Serologic and molecular detection of Ehrlichia chaffeensis and Anaplasma phagocytophila (human granulocytic ehrlichiosis agent) in Korean patients

Human monocytotropic ehrlichiosis-A systematic review and analysis of the literature

Human monocytotropic ehrlichiosis (HME) is a tick-borne bacterial infection caused by Ehrlichia chaffeensis. Most available data come from case reports, case series and retrospective studies, while prospective studies and clinical trials are largely lacking. To obtain a clearer picture of the currently known epidemiologic distribution, clinical and paraclinical presentation, diagnostic aspects, complications, therapeutic aspects, and outcomes of HME, we systematically reviewed the literature and analyzed and summarized the data. Cases of HME are almost exclusively reported from North America. Human infections due to other (non-chaffeensis) Ehrlichia spp. are rare. HME primarily presents as an unspecific febrile illness (95% of the cases), often accompanied by thrombocytopenia (79.1% of the cases), leukopenia (57.8% of the cases), and abnormal liver function tests (68.1% of the cases). Immunocompromized patients are overrepresented among reviewed HME cases (26.7%), which indicates the role of HME as an opportunistic infection. The incidence of complications is higher in immunocompromized compared to immunocompetent cases, with ARDS (34% vs 19.8%), acute renal failure (34% vs 15.8%), multi organ failure (26% vs 14.9%), and secondary hemophagocytic lymphohistiocytosis (26% vs 14.9%) being the most frequent reported. The overall case fatality is 11.6%, with a significant difference between immunocompetent (9.9%) and immunocompromized (16.3%) cases, and sequelae are rare (4.2% in immunocompetent cases, 2.5% in immunocompromised cases).

Under-diagnosis of vector-borne diseases among individuals suspected of having Scrub Typhus in South Korea

Due to environmental and ecological changes and suitable habitats, the occurrence of vector-borne diseases is increasing. We investigated the seroprevalence of four major vector-borne pathogens in human patients with febrile illness who were clinically suspected of having Scrub Typhus (ST) caused by Orientia tsutsugamushi. A total of 187 samples (182 patient whole blood and sera samples, including 5 follow-up) were collected. Antibodies to Anaplasma phagocytophilum, Ehrlichia chaffeensis, Borrelia burgdorferi, and Bartonella henselae were tested by using indirect immunofluorescence assays. Molecular diagnoses were performed using real-time PCR. Of the 182 cases, 37 (20.3%) cases were designated as confirmed cases of ST, and the remaining 145 (79.7%) cases as other febrile diseases (OFDs). The seroprevalence of A. phagocytophilum, E. chaffeensis, B. burgdorferi, and B. henselae was 51.4% (19/37), 10.8% (4/37), 86.5% (32/37), and 10.8% (4/37) among the ST group, and 42.8% (62/145), 10.4% (19/145), 57.7% (105/145), and 15.9% (29/145) among the OFD group, respectively. There were no significant differences in the seroprevalence between the ST and the OFD groups. Considering the co-occurrence, 89.0% (162/182) had at least one antibody to tick-borne pathogens, 37.0% (60/162) were positive for two pathogens, 17.3% (28/162) for three pathogens, and 6.2% (10/162) for four pathogens. In real-time PCR, O. tsutsugamushi was positive in 16 cases [15 (40.5%) in ST group and 1 (2.2%) in OFD group], and the four other pathogens were negative in all cases except one confirmed as anaplasmosis. In evaluating the five follow-up samples, the appearance of new antibodies or an increase in the pre-existing antibody titers was detected. Our data highlighted that acute febrile illness and manifestations suggestive of a vector-borne infection must be recognized and further considered for coinfections in clinical practice and the laboratory.

Human case of Anaplasma phagocytophilum infection in Eastern Taiwan

Human granulocytic anaplasmosis (HGA) is a tick-borne infection caused by the bacterium Anaplasma phagocytophilum. In this study, we report an indigenous case of clinically diagnosed HGA. The patient was a 41-year-old man who experienced a tick bite and later developed fever, chills, myalgia, malaise, thrombocytopenia, leukocytosis with a left shift, elevated hepatic transaminase levels, and splenomegaly upon admission to the hospital. Immunofluorescence assays detected seroconversion against A. phagocytophilum, whereas tests for spotted fever group rickettsiae, murine typhus, scrub typhus, Q fever, and ehrlichiosis were negative. ELISA and Western blot analysis using recombinant MSP2 protein confirmed the exposure to A. phagocytophilum. Oral doxycycline and intravenous ceftriaxone were prescribed, and the patient made a full recovery. Our findings indicate the presence of HGA on the main island of Taiwan. Precautions against tick bites should be taken when engaging in outdoor activities, and HGA should be considered by physicians in the differential diagnosis.

Molecular Detection of Anaplasma phagocytophilum and Ehrlichia Species in Ticks Removed from Humans in the Republic of Korea

Human granulocytic anaplasmosis (HGA) and human monocytic ehrlichiosis (HME) are zoonotic tick-borne diseases transmitted via tick bites. To determine the state of human Anaplasma and Ehrlichia infections caused by tick bites in the Republic of Korea (ROK), we conducted a nationwide investigation of human cases of tick bites in 2020. A total of 180 ticks were obtained, comprising Haemaphysalis longicornis (70.0%), Amblyomma testudinarium (17.8%), Ixodes nipponensis (6.1%), H. flava (4.4%), and I. persulcatus (1.7%). In three cases (1.7%; 95% CI: 0.3-4.9), A. phagocytophilum was detected in Ixodes ticks using primers for Anaplasma-specific genes (16s rRNA, ankA, and msp4). Conversely, Ehrlichia sp. was only detected in H. longicornis, in two cases (1.1%; 95% CI: 0.1-4.0). To the best of our knowledge, this is the first record of Ehrlichia sp. in ticks parasitizing humans in the ROK. As concerns remain about the possibility of HGA and HME transmission, continuous monitoring and management of the pathogens and vectors are necessary.

