dogs, as possible sentinels for tick-borne diseases, could serve as an indicator for the distribution of different Rickettsia species.

Methods

In this study, a micro-immunofluorescence assay (micro-IFA) was established for detection and differentiation of antibodies against five Rickettsia species in dogs (R. helvetica, R. raoultii, R. slovaca, R. monacensis and R. felis). Dogs that never left Germany (n = 605) previously investigated with an SFG-ELISA were included in this study and screened at a 1:128 dilution. Endpoint titres of fifty randomly selected seropositive samples of each of the five investigated regions in Germany were determined in order to allow a differentiation of the causative Rickettsia species. Sensitivity and specificity of the micro-IFA were compared with ELISA results of the previous study.

Results

A total of 93.9% of the dogs were positive for antibodies of the SFG Rickettsiae at the screening titer of 1:128. Differentiation of SFG Rickettsiae with the micro-IFA was possible in 70.4%, but in 29.6% of the cases the detected antibodies were not differentiable. Considering a clear differentiation by a twofold titre difference between observed reactions, the seroprevalence rates were 66.0% for R. helvetica, 2.8% for R. raoultii, 1.6% for R. slovaca, but no serological reaction could be clearly attributed to R. monacensis or R. felis. No statistically significant regional differences were found for R. helvetica, R. slovaca and R. raoultii comparing the five regions of Germany. Comparison of micro-IFA with ELISA revealed a sensitivity of 82.0% and a specificity of 83.8% for the Rickettsia SFG ELISA.

Conclusions

The micro-IFA is a useful serological tool to differentiate antibodies against different Rickettsia species in dogs. Seroprevalence rates in dogs correspond to the prevalence rates and distribution of Rickettsia-carrying tick species.

Inadequacy of IgM antibody tests for diagnosis of Rocky Mountain Spotted Fever

Among 13 suspected Rocky Mountain spotted fever (RMSF) cases identified through an enhanced surveillance program in Tennessee, antibodies to Rickettsia rickettsii were detected in 10 (77%) patients using a standard indirect immunofluorescent antibody (IFA) assay. Immunoglobulin M (IgM) antibodies were observed for 6 of 13 patients (46%) without a corresponding development of IgG, and for 3 of 10 patients (30%) at least 1 year post-onset. However, recent infection with a spotted fever group rickettsiae could not be confirmed for any patient, based on a lack of rising antibody titers in properly timed acute and convalescent serologic specimens, and negative findings by polymerase chain reaction testing. Case definitions used in national surveillance programs lack specificity and may capture cases that do not represent current rickettsial infections. Use of IgM antibodies should be reconsidered as a basis for diagnosis and public health reporting of RMSF and other spotted fever group rickettsiae in the United States.

The seroprevalence of human infection withRickettsia slovaca, in an area of northern Spain

An epidemiological survey was undertaken to explore human exposure to Rickettsia slovaca in two provinces of northern Spain. When IFAT were used to test 200 members of the general population for antibodies to rickettsiae of the spotted-fever group, six (3.3%) were found positive, presumably, since Dermacentor is one of the most common genera of human-biting tick in the study area, for antibodies to R. slovaca. Thirty-one (16.9%) of an additional 183 subjects who presented shortly after being bitten by ticks were also found seropositive. The difference in seroprevalence between the general and the tick-bitten populations was significant. Subject gender had no influence on seroprevalence in either population, although, in the tick-bitten group, age and occupation did have a significant influence on the prevalence recorded. Immunoblotting was used to confirm the presence of antibodies in the five subjects, all from the tick-bitten group, found to have acute infections. Three D. marginatus ticks obtained from three of these acute cases were found PCR-positive for R. slovaca DNA.

Advances in rickettsia pathogenicity

One century after the first description of rickettsiae as human pathogens, the rickettsiosis remained poorly understood diseases. These microorganisms are indeed characterized by a strictly intracellular location which has, for long, prohibited their detailed study. Within the last ten years, the completion of the genome sequences of several strains allowed gaining a better knowledge about the molecular mechanisms involved in rickettsia pathogenicity. Here, we summarized available data concerning the critical steps of rickettsia-host cell interactions that should contribute to tissue injury and diseases, that is, adhesion, phagosomal escape, motility, and intracellular survival of the bacteria.