Surveillance and Molecular Identification of Borrelia Species in Ticks Collected at U.S. Army Garrison Humphreys, Republic of Korea, 2018-2019

Tick-borne pathogens are contributing factors for the increased incidence of vector-borne diseases throughout the world, including Lyme borreliosis, one of the most prevalent spirochetes belonging to the Borrelia burgdorferi sensu lato group. The present study focused on the detection of Borrelia species from hard ticks collected at U.S. Army Garrison Humphreys, Republic of Korea (ROK), using molecular and genotypic analyses. Tick-borne disease surveillance was conducted from January to December, 2018-2019. A total of 24,281 ticks (2 genera and 5 species) were collected from road-killed Korean Water deer (KWD) and by tick drag. Haemaphysalis longicornis (92.0%) was the most commonly collected species, followed by Haemaphysalis flava (4.9%), Ixodes nipponensis (3.1%), Haemaphysalis phasiana (0.07%), and Haemaphysalis japonica (<0.01%). The ospA gene sequences of Borrelia afzelii were detected in 12/529 pools of I. nipponensis. Three and one pools were positive for B. afzelii and Borrelia miyamotoi, respectively, using the 16s rRNA gene. None of the pools of Haemaphysalis ticks collected from KWD or by tick drag were positive for Borrelia species. I. nipponensis was collected throughout the year from KWD and from February to November by tick drag, suggesting that they were active throughout the year, and expanding the risk period for acquiring Lyme borreliosis and Borrelia relapsing fever in the ROK. This study assessed disease risk factors associated with the prevalence of Lyme disease in ticks collected from KWD and by tick drag using molecular analysis. These results provide an understanding and awareness into the prevalence and molecular characteristics of Borrelia species in the ROK.

Seroepidemiologic survey of emerging vector-borne infections in South Korean forest/field workers

With global warming and lush forest change, vector-borne infections are expected to increase in the number and diversity of agents. Since the first report of severe fever with thrombocytopenia syndrome (SFTS) in 2013, the number of reported cases has increased annually in South Korea. However, although tick-borne encephalitis virus (TBEV) was detected from ticks and wild rodents, there is no human TBE case report in South Korea. This study aimed to determine the seroprevalence of TBEV and SFTS virus (SFTSV) among forest and field workers in South Korea. From January 2017 to August 2018, a total 583 sera were obtained from the forest and field workers in South Korea. IgG enzyme-linked immunosorbent assay (ELISA) and neutralization assay were conducted for TBEV, and indirect immunofluorescence assay (IFA) and neutralization assay were performed for SFTSV. Seroprevalence of TBEV was 0.9% (5/583) by IgG ELISA, and 0.3% (2/583) by neutralization assay. Neutralizing antibody against TBEV was detected in a forest worker in Jeju (1:113) and Hongcheon (1:10). Only 1 (0.2%) forest worker in Yeongju was seropositive for SFTSV by IFA (1:2,048) and neutralizing antibody was detected also. In conclusion, this study shows that it is necessary to raise the awareness of physicians about TBEV infection and to make efforts to survey and diagnose vector-borne diseases in South Korea.

Molecular investigation of tick-borne pathogens in ticks removed from tick-bitten humans in the southwestern region of the Republic of Korea

In this study, we investigated the presence of tick-borne pathogens in ticks removed from tick-bitten humans in the southwestern provinces of the Republic of Korea (ROK). We identified 33 ticks from three tick species, namely Amblyomma testudinarium (60.6%), Haemaphysalis longicornis (27.3%), and Ixodes nipponensis (12.1%) in order of occurrence via morphology and 16S rDNA-targeting polymerase chain reaction (PCR). Tick-borne pathogens were detected in 16 ticks using pathogen-specific PCR. From the results, 12 ticks (36.4%) tested positive for spotted fever group (SFG) Rickettsia: Rickettsia monacensis (1/12), R. tamurae (8/12), and Candidatus Rickettsia jingxinensis (3/12). Three ticks (9.1%) were positive for Anaplasma phagocytophilum. In addition, three ticks (9.1%) tested positive for Babesia gibsoni (1/3) and B. microti (2/3). In conclusion, we identified three tick species; the most common species was A. testudinarium, followed by H. longicornis and I. nipponensis. SFG Rickettsia, A. phagocytophilum, and Babesia spp. were the most frequently detected pathogens in ticks removed from tick-bitten humans. To our knowledge, this is the first report of R. tamurae and Ca. R. jingxinensis detection in Korea. The present results will contribute to the understanding of tick-borne infections in animals and humans in the ROK.

Are other tick-borne infections overlooked in patients investigated for Lyme neuroborreliosis? A large retrospective study from South-eastern Sweden