Serological and molecular evidence of Rickettsia helvetica in Denmark

Recent seroepidemiological studies and examinations of Ixodes ricinus ticks in Europe have demonstrated the presence of an emerging tick-borne infection with Rickettsia helvetica. We conducted a serosurvey in 168 Danish patients seropositive for borreliosis reflecting their exposure to I. ricinus ticks. A total of 21 patients (12.5%) had positive antibody titres to R. helvetica including 4 cases of seroconversion. None of the samples were positive for antibodies to Ehrlichia. We conclude that in humans exposed to I. ricinus ticks in Denmark the risk of acquiring rickettsial infection is for the first time demonstrated. In the same region of Denmark we collected 570 I. ricinus ticks from various sources, and examinations by PCR for Rickettsia were performed. Positive reactions were obtained in 23 ticks (4%), and R. helvetica was identified in all 13 of those for which sequencing was performed.

A study of the antigenicity of Rickettsia helvetica proteins using two-dimensional gel electrophoresis

Rickettsia helvetica is an obligate intracellular Gram-negative microorganism found in Ixodes ricinus ticks. When R. helvetica was first discovered in 1979, little was known about its physiology and it fell into oblivion until it recently was suspected of being pathogenic to humans. However, all efforts to isolate R. helvetica from patients have been unsuccessful, although serological responses against R. helvetica can be demonstrated. The aim of our study was to investigate the protein profile of R. helvetica and study the antigenicity of its proteins using two-dimensional (2D) immunoblot in order to characterize the immunological response against R. helvetica infection. Our results show that in addition to the known PS120 and OmpB antigenic R. helvetica proteins, three other antigens exist: a 60 kDa GroEL protein, a 10 kDa GroES protein and a hitherto unknown 35 kDa hypothetical protein that has similarities with ORF-RC0799 of Rickettsia conorii. Furthermore, the lipopolysaccharide showed strong antigenicity. In this study, we present the first proteome map and the first 2D immunoblot profile of R. helvetica and finally we present the 35 kDa R. helvetica as an additional antigen to the previously known rickettsial antigens.

Analysis of the Rickettsia africae genome reveals that virulence acquisition in Rickettsia species may be explained by genome reduction

Background

The Rickettsia genus includes 25 validated species, 17 of which are proven human pathogens. Among these, the pathogenicity varies greatly, from the highly virulent R. prowazekii, which causes epidemic typhus and kills its arthropod host, to the mild pathogen R. africae, the agent of African tick-bite fever, which does not affect the fitness of its tick vector.

Results

We evaluated the clonality of R. africae in 70 patients and 155 ticks, and determined its genome sequence, which comprises a circular chromosome of 1,278,540 bp including a tra operon and an unstable 12,377-bp plasmid. To study the genetic characteristics associated with virulence, we compared this species to R. prowazekii, R. rickettsii and R. conorii. R. africae and R. prowazekii have, respectively, the less and most decayed genomes. Eighteen genes are present only in R. africae including one with a putative protease domain upregulated at 37°C.

Conclusion

Based on these data, we speculate that a loss of regulatory genes causes an increase of virulence of rickettsial species in ticks and mammals. We also speculate that in Rickettsia species virulence is mostly associated with gene loss.

The genome sequence was deposited in GenBank under accession number [GenBank: NZ_AAUY01000001].

Rickettsia conorii transcriptional response within inoculation eschar

Background

Rickettsia conorii, the causative agent of the Mediterranean spotted fever, is transmitted to humans by the bite of infected ticks Rhipicephalus sanguineus. The skin thus constitutes an important barrier for the entry and propagation of R. conorii. Given this, analysis of the survival strategies used by the bacterium within infected skin is critical for our understanding of rickettsiosis.

Methodology/Principal Findings

Here, we report the first genome-wide analysis of R. conorii gene expression from infected human skin biopsies. Our data showed that R. conorii exhibited a striking transcript signature that is remarkably conserved across patients, regardless of genotype. The expression profiles obtained using custom Agilent microarrays were validated by quantitative RT-PCR. Within eschars, the amount of detected R. conorii transcripts was of 55%, this value being of 74% for bacteria grown in Vero cells. In such infected host tissues, approximately 15% (n = 211) of the total predicted R. conorii ORFs appeared differentially expressed compared to bacteria grown in standard laboratory conditions. These genes are mostly down-regulated and encode proteins essential for bacterial replication. Some of the strategies displayed by rickettsiae to overcome the host defense barriers, thus avoiding killing, were also pointed out. The observed up-regulation of rickettsial genes associated with DNA repair is likely to correspond to a DNA-damaging agent enriched environment generated by the host cells to eradicate the pathogens. Survival of R. conorii within eschars also involves adaptation to osmotic stress, changes in cell surface proteins and up-regulation of some virulence factors. Interestingly, in contrast to down-regulated transcripts, we noticed that up-regulated ones rather exhibit a small nucleotide size, most of them being exclusive for the spotted fever group rickettsiae.

Conclusion/Significance

Because eschar is a site for rickettsial introduction, the pattern of rickettsial gene expression observed here may define how rickettsiae counteract the host defense.

Serologic study of rickettsioses among acute febrile patients in central Tunisia

Although Mediterranean spotted or "boutonneuse" fever (MSF) has been documented in central Tunisia, other spotted fever group rickettsioses (SFGR) and typhus group rickettsioses (TGR) have received little attention in our region. We sought to determine the role of rickettsioses, Q fever, ehrlichioses, and bartonelloses among patients with acute fever. The results of this study of 47 persons with acute fever of undetermined origin are reported in this paper. We concluded that SFGR, murine typhus, and acute Q fever are common causes of acute isolate fever in summer in central Tunisia and should be investigated systematically in patients with acute fever of unknown origin.

Reemergence of Rickettsiosis in Oran, Algeria

The presumptive cases of Mediterranean spotted fever have been identified in 1993 and since that time, its frequency has steadily increased. The prospective study, in summer 2004, was conducted in order to present the descriptive clinic and epidemiology, to identify more severe forms, the presence of the multiple eschars, and different rickettsial strains caused the disease in our region. In Oran, the cases were diagnosed clinically. In Marseille, serum specimens were tested by IFA using the panel of eight rickettsial antigen; Western blot and cross-adsorption studies were also performed in order to confirm the diagnosis. Ninety-three patients clinically diagnosed were recorded from July 3 to October 28, 2004. Eighty percent were male, the mean age was 44.3 years, 90% were exposed to dog and 32% reported tick bites. Clinical signs were as follow: presence of underlying disease (44%), sudden onset (78%), fever (100%), loss of weight (63%), conjunctivitis (43%), and a tache noire was noticed in 70%. Interestingly, two patients had two and three eschars, respectively. The rash was maculopapular (palm and sole) and purpuric in nine cases. Doxycycline was the most antibiotic (91%) with favourable outcome in 91% of the cases. Malignant form with death is reported for three patients (3.2%). Among the 93 patients, 104 serum from 65 patients were tested (serums of others patients were lost or ticket not found on tube. Sixty-three patients out of 65 had a positive serology by IFA with cross-reactive antibodies especially between R. conorii, R. felis and/or R. typhi. Two others negative serology were: one precocious serum and second from the patient, which presented symptoms of MSF and tested two serums, Western blot and cross-adsorption.

Phylogenetic study of Rickettsia species using sequences of the autotransporter protein-encoding gene sca2

The analyses of genome sequences from Rickettsia conorii and R. prowazekii have allowed the identification of five genes encoding autotransporter proteins, including ompA and four genes annotated in the R. prowazekii genome as "surface cell antigen" (sca) genes. Of these, ompA and sca5 (ompB) are known to encode membrane-exposed antigenic proteins playing a major role in the host's immune response, and sca4 encodes a truncated autotransporter protein. In order to study further the phylogeny of the genus Rickettsia, we attempted amplification and sequencing of the sca2 genes from the 20 currently validated Rickettsia species. Sixteen species exhibited a complete sca2 gene, ranging from 2,727 bp in R. bellii to 5,580 bp in R. rhipicephali. R. helvetica and R. canadensis had a split gene, and R. prowazekii and R. typhi had remnant fragments of sca2. We also identified in R. akari, R. prowazekii, and R. typhi a duplication of the sca2 gene. The phylogenetic trees inferred from both the nucleotide and protein sequences of sca2 showed four clusters of rickettsiae, that is, the R. rickettsii, R. massiliae, R. akari, and typhus groups, which were supported by significant bootstrap values.