In Europe, the hard tick Ixodes ricinus is considered the most important vector of human zoonotic diseases. Human pathogenic agents spread by I. ricinus in Sweden include Borrelia burgdorferi sensu lato (s.l.), Anaplasma phagocytophilum, Rickettsia helvetica, the recently described Neoehrlichia mikurensis, Borrelia miyamotoi, tick-borne encephalitis virus (TBEV), and Babesia spp. (Babesia microti, Babesia venatorum and Babesia divergens). Since these pathogens share the same vector, co-infections with more than one tick-borne pathogen may occur and thus complicate the diagnosis and clinical management of the patient due to possibly altered symptomatology. Borrelia burgdorferi s.l., TBEV and B. miyamotoi are well-known to cause infections of the central nervous system (CNS), whereas the abilities of other tick-borne pathogens to invade the CNS are largely unknown. The aim of this study was to investigate the presence and clinical impact of tick-borne pathogens other than B. burgdorferi s.l. in the cerebrospinal fluid (CSF) and serum samples of patients who were under investigation for Lyme neuroborreliosis (LNB) in a tick-endemic region of South-eastern Sweden. CSF and serum samples from 600 patients, recruited from the Regions of Östergötland County, Jönköping County and Kalmar County in South-eastern Sweden and investigated for LNB during the period of 2009-2013, were retrospectively collected for analysis. The samples were analysed by real-time PCR for the presence of nucleic acid from B. burgdorferi s.l., B. miyamotoi, A. phagocytophilum, Rickettsia spp., N. mikurensis, TBEV and Babesia spp. Serological analyses were conducted in CSF and serum samples for all patients regarding B. burgdorferi s.l., and for the patients with CSF mononuclear pleocytosis, analyses of antibodies to B. miyamotoi, A. phagocytophilum, spotted fever group (SFG) rickettsiae, TBEV and B. microti in serum were performed. The medical charts of all the patients with CSF mononuclear pleocytosis and patients with positive PCR findings were reviewed. Of the 600 patients, 55 (9%) presented with CSF mononuclear pleocytosis, 13 (2%) of whom had Borrelia-specific antibodies in the CSF. One patient was PCR-positive for N. mikurensis, and another one was PCR-positive for Borrelia spp. in serum. No pathogens were detected by PCR in the CSF samples. Four patients had serum antibodies to B. miyamotoi, four patients to A. phagocytophilum, five patients to SFG rickettsiae, and six patients to TBEV. One patient, with antibodies to SFG rickettsiae, had both clinical and laboratory signs suggestive of a current infection. Nine patients had serum antibodies to more than one pathogen, although none of these was assessed as a current co-infection. We can conclude from this study that tick-borne co-infections are uncommon in patients who are being investigated for suspected LNB in South-eastern Sweden, an area endemic for borreliosis and TBE.

Co-Infection with Anaplasma Species and Novel Genetic Variants Detected in Cattle and Goats in the Republic of Korea

Anaplasmosis, a tick-borne disease with multiple reservoirs, has been evolving in its pathogenesis, increasing domestic ruminants susceptibility to simultaneous infections with multiple pathogens. However, there is limited information regarding anaplasmosis in domestic ruminants in the Republic of Korea (ROK). We aimed to evaluate the role of Korean cattle and goats in Anaplasma infection maintenance. Polymerase chain reaction was performed to investigate the prevalence and genetic diversity of Anaplasma spp. from 686 whole blood samples collected from different ROK provinces. Anaplasma infection was mostly caused by A. phagocytophilum (21.1%) in cattle, and A. bovis (7.3%) in goats. Co-infection cases were found in cattle: A. bovis and A. phagocytophilum (16.7%), and in goats: A. bovis and A. capra (1.0%). Notably, a triple co-infection with A. bovis, A. phagocytophilum, and A. capra was found in one cow. Phylogenetic analysis revealed novel variants of the A. phagocytophilum 16S rRNA and A. capra gltA genes. This research contributes to the ratification of cattle as a potential reservoir of A. capra and demonstrates Anaplasma co-infection types in Korean domestic ruminants. As anaplasmosis is a zoonotic disease, our study could be crucial in making important decisions for public health.

First identification of Anaplasma phagocytophilum in both a biting tick Ixodes nipponensis and a patient in Korea: a case report

BACKGROUND

Human granulocytic anaplasmosis (HGA) is a tick-borne infectious disease caused by Anaplasma phagocytophilum. To date, there have been no reported cases of A. phagocytophilum infection found in both the biting tick and the patient following a tick bite.

CASE PRESENTATION

An 81-year-old woman presented with fever following a tick bite, with the tick still intact on her body. The patient was diagnosed with HGA. The tick was identified as Ixodes nipponensis by morphological and molecular biological detection methods targeting the 16S rRNA gene. The patient's blood was cultured after inoculation into the human promyelocytic leukemia cell line HL-60. A. phagocytophilum growth was confirmed via culture and isolation. A. phagocytophilum was identified in both the tick and the patient's blood by Anaplasma-specific groEL- and ankA-based nested polymerase chain reaction followed by sequencing. Moreover, a four-fold elevation in antibodies was observed in the patient's blood.

CONCLUSION

We report a case of a patient diagnosed with HGA following admission for fever due to a tick bite. A. phagocytophilum was identified in both the tick and the patient, and A. phagocytophilum was successfully cultured. The present study suggests the need to investigate the possible incrimination of I. nipponensis as a vector for HGA in Korea.

Human Case of Ehrlichia chaffeensis Infection, Taiwan

In 2018, an immunosuppressed woman in southern Taiwan had onset of fever, chills, myalgia, malaise, thrombocytopenia, lymphocytopenia, and elevated hepatic transaminases. Investigation revealed infection with Ehrlichia chaffeensis. This autochthonous case of human monocytotropic ehrlichiosis was confirmed by PCR, DNA sequencing, and seroconversion.

Co-Infection of Scrub Typhus and Human Granulocytic Anaplasmosis in Korea, 2006

BACKGROUND

Scrub typhus, severe fever with thrombocytopenia syndrome (SFTS) and human granulocytic anaplasmosis (HGA) are important arthropod-borne infectious diseases in Korea and share a common point that they are transmitted by arthropod bites mostly during outdoor activities and there are considerable overlaps of epidemiologic and clinical features at presentation. We investigated the co-infection of these infections.

METHODS

The study subjects were patients with laboratory-confirmed scrub typhus who were enrolled retrospectively in 2006. SFTS virus (SFTSV) infection was confirmed by a reverse transcriptase polymerase chain reaction (PCR) to amplify partial L segment of SFTSV for molecular diagnosis. HGA was confirmed by a nested PCR to amplify 16S rRNA gene of Anaplasma phagocytophilum. Direct sequencing of the positive PCR products was performed. Clinical features of co-infected subjects were described.

RESULTS

One-hundred sixty-seven patients with scrub typhus were included in the analysis. Co-infection of A. phagocytophilum was identified in 4.2% of scrub typhus patients (7/167). The route of co-infection was uncertain. The co-infected patients had not different clinical manifestations compared to the patients with scrub typhus only. All the study subjects were negative for SFTSV.

CONCLUSION

We found retrospective molecular evidence of the co-infection of scrub typhus and HGA in Korea. HGA may be more prevalent than expected and need to be considered as an important differential diagnosis of febrile patients in Korea.