Human Rickettsia felis infection, Canary Islands, Spain

We report the first cases of human infection by Rickettsia felis in the Canary Islands. Antibodies against R. felis were found in 5 adsorbed serum samples from 44 patients with clinically suspected rickettsiosis by Western blot serology. Fleas from 1 patient's dog were positive for R. felis by polymerase chain reaction.

Sca1, a previously undescribed paralog from autotransporter protein-encoding genes in Rickettsia species

BACKGROUND

Among the 17 genes encoding autotransporter proteins of the "surface cell antigen" (sca) family in the currently sequenced Rickettsia genomes, ompA, sca5 (ompB) and sca4 (gene D), have been extensively used for identification and phylogenetic purposes for Rickettsia species. However, none of these genes is present in all 20 currently validated Rickettsia species. Of the remaining 14 sca genes, sca1 is the only gene to be present in all nine sequenced Rickettsia genomes. To estimate whether the sca1 gene is present in all Rickettsia species and its usefulness as an identification and phylogenetic tool, we searched for sca1genes in the four published Rickettsia genomes and amplified and sequenced this gene in the remaining 16 validated Rickettsia species.

RESULTS

Sca1 is the only one of the 17 rickettsial sca genes present in all 20 Rickettsia species. R. prowazekii and R. canadensis exhibit a split sca1 gene whereas the remaining species have a complete gene. Within the sca1 gene, we identified a 488-bp variable sequence fragment that can be amplified using a pair of conserved primers. Sequences of this fragment are specific for each Rickettsia species. The phylogenetic organization of Rickettsia species inferred from the comparison of sca1 sequences strengthens the classification based on the housekeeping gene gltA and is similar to those obtained from the analyses of ompA, sca5 and sca4, thus suggesting similar evolutionary constraints. We also observed that Sca1 protein sequences have evolved under a dual selection pressure: with the exception of typhus group rickettsiae, the amino-terminal part of the protein that encompasses the predicted passenger domain, has evolved under positive selection in rickettsiae. This suggests that the Sca1 protein interacts with the host. In contrast, the C-terminal portion containing the autotransporter domain has evolved under purifying selection. In addition, sca1 is transcribed in R. conorii, and might therefore be functional in this species.

CONCLUSION

The sca1 gene, encoding an autotransporter protein that evolves under dual evolution pressure, is the only sca-family gene to be conserved by all Rickettsia species. As such, it is a valuable identification target for these bacteria, especially because rickettsial isolates can be identified by amplification and sequencing of a discriminatory gene fragment using a single primer pair. It may also be used as a phylogenetic tool. However, its current functional status remains to be determined although it was found expressed in R. conorii.

Improved purification of Piscirickettsia salmonis using Percoll gradients

Viable preparations of intact Piscirickettsia salmonis, purified from host cell material, are necessary for studying characteristics associated with this bacterium. However, purification of the organism is difficult due to its obligate intracellular nature. A simple and effective method for isolating whole P. salmonis, which is quick and easy to perform, but still maintains the viability and antigenicity of the bacterium is described. P. salmonis was purified by differential pelleting and density gradient centrifugation using 30%, 40%, or 50% (v/v) Percoll gradients. Following fractionation, a band with a density of 1.056-1.080 was found to be composed entirely of rickettsiae, confirmed by fluorescent antibody technique (IFAT). Purity of the P. salmonis from different stages of the purification process was assessed by light and transmission electron microscopy, and the viability of yields determined from a plaque assay and a tissue culture infective dose (TCID(50) ml(-1)). P. salmonis recovered from the 30% Percoll gradient appeared to retain their intracellular structure better than P. salmonis obtained from the 40% and 50% Percoll gradients, and appeared to have a greater viability. Differences were seen between P. salmonis-infected CHSE-214 cells and purified P. salmonis when compared by SDS-PAGE and Western blotting, and less host cell contamination was present in preparations obtained from the 30% Percoll gradient. Finally ten different P. salmonis isolates obtained from three different geographical locations and four different fish species, were purified using the 30% Percoll gradient. When the morphology of these was compared by transmission electron microscopy (TEM), they appeared similar in size and appearance, although isolate R980769 was highly pleomorphic and isolate R-29 was larger than the other isolates examined.

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.