Recent Increase of Human Granulocytic Anaplasmosis and Co-Infection with Scrub Typhus or Korean Hemorrhagic Fever with Renal Syndrome in Korea

We report 17 patients with human granulocytic anaplasmosis between January 2015 and September 2018 at two tertiary university hospitals in Korea. Monthly incidence peaked in May and June. Among these patients, we identified three who were co-infected with scrub typhus, and one patient with hemorrhagic fever with renal syndrome.

First detection and identification of Candidatus Neoehrlichia mikurensis in South Korea

Candidatus Neoehrlichia mikurensis (Ca. N. mikurensis; family Anaplasmataceae) is an emerging tick-borne pathogen that causes a systemic inflammatory syndrome with thrombotic complications. We report here the first identification of Ca. N. mikurensis in organ samples from small mammals captured in southwest South Korea. Nested PCR of groEL and 16S rRNA genes was used to confirm the identity of the bacteria present, and successfully amplified fragments were sequenced. All captured animals were identified as striped field mice (Apodemus agrarius), approximately 28.6% (4/14) and 21.4% (3/14) of which were found to be PCR-positive for Ca. N. mikurensis and Anaplasma phagocytophilum, respectively. The detection of Ca. N. mikurensis in these animals represents the first evidence of this pathogen in South Korea. Carriage of this bacterium by rodents highlights the need for more detailed investigation of their role in its transmission to humans.

Diagnosis and molecular characteristics of human infections caused by Anaplasma phagocytophilum in South Korea

Human granulocytic anaplasmosis (HGA) is a tick borne infection caused by Anaplasma phagocytophilum. HGA cases in South Korea have been identified since the first report in 2014. In this study, we investigated the serological response in 594 clinical samples of patients with acute febrile illness and molecular characteristics of A. phagocytophilum clinical isolates obtained from HGA patients. In serological test for A. phagocytophilum, 7.91% (47/594 cases) were positive for IgG and Ig M and 13 of 47 cases showed seroconversion. In the detection rate of the 16S rRNA, msp2(p44), and ankA, genes were showed 3.68% (14/380 cases) for A. phagocytophilum-specific 16S rRNA gene. Phylogenetic analysis of three clinical isolates demonstrated high sequence similarity (98.58-100%) with A. phagocytophilum 16S rRNA sequences identified from public databases. Analysis of the msp2(p44) gene showed highly variable similarity rates (7.24-98.85%) even within isolated countries and host ranges. These results provide clues into the bacterial characterization of A. phagocytophilum originating from Korean patients, providing useful guidance for treatment and improving clinical outcomes.

Current Status of Tick-Borne Diseases in South Korea

BACKGROUND

Bites with tick-borne pathogens can cause various bacterial, viral, or parasitic diseases in humans. Tick-transmitted diseases are known as contributing factors to the increasing incidence and burden of diseases. The present article investigated the epidemiology of tick-borne diseases in South Korea.

METHODS

The incidence and distribution of common tick-borne diseases in Korea (Lyme disease, Q fever, and severe fever with thrombocytopenia syndrome [SFTS]) were investigated and analyzed, using data from the Korea Centers for Disease Control and Prevention (KCDC) infectious disease reporting system. A literature review was compiled on the current status of uncommon tick-borne diseases (Rickettsia, anaplasmosis, ehrlichiosis, bartonellosis, tularemia, tick-borne encephalitis, and babesiosis).

RESULTS AND CONCLUSIONS

In South Korea, SFTS is an emerging disease, showing a rapid increase in reports since 2012, with high mortality. Likewise, reports of Lyme disease and Q fever cases have also been rapidly increasing during 2012-2017, although caution should be taken when interpreting these results, considering the likely influence of increased physician awareness and reporting of these diseases. Other tick-borne diseases reported in South Korea included spotted fever group rickettsiae, anaplasmosis, ehrlichiosis, tularemia, Bartonella, and babesiosis. Evidences on human infection with tick-borne encephalitis virus and Crimean-Congo hemorrhagic fever were recently unavailable, but both need constant monitoring.

Serological Detection of Antibodies against Anaplasma spp. in Cattle Reared in the Gyeongsangbuk-do, Korea

Anaplasmosis is a tick-borne, non-contagious, zoonotic disease caused by Anaplasma spp., which include Anaplasma marginale, A. centrale, A. phagocytophilum, A. platys, A. ovis, and A. bovis. Recently, in Korea, the prevalence of Anaplasma spp. has been investigated in some animals, such as dogs, horses, goats, cats, and Korean water deer. In cattle, A. marginale is the most virulent species and regarded as the typical type of species. However, data on the seroprevalence of Anaplasma spp. in cattle in Korea during the last decade is limited. This study was designed to investigate the seroprevalence of bovine anaplasmosis in Korea. From 2010 to 2013, blood samples were collected from 568 cattle. Forty animals (7.0%) tested seropositive for Anaplasma spp. by cELISA. Despite that current bovine anaplasmosis seropositivity rate in the Gyeongsangbuk-do is lower than those in tropical countries, anaplasmosis needs to be regarded as a concerning disease. The identification of the specific Anaplasma species infecting cattle in this province requires additional molecular studies. Moreover, further monitoring and control programs for bovine anaplasmosis is required, and the information from this study will be beneficial to develop these programs.

Non-traumatic splenic rupture in a patient with human granulocytic anaplasmosis and focused review of the literature

We report a rare case of a 53-year-old man with no significant past medical history who reported multiple tick bites within a 2-month period. The patient reported not "feeling well" for the 2 ½ weeks. He complained of generalized body aches, pains, and chills. He did not report nausea, vomiting, or yellowish discoloration of the eyes or skin. He presented to the emergency room with syncope preceded by severe abdominal pain. Upon presentation, he was pale and hypotensive. He had not experienced any trauma. Computed tomography revealed a splenic rupture, hemoperitoneum, and active extravasation of contrast material. The estimated amount of hemoperitoneum was 1.5 liters of blood. Subsequently, an infectious disease work-up revealed a positive Anaplasma phagocytophilum polymerase reaction in blood. The patient was aggressively resuscitated, and a splenectomy was performed followed by doxycycline therapy. He successfully recovered.