Molecular evolution of rickettsia surface antigens: evidence of positive selection

The Rickettsia genus is a group of obligate intracellular parasitic alpha-proteobacteria that includes human pathogens responsible for the typhus disease and various types of spotted fevers. rOmpA and rOmpB are two members of the "surface cell antigen" (Sca) autotransporter (AT) protein family that may play key roles in the adhesion of the Rickettsia cells to the host tissue. These molecules are likely determinants for the pathogenicity of the Rickettsia and represent good candidates for vaccine development. We identified the 17 members of this family of outer-membrane proteins in nine fully sequenced Rickettsia genomes. The typical architecture of the Sca proteins is composed of an N-terminal signal peptide and a C-terminal AT domain that promote the export of the central passenger domain to the outside of the bacteria. A characteristic of this family is the frequent degradation of the genes, which results in different subsets of the sca genes being expressed among Rickettsia species. Here, we present a detailed analysis of their phylogenetic relationships and evolution. We provide strong evidence that rOmpA and rOmpB as well as three other members of the Sca protein family--Sca1, Sca2, and Sca4--have evolved under positive selection. The exclusive distribution of the predicted positively selected sites within the passenger domains of these proteins argues that these regions are involved in the interaction with the host and may be locked in "arms race" coevolutionary conflicts.

Lymphangitis-associated rickettsiosis, a new rickettsiosis caused by Rickettsia sibirica mongolotimonae: seven new cases and review of the literature

BACKGROUND

Rickettsia sibirica mongolotimonae has been found in Hyalomma ticks in Inner Mongolia (in China) and Niger and in humans in France and South Africa. To date, only 3 cases of human infection have been reported.

METHODS

Patients received a diagnosis of R. sibirica mongolotimonae infection on the basis of culture and/or PCR results plus serological test results.

RESULTS

From January 2000 to June 2004, R. sibirica mongolotimonae infection was diagnosed in 7 patients. In 3 patients, the bacterium was cultivated from the inoculation eschar. The other 4 patients had cases that were diagnosed with use of PCR of samples obtained from the eschar (2 patients) or blood (2 patients), plus specific Western blot before (2 patients) and after (2 patients) cross-adsorption. The clinical presentation included fever (temperature, >38.5 degrees C), a maculopapular rash, and > or =1 inoculation eschar in 6 patients, enlarged regional lymph nodes in 4 patients, and lymphangitis in 3 patients. On the basis of the study of 9 cases, R. sibirica mongolotimonae infection differed from other tick-borne rickettsioses in the Mediterranean area in the following ways: it involved a specific incidence in the spring, the presence of 2 eschars in 2 (22%) of the patients, the presence of a draining lymph node in 5 (55%) of the patients, and lymphangitis expanding from the inoculation eschar to the draining node in 4 (44%) of the patients. The most recent patient in our series received a clinical diagnosis on the basis of such findings. All patients recovered without any sequelae.

CONCLUSIONS

We propose that this new rickettsiosis be named "lymphangitis-associated rickettsiosis." Lymphangitis-associated rickettsiosis should be considered in the differential diagnosis of tick-borne rickettsioses in Europe, Africa, and Asia.

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.

Comparison of immunofluorescence, Western blotting, and cross-adsorption assays for diagnosis of African tick bite fever

In testing paired serum samples from 40 consecutive cases of African tick bite fever, we detected diagnostic antibodies against spotted fever group rickettsiae in 45% of the patients by immunofluorescence assay (IFA) and in 100% of the patients by Western blotting (WB) (P < 0.01). A specific diagnosis of Rickettsia africae infection could be established in 15% of the patients by IFA and in 73% of the patients by a combination of WB and cross-adsorption assays (P < 0.01).

Guidelines for the diagnosis of tick-borne bacterial diseases in Europe

Ticks are obligate haematophagous acarines that parasitise every class of vertebrate (including man) and have a worldwide distribution. An increasing awareness of tick-borne diseases among clinicians and scientific researchers has led to the recent description of a number of emerging tick-borne bacterial diseases. Since the identification of Borrelia burgdorferi as the agent of Lyme disease in 1982, 11 tick-borne human bacterial pathogens have been described in Europe. Aetiological diagnosis of tick-transmitted diseases is often difficult and relies on specialised laboratories using very specific tools. Interpretation of laboratory data is very important in order to establish the diagnosis. These guidelines aim to help clinicians and microbiologists in diagnosing infection transmitted by tick bites and to provide the scientific and medical community with a better understanding of these infectious diseases.

Suicide PCR on skin biopsy specimens for diagnosis of rickettsioses

As rickettsioses may be severe diseases and Rickettsia prowazekii is a potential agent of bioterrorism, highly efficient diagnostic techniques are required to detect rickettsiae in patients. We developed a nested PCR assay using single-use primers targeting single-use gene fragments present in the genomes of both Rickettsia conorii and R. prowazekii. We used this "suicide" PCR with DNA from 103 skin biopsy specimens from patients who definitely had a rickettiosis, 109 skin biopsy specimens from patients who possibly had a rickettsiosis, and 50 skin biopsy specimens from patients with nonrickettsial diseases. The suicide PCR detected "R. conorii conorii" in 38 biopsy specimens, R. africae in 28 biopsy specimens, R. slovaca in 12 biopsy specimens, "R. sibirica mongolotimonae" in 5 biopsy specimens, R. aeschlimannii in 2 biopsy specimens, and "R. conorii caspia" and "R. sibirica sibirica" in 1 biopsy specimen each. The technique had a specificity of 100% and a sensitivity of 68%. It was 2.2 times more sensitive than culture (P < 10(-2)) and 1.5 times more sensitive than regular PCR (P < 10(-2)). The efficacy of the suicide PCR was reduced by antibiotic therapy prior to biopsy (P < 10(-2)) and was increased when it was performed with eschar biopsy specimens (P = 0.03). We propose the use of the suicide PCR as a sensitive, specific, and versatile technique for improving the diagnosis of rickettsioses, especially when it is used on eschar biopsy specimens taken prior to antibiotic therapy.

Rickettsia mongolotimonae infection in South Africa

We report the first laboratory-confirmed case of Rickettsia mongolotimonae infection in Africa. The patient sought treatment for an eschar on his toe; lymphangitis, severe headaches, and fever subsequently developed. After a regimen of doxycycline, symptoms rapidly resolved. R. mongolotimonae infection was diagnosed retrospectively by serologic tests and molecular-based detection of the organism in biopsy specimens of eschar material.

Aneruptive fever associated with antibodies to Rickettsia helvetica in Europe and Thailand

We report that eight patients from France, Italy, and Thailand had serological evidence of Rickettsia helvetica infection. The infection presented as a mild disease in the warm season and was associated with fever, headache, and myalgia but not with a cutaneous rash. R. helvetica should be suspected in patients with unexplained fever, especially following a bite from an Ixodes sp. tick.

Serosurvey among Mediterranean spotted fever patients of a new spotted fever group rickettsial strain (Bar29)

Mediterranean spotted fever is an endemic disease in Catalonia, Spain. A new spotted fever group (SFG) rickettsial strain (Bar29) of unknown pathogenicity for humans was isolated by our group, in 1996, from the dog brown tick, Rhipicephalus sanguineus. Interestingly, Rickettsia conorii was not isolated in this study. The aim of the present study was to assess the possible pathogenic role of the Bar29 strain. To this purpose, serum samples from 15 patients with Mediterranean spotted fever were obtained and tested by immunofluorescence for antibodies against four related rickettsial strains (R. conorii, R. africae, R. massiliae, and Bar29). Eight of the studied sera reacted at high titers with only R. conorii and Bar29 antigens. For five of the eight sera, the titers against Bar29 were clearly higher than for R. conorii. Four of these sera were also studied by Western blot immunoassay to confirm a specific response. Two of these sera reacted with the high-molecular-mass specific proteins of Bar29 as well as with the low-molecular-mass region (LPS antigen) whereas their reactions with R. conorii were located only on bands of the LPS. This specific response would support the possible pathogenic role of the Bar29 strain for humans. According to this finding, spotted fever caused by R. conorii and rickettsial strain Bar29 may be present in our area. The epidemiological implications of spotted fever caused by R. conorii and by rickettsial strain Bar29 in the Catalonia deserve further studies with isolation and characterization of more rickettsial strains.