Clinical Isolation of Anaplasma phagocytophilum in South Korea

We report the first isolation of Anaplasma phagocytophilum in South Korea. A 61-year-old woman presented with a 6-day history of fever, headache, and myalgia. Initial investigation showed neutropenia and thrombocytopenia. We diagnosed human granulocytic anaplasmosis by microscopic examination and serologic testing. The patient recovered fully without antibiotic therapy. The isolate was obtained from the patient's blood by cell culture and mouse inoculation. Its identity was confirmed by an immunofluorescence assay, sequencing of the 16S rRNA gene, msp2 (p44), and ankA genes, and staining and electron microscopy of morulae of A. phagocytophilum in cultured human promyelocytic leukemia HL-60 cells.

Francisella-Like Endosymbiont Detected in Haemaphysalis Ticks (Acari: Ixodidae) From the Republic of Korea

A total of 6,255 ticks belonging to three genera and six species (Haemaphysalis flava Neumann, Haemaphysalis longicornis Neumann, Haemaphysalis phasiana Saito, Ixodes nipponensis Kitaoka & Saito, Ixodes persulcatus Schulze, and Amblyomma testudinarium Koch) collected from May-August, 2013, at four southwestern provinces in the Republic of Korea (ROK) were submitted to the Armed Forces Research Institute of Medical Sciences and assayed for selected tick-borne pathogens. One pool each of H. flava and H. phasiana was positive by PCR and sequencing for a Francisella-like endosymbiont, while all pools were negative for Francisella tularensis, the causative agent of tularemia.

Assessment of antibodies against surface and outer membrane proteins of Anaplasma phagocytophilum in Lyme borreliosis and tick-borne encephalitis paediatric patients

To examine evidence of positive antibodies against immunogenic proteins of Anaplasma phagocytophilum in patients with other tick-borne infections and to diagnose possible co-infections, 412 serum specimens were tested by immunoblotting using three specific Anaplasma antigens: surface proteins p44 and Asp62 and outer membrane protein A (OmpA). In total, 284 serum samples from children with Lyme borreliosis and 12 serum samples from children with tick-borne encephalitis were tested. Sera from patients with viral aseptic meningitis (n = 47) and from blood donors (n = 69) were used as controls. Among all serum specimens from patients with tick-borne infections submitted for this study, six samples (2·0%) showed positive IgM reactions and seven samples (2·4%) were IgG positive for A. phagocytophilum by immunoblot. Borderline reactivity was found in 30 samples (10·14%) for IgM and 36 samples (12·2%) for IgG. The difference between patients and blood donors was statistically significant for IgM (P = 0·006) and for IgG (P = 0·0007) antibodies. A statistically significant result was obtained for IgG (P = 0·02) but not for IgM between patients and children with aseptic meningitis. Immunoblot using three specific antigens provides novel information about the positivity of antibodies to A. phagocytophilum in children with other tick-borne infections. Taking into account clinical and laboratory findings of children despite antibody positivity, no case of human granulocytic anaplasmosis was demonstrated.

Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States

Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.

Vector-Borne Diseases in Stray Dogs in Peninsular Malaysia and Molecular Detection of Anaplasma and Ehrlichia spp. from Rhipicephalus sanguineus (Acari: Ixodidae) Ticks

Little data are available on the prevalence and transmission of vector-borne diseases in stray dogs in Peninsular Malaysia. This study was designed to determine the occurrence of vector-borne pathogens in Malaysian stray dogs using serological and molecular approaches. In total, 48 dog blood samples were subjected to serological analysis using SNAP 4Dx kit (IDEXX Laboratories, Westbrook, ME). The presence of Ehrlichia and Anaplasma DNA in the dog blood samples and Rhipicephalus sanguineus (Latreille) ticks was detected using nested polymerase chain reaction assays. Positive serological findings against Ehrlichia canis and Anaplasma phagocytophilum were obtained in 17 (39.5%) and four (9.3%) of 43 dog samples, respectively. None of the dog blood samples were positive for Borrelia burgdorferi and Dirofilaria immitis. DNA of E. canis and A. phagocytophilum was detected in 12 (25.5%) and two (4.3%) of 47 dog blood samples, and 17 (51.5%) and one (3.0%) of 33 R. sanguineus ticks, respectively. Additionally, DNA of Ehrlichia spp. closely related to Ehrlichia chaffeensis was detected in two (6.1%) R. sanguineus ticks. This study highlights the prevalence of anaplasmosis and ehrlichiosis in dogs in Malaysia. Due to the zoonotic potential of Ehrlichia and Anaplasma spp., appropriate measures should be instituted for prevention and control of vector-borne diseases in dogs.

Clinical and laboratory features parameters of human granulocytic anaplasmosis (HGA) in patients admitted to hospital in Guangdong Province, China

BACKGROUND

Human granulocytic anaplasmosis (HGA) is an acute tick-borne infectious disease with increasing morbidity and mortality, but is rarely considered in clinical practice. Because human-to-human transfusion or nosocomial transmission can occur, diagnosis is difficult when the history of tick bites is not clear.

METHODS

We present clinical features and laboratory data of HGA patients who had no clear tick bite history.

RESULTS

All patients in the study presented with a high fever, petechiae, purpura, nose bleeding and leukopenia, and patients had abnormally high levels of serum ferritin and C-reactive protein. Morulae in leukocytes were observed in three patients. Foamy histiocytes and slight erythrophagocytic activity were only found in severely ill patients.

CONCLUSION

In patients with fever and thrombocytopenia in whom no other diagnosis is evident on clinical assessment, HGA should be considered in the differential diagnosis, and tested for serologically if possible. For patients in whom the diagnosis of HGA is possible, and to whom tetracyclines can safely be given, it is apparent that these drugs hasten recovery and improve the prognosis.