Isolation of a rickettsia related to Astrakhan fever rickettsia from a patient in Chad

We isolated a novel spotted fever group rickettsia from a patient coming back from Chad with fever and a maculopapulous rash. In Africa, only six pathogenic spotted fever group rickettsiae have been identified, R. conorii, R. africae, R. akari, R. aeschlimannii, "R. mongolotimonae," and R. felis. Our isolate was identified by PCR amplification and sequencing of the 16S rRNA (16S rDNA), citrate synthase (gltA), and rOmpA (ompA) encoding genes. The 16S rDNA, gltA, and ompA sequences of the isolate were found to be 99.7, 99.6, and 99.5% identical with that of Astrakhan fever rickettsia, respectively. This rickettsia is endemic in the Caspian sea area and has also recently been identified in Kosovo. Using mouse serotyping, the currently accepted method for the identification of spotted fever group rickettsiae, the Chad isolate exhibited a specificity difference of 2 when compared to Astrakhan fever rickettsia and at least 4 when compared with other members of the R. conorii complex. The Chad isolate should be considered a variant of Astrakhan fever rickettsia. This is the first description of Astrakhan fever rickettsia outside Europe and the bacterium may be responsible for cases of spotted fever in Chad. Although Astrakhan fever rickettsia is transmitted by Rhipicephalus ticks in Europe, further studies are indicated to identify its vector in Africa where these ticks are also prevalent.

Spotless rickettsiosis caused by Rickettsia slovaca and associated with Dermacentor ticks

The pathogenic role of Rickettsia slovaca was first demonstrated in 1997 in a patient who presented with a single inoculation lesion of the scalp and enlarged cervical lymph nodes after receiving a bite from a Dermacentor tick. Subsequently, we evaluated the occurrence of R. slovaca infections among patients living in France and Hungary who presented with these symptoms. R. slovaca infections were confirmed by polymerase chain reaction (PCR) in 17 of 67 enrolled patients. Infections were most likely to occur in patients aged <10 years and in patients who were bitten during the colder months of the year. The median duration of incubation for the disease was 7 days. Fever was present in only 2 patients, and only 1 patient developed a rash. Sequelae included persistent asthenia (3 cases) and localized alopecia (4 cases). Immunofluorescence and/or Western blot analysis detected antibodies in 50% of tested patients. Three Dermacentor ticks obtained from patients revealed R. slovaca by PCR.

Rickettsia felis infection acquired in Europe and documented by polymerase chain reaction

We report the first case of Rickettsia felis infection in Europe to be documented by polymerase chain reaction (PCR) and serologic testing.

Rickettsia africae, a tick-borne pathogen in travelers to sub-Saharan Africa

BACKGROUND

African tick-bite fever occurs after contact with ticks that carry Rickettsia africae and that parasitize cattle and game. Sporadic reports suggest that this infection has specific clinical and epidemiologic features.

METHODS

We studied patients who were tested for a rickettsial disease after returning from a visit to Africa or Guadeloupe. To assess the value of the microimmunofluorescence assay, Western blotting, and cross-adsorption assays, we compared the results of these tests in 39 patients in whom African tick-bite fever had been confirmed by the polymerase-chain reaction assay, cell culture, or both; 50 patients with documented R. conorii infection; and 50 blood donors. These diagnostic criteria were then applied to 376 additional patients who had returned from southern Africa and 2 who had returned from Guadeloupe and whose serum was being tested for rickettsial disease.

RESULTS

In the 39 patients with direct evidence of R. africae infection, the combination of microimmunofluorescence assay, Western blotting, and cross-adsorption assays showing antibodies specific for R. africae had a sensitivity of 0.56; however, each test had a positive predictive value and a specificity of 1.0. An additional 80 patients were found to have an R. africae infection on the basis of these serologic criteria. Infections with R. africae were acquired by visitors to 11 African countries and Guadeloupe. The illness was generally mild and was characterized by a rash in 46 percent of the patients; the rash was usually maculopapular or vesicular and rarely purpuric. Ninety-five percent of patients had an inoculation eschar or eschars, and 54 percent of these patients had multiple eschars, a finding that is unusual in patients with rickettsial infection.

CONCLUSIONS

In this series, R. africae was the cause of nearly all cases of tick-bite rickettsiosis in patients who became ill after a trip to sub-Saharan Africa.