Human granulocytic anaplasmosis, South Korea, 2013

We report a patient with human granulocytic anaplasmosis in South Korea. The patient had fever and thrombocytopenia. Human granulocytic anaplasmosis was confirmed by seroconversion, PCR, and sequence analysis for Anaplasma phagocytophilum. Morulae were observed in the cultured HL-60 cells inoculated with blood from the patient.

Human granulocytic Anaplasmosis, Japan

We retrospectively confirmed 2 cases of human Anaplasma phagocytophilum infection. Patient blood samples contained unique p44/msp2 for the pathogen, and antibodies bound to A. phagocytophilum antigens propagated in THP-1 rather than HL60 cells. Unless both cell lines are used for serodiagnosis of rickettsiosis-like infections, cases of human granulocytic anaplasmosis could go undetected.

Molecular investigation of tick-borne pathogens in ticks from grazing cattle in Korea

This study was carried out to identify the tick species that infest grazing cattle and to determine the presence of tick-borne pathogens transmitted by these ticks in Korea. A total of 903 ticks (categorized into 566 tick pools) were collected from five provinces during 2010-2011. The most prevalent tick species was Haemaphysalis longicornis, followed by three Ixodes spp. ticks. The collected ticks were infected with both rickettsial and protozoan pathogens. In all, 469 (82.9%) tick pools tested positive for the Anaplasma/Ehrlichia 16S rRNA gene, whereas 67 (11.8%) were positive for the Babesia/Theileria 18S rRNA gene. Among the rickettsial pathogens, E. canis was detected with the highest rate (22.3%), followed by A. platys (20%), E. chaffeensis (19.4%), E. ewingii (19.3%), Rickettsia sp. (12.4%), A. phagocytophilum (5.5%) and E. muris (0.5%). Among the protozoan pathogens, T. equi was detected with the highest rate (7.2%), followed by T. sergenti/T. buffeli (3.7%) and B. caballi (0.35%). Simultaneous infections with up to seven pathogens were also identified. In particular, ticks infected with rickettsial pathogens were also infected with protozoan pathogens (22 samples). All five provinces investigated infected with tick-borne pathogens.

Seroprevalence of tick-borne infections in military working dogs in the Republic of Korea

In this study we endeavored to determine the seroprevalence of tick-borne infections in the military working dog (MWD) population in the Republic of Korea (ROK). Our sample population consisted of 182 serum samples from MWDs for 3 different years (1996, 2002, and 2007). In addition, 63 whole blood samples from 2007 were available for polymerase chain reaction (PCR). Serum samples were evaluated by a commercially available enzyme-linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA) for Ehrlichia canis and Anaplasma phagocytophilum, and by ELISA only for Borrelia burgdorferi. PCR amplification of DNA was performed to screen for Ehrlichia canis, E. chaffeensis, E. ewingii, Anaplasma phagocytophilum, A. platys, Borrelia burgdorferi, and Rickettsia rickettsii, as well as Babesia and Theileria species using previously published primers and probes. A total of 56 (30.8%) MWDs were positive by at least one serologic test. Seroprevalences for Anaplasma and Ehrlichia were 4.4% and 0.6% based on the ELISA, and 24.7% and 22.5% based on the IFA, respectively. ELISA testing for Borrelia yielded 2 (1.1%) positive results. In parallel testing using both the ELISA and IFA tests, the percentages of dogs with one or more positive results were 34.1%, 25.9%, and 28.4%, for 1996, 2002, and 2007, respectively. There was no significant differences in seroprevalence based on location, year, breed, or sex of the MWD. There was poor agreement between IFA and ELISA test results. No MWD sample had a positive PCR result. MWDs stationed in Korea had serologic evidence of exposure to several tick-borne pathogens, but PCR testing did not identify any active infections.

Investigation of anaplasmosis in Yiyuan County, Shandong Province, China

OBJECTIVE

To investigate the situation of anaplasmosis in Yiyuan county, Shandong Province.

METHODS

A total of 26 blood samples from febrile patients suspected of anaplasmosis, 48 blood samples from healthy farmers, 8 from dogs, and 10 from goats and 170 ticks were collected in the same area during 2005-2007, and detected by serological and molecular methods.

RESULTS

Eight confirmed cases and 6 probable cases were determined using serologic and molecular methods. The seroprevalence of Anaplasma phagocytophilum (A. phagocytophilum) was 26.7% in healthy cases. Nine out of 10 sheep samples and 7 out of 8 dog samples reacted positively to the A. phagocytophilum antigen. PCR amplification and sequencing of the 16SrRNA of A. phagocytophilum gene showed that some samples from patients, goats and ticks were 100% identical. The seroprevalence of Rickettsia typhi was 22.9%, Orientia tsutsugamushi 6.3%, Rickettsia sibirica 27.1%, Coxiella burnetii 18.8%, Bartonella henselae 31.3%, and Borrelia burgdorferi 41.6%.

CONCLUSIONS

It is important to make differential diagnosis of febrile patients and to apply treatment with specific antibiotics. It is needed to enforce essential prevention and control measures including tick control and to improve sanitation conditions.

Serologic evidence of equine granulocytic anaplasmosis in horses from central West Brazil

Ehrlichiosis is a zoonotic disease caused by gram-negative and intracellular obligatory bacterial organisms. Equine Granulocytic Anaplasmosis - EGA (formerly Equine Granulocytic Ehrlichiosis, EGE) is a seasonal disease, normally self-limited in horses. There are few reports in Brazil about this ehrlichial agent, as well as its natural vectors. Nowadays, veterinarians are considering the suspicion of EGA in horses with suggestive symptoms of ehrlichiosis and which do not respond to piroplasmosis treatment. The aim of the present study was to identify horses exposed to the agent A. phagocytophilum by serological and molecular techniques. Twenty equine blood and serum samples from the central West region of Brazil were evaluated by microscopic examination of buffy coat smear, enzyme-linked immunosorbent assay (ELISA), indirect fluorescent antibody test (IFAT) and nested polymerase chain reaction (nPCR). Additionally, the serodiagnosis of Theileria equi by IFA and ELISA were carried out, as well as molecular diagnosis by nPCR. Thirteen (65%) serum samples were positive for A. phagocytophilum by ELISA, but none of them were positive by buffy-coat smear examination or nPCR. Antibodies IgG anti-T. equi were detected in 18 (90%) and 17 (85%) horses by IFA and ELISA, respectively and the agent was detected in 9 (45%) animals by nPCR. Our data may be considered as important information to understanding the occurrence of EGA and equine piroplasmosis in central West Brazil.

Molecular detection of Ehrlichia chaffeensis and Anaplasma bovis in the salivary glands from Haemaphysalis longicornis ticks

The salivary gland (SG) of tick plays an important role as a route in the dissemination of tick-borne pathogens to their hosts. We evaluated the presence of these pathogens in the SGs of Haemaphysalis longicornis ticks, and these ticks were collected from grazing cattle in Jeju Island, Korea. Of total 463 one-side SGs, 56 (12.1%) SGs were positive for Ehrlichia chaffeensis and 11 (2.4%) were positive for Anaplasma bovis. In addition, two (0.4%) SGs were co-infected with both E. chaffeensis and A. bovis. In conclusion, we specifically describe the presence of E. chaffeensis and A. bovis in the SGs of H. longicornis ticks in Korea.

Molecular and clinical evidence of Ehrlichia chaffeensis infection in Cameroonian patients with undifferentiated febrile illness

In the U.S.A., human monocytotropic ehrlichiosis (HME) caused by Ehrlichia chaffeensis is an emerging tick-transmitted zoonosis. In Cameroon, where E. canis, E. chaffeensis and E. ewingii have recently been detected in dogs and/or ticks (Rhipicephalus sanguineus), the potential exists for human infections. Patients from the coastal region of Cameroon who had acute fevers of unknown aetiology were therefore checked for ehrlichial infection, using a real-time PCR that amplifies part of a genus-specific gene (dsb) that codes for a disulphide-bond formation protein. Ehrlichial blood was detected in the peripheral blood from 12 (10%) of the 118 patients investigated by PCR. When the 12 amplicons from the positive cases were sequenced, they were found to be identical to each other and to the corresponding dsb sequence of an Arkansas strain of E. chaffeensis. The 12 patients who were PCR-positive for E. chaffeensis suffered from fever (100%), headache (67%), myalgia (42%), arthralgia (58%), pulmonary involvement (17%) and/or a diffuse rash (17%).

Predominance of Ehrlichia chaffeensis in Rhipicephalus sanguineus ticks from kennel-confined dogs in Limbe, Cameroon

Rhipicephalus sanguineus ticks (n = 63) collected from five dogs (two adults and three puppies) housed in a kennel were screened for Ehrlichial agents (Ehrlichia canis, E. chaffeensis, and E. ewingii) using a species-specific multicolor real-time TaqMan PCR amplification of the disulphide bond formation protein (dsb) gene. Ehrlichia chaffeensis DNA was detected in 33 (56%) ticks, E. canis DNA was detected in four (6%) ticks, and one tick was coinfected. The E. chaffeensis and E. canis nucleotide sequences of the amplified dsb gene (374 bp) obtained from the Cameroonian R. sanguineus ticks were identical to the North American genotypes.

Natural history of Ehrlichia chaffeensis: vertebrate hosts and tick vectors from the United States and evidence for endemic transmission in other countries

Ehrlichia chaffeensis, an intracellular gram-negative zoonotic bacterium, is the causative agent of human monocytotropic ehrlichiosis (HME). In humans, the disease can range from a mild, non-specific illness with few to no clinical signs to a moderately severe to fatal disease, especially those with compromised immune systems. E. chaffeensis is maintained in a complex cycle involving white-tailed deer (WTD; Odocoileus virginianus) as a primary reservoir and the lone star tick (LST; Amblyomma americanum) as a primary vector. Numerous other species are naturally exposed to E. chaffeensis and disease has been documented in some domestic animals and wildlife including domestic dogs and ring-tailed lemurs. The organism has been found throughout the natural range of the LST and as the tick continues to expand its range, the geographic range of risk for E. chaffeensis infections will likely continue to expand. Recent data have indicated that E. chaffeensis, or a closely related organism, has been found in many species of ticks and vertebrate hosts in numerous countries.

Current management of human granulocytic anaplasmosis, human monocytic ehrlichiosis and Ehrlichia ewingii ehrlichiosis

Anaplasma phagocytophilum, Ehrlichia chaffeensis and Ehrlichia ewingii are emerging tick-borne pathogens and are the causative agents of human granulocytic anaplasmosis, human monocytic ehrlichiosis and E. ewingii ehrlichiosis, respectively. Collectively, these are referred to as human ehrlichioses. These obligate intracellular bacterial pathogens of the family Anaplasmataceae are transmitted by Ixodes spp. or Amblyomma americanum ticks and infect peripherally circulating leukocytes to cause infections that range in clinical spectra from asymptomatic seroconversion to mild, severe or, in rare instances, fatal disease. This review describes: the ecology of each pathogen; the epidemiology, clinical signs and symptoms of the human diseases that each causes; the choice methods for diagnosing and treating human ehrlichioses; recommendations for patient management; and is concluded with suggestions for potential future research.

Natural co-infection of Ehrlichia chaffeensis and Anaplasma bovis in a deer in South Korea

Both ehrlichioses and anaplasmoses are zoonotic, fatal infectious diseases that caused by ticks. White-tailed deer (Odocoileus virginianus) are important hosts for Ehrlichia chaffeensis, Anaplasma phagocytophilum and Anaplasma-like organisms. In the present study, an evaluation of infection with tick-borne pathogens was conducted using a PCR assay on the blood of a deer that expressed anorexia and decreased activity. The results of the PCR assay revealed natural co-infection of E. chaffeensis and A. bovis in the deer. This indicates that deer may be a natural reservoir of both E. chaffeensis and A. bovis in South Korea.