A flea-associated Rickettsia pathogenic for humans

A rickettsia named the ELB agent, or "Rickettsia felis," was identified by molecular biology techniques in American fleas in 1990 and later in four patients from Texas and Mexico. We attempted to isolate this rickettsia from infected fleas at various temperatures and conditions. A representative isolate of the ELB agent, the Marseille strain, was characterized and used to develop a microimmunofluorescence test that detected reactive antibodies in human sera. The ELB agent was isolated from 19 of 20 groups of polymerase chain reaction-proven infected fleas. The microimmunofluorescence results provided serologic evidence of infection by the ELB agent in four patients with fever and rash in France (2) and Brazil (2), supporting the pathogenic role of this rickettsia. Our successful isolation of this rickettsia makes it available for use in serologic tests to determine its clinical spectrum, prevalence, and distribution.

Rickettsia mongolotimonae: a rare pathogen in France

We report a second case of laboratory-confirmed infection caused by Rickettsia mongolotimonae in Marseille, France. This rickettsiosis may represent a new clinical entity; moreover, its geographic distribution may be broader than previously documented. This pathogen should be systematically considered in the differential diagnosis of atypical rickettsioses, especially rashless fevers with lymphangitis and lymphadenopathy, in southern France and perhaps elsewhere.

Evidence of Rickettsia helvetica infection in humans, eastern France

A 37-year-old man living in eastern France seroconverted to Rickettsia helvetica in August 1997, 4 weeks after the onset of an unexplained febrile illness. Results of a serosurvey of forest workers from the area where the patient lived showed a 9.2% seroprevalence against R. helvetica. This organism may pose a threat for populations exposed to Ixodes ricinus ticks.

Association of Rickettsia helvetica with chronic perimyocarditis in sudden cardiac death

BACKGROUND

Rickettsia helvetica is the only non-imported rickettsia found in Scandinavia. It was first detected in Ixodes ricinus ticks, but has never been linked to human disease. We studied two young Swedish men who died of sudden cardiac failure during exercise, and who showed signs of perimyocarditis similar to those described in rickettsial disease.

METHODS

Samples from the heart and other organs were analysed by PCR and DNA sequencing. May-Grünwald-Giemsa, Grocott, and acridine-orange stains were used for histopathological examinations. Staining of R. helvetica grown on shell-vials in vero cells, and the early descriptions of R. rickettsii by H T Ricketts and S B Wohlbach served as controls. Immunohistochemistry was done with Proteus OX-19 rabbit antisera as the primary antibody. The structure of rickettsia-like organisms was investigated by transmission electron microscopy. Serological analyses were carried out by indirect immunofluorescence with R. helvetica as the antigen.

FINDINGS

By use of a semi-nested PCR, with primers specific for the 16S rRNA and 17-kDa outer-membrane-protein genes, and sequence analysis of the amplified products, genetic material from R. helvetica was detected in the pericardium and in a lymph node from the pulmonary hilum in case 1, and in a coronary artery and the heart muscle in case 2. A serological response in case 1 revealed an endpoint titre for R. helvetica of 1/320 (1/256 with R. rickettsii as the antigen). Examination of PCR-positive tissue showed chronic interstitial inflammation and the presence of rickettsia-like organisms predominantly located in the endothelium. These organisms reacted with Proteus OX-19 antisera, and their size and form were consistent with rickettsia. Electron microscopy confirmed that the appearance of the organisms was similar to that described for spotted-fever rickettsia.

INTERPRETATION

R. helvetica, transmitted by I. ricinus ticks, may be an important pathogen in the aetiology of perimyocarditis, which can result in sudden unexpected cardiac death in young people.

First isolation of Rickettsia helvetica from Ixodes ricinus ticks in France

Two rickettsial isolates recovered from Ixodes ricinus ticks in Puy-de-Dôme (Central France) were characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, Western blot immunoassay, restriction fragment length polymorphism analysis, and sequencing of a portion of the citrate-synthase gene. By these methods, the isolates appeared to be identical to a member of the spotted fever group rickettsiae, Rickettsia helvetica. This first isolation of Rickettsia helvetica in France has epidemiologic importance; a serosurvey on Mediterranean spotted fever conducted previously in Puy-de-Dôme, where the infection is not endemic, demonstrated a high seroprevalence of nonspecific antibodies directed against spotted fever group rickettsiae lipopolysaccharides, and thus the possibility of infection due to a rickettsia different from Rickettsia conorii was suggested. The isolation of Rickettsia helvetica in anthropophilic ticks in the same area further supports this hypothesis.