Microbial pathogens in ticks, rodents and a shrew in northern Gyeonggi-do near the DMZ, Korea

A total of 1,618 ticks [420 individual (adults) and pooled (larvae and nymphs) samples], 369 rodents (Apodemus agrarius, Rattus norvegicus, Tscherskia triton, Mus musculus, and Myodes regulus), and 34 shrews (Crocidura lasiura) that were collected in northern Gyeonggi-do near the Demilitarized Zone (DMZ) of Korea during 2004-2005, were assayed by PCR for selected zoonotic pathogens. From a total of 420 individual and pooled tick DNA samples, Anaplasma (A.) phagocytophilum (16), A. platys (16), Ehrlichia (E.) chaffeensis (63), Borrelia burgdorferi (16), and Rickettsia spp. (198) were detected using species-specific PCR assays. Out of 403 spleens from rodents and shrews, A. phagocytophilum (20), A. platys (34), E. chaffeensis (127), and Bartonella spp. (24) were detected with species-specific PCR assays. These results suggest that fevers of unknown causes in humans and animals in Korea should be evaluated for infections by these vector-borne microbial pathogens.

Predicting the emergence of tick-borne infections based on climatic changes in Korea

Granulocytic anaplasmosis (GA) and monocytic ehrlichiosis (ME) are maintained in wild rodent reservoirs and tick vectors in the Republic of Korea. This study investigated the prevalence of 2 tick-borne pathogens, Anaplasma phagocytophilum and Ehrlichia chaffeensis, in wild rodents and ticks in central Korea to identify any significant associations with existing or changing climatic conditions. Specifically, the goal of this study was to develop simple models for the probability of occurrence of an epidemic of GA or ME as a function of climate in an area in a given year. Climatic data from 2 regions, Munsan and Dongducheon, Gyeonggi, in central Korea (between the Demilitarized Zone and Seoul, latitude between 37 degrees N-38 degrees N and longitude between 127 degrees E-128 degrees E), were analyzed with respect to the prevalence of GA and ME in Paju, Yoncheon, Pocheon, and Dongducheon for the period from 2001 to 2005. Rates of A. phagocytophilum and E. chaffeensis decreased as the total yearly precipitation levels and daily humidity increased, and as the daily mean sunshine hours decreased. Rates of A. phagocytophilum and E. chaffeensis from rodent ticks and rodents increased in the fall season. Linear regression analyses evaluating the numbers of positive samples by sample type found that rodent ticks were 6.64 times more likely to be actively infected with A. phagocytophilum than grass ticks or rodents, though the likelihood of any samples testing positive for this pathogen decreased by 0.17 as the annual mean level of precipitation increased by 1 mm. For E. chaffeensis, rodents were 15.67 times more likely to be infected than ticks. Logistic regression analyses evaluating each sample separately found that the odds of infection with A. phagocytophilum were nearly 5 times greater for rodents than ticks. In these analyses, precipitation was one potential factor to account for the prevalence of tickborne diseases.

Characterization of Anaplasma phagocytophilum major surface protein 5 and the extent of its cross-reactivity with A. marginale

Major surface protein 5 (Msp5) of Anaplasma marginale is highly conserved in the genus Anaplasma and the antigen used in a commercially available competitive enzyme-linked immunosorbent assay (cELISA) for serologic identification of cattle with anaplasmosis. This study analyzes the degrees of conservation of Msp5 among various isolates of Anaplasma phagocytophilum and the extent of serologic cross-reactivity between recombinant Msp5 (rMsp5) of Anaplasma marginale and A. phagocytophilum. The msp5 genes from various isolates of A. phagocytophilum were sequenced and compared. rMsp5 proteins of A. phagocytophilum and A. marginale were used separately in an indirect ELISA to detect cross-reactivity in serum samples from humans and dogs infected with A. phagocytophilum and cattle infected with A. marginale. Serum samples were also tested with a commercially available competitive ELISA that uses monoclonal antibody ANAF16C1. There were 100% sequence identities in the msp5 genes among all of the A. phagocytophilum isolates from the United States and a horse isolate from Sweden. Sheep isolates from Norway and dog isolates from Sweden were 99% identical to one another but differed in 17 base pairs from the United States isolates and the horse isolate. Serologic cross-reactivity was identified when serum samples from cattle infected with A. marginale were reacted with rMsp5 of A. phagocytophilum and when serum samples from humans and dogs infected with A. phagocytophilum were reacted with rMsp5 of A. marginale in an indirect-ELISA format. Serum samples from dogs or humans infected with A. phagocytophilum did not cross-react with rMsp5 of A. marginale when tested with the commercially available cELISA. These results suggest that rMsp5 of A. phagocytophilum is highly conserved among United States and European isolates and that serologic distinction between A. phagocytophilum and A. marginale infections cannot be accomplished if rMsp5 from either organism is used in an indirect ELISA.

Tick-borne rickettsial pathogens in ticks and small mammals in Korea

In order to investigate the prevalence of tick-borne infectious agents among ticks, ticks comprising five species from two genera (Hemaphysalis spp. and Ixodes spp.) were screened using molecular techniques. Ticks (3,135) were collected from small wild-caught mammals or by dragging/flagging in the Republic of Korea (ROK) and were pooled into a total of 1,638 samples (1 to 27 ticks per pool). From the 1,638 tick samples, species-specific fragments of Anaplasma phagocytophilum (1 sample), Anaplasma platys (52 samples), Ehrlichia chaffeensis (29 samples), Ehrlichia ewingii (2 samples), Ehrlichia canis (18 samples), and Rickettsia rickettsii (28 samples) were amplified by PCR assay. Twenty-one pooled and individual tick samples had mixed infections of two (15 samples) or three (6 samples) pathogens. In addition, 424 spleen samples from small captured mammals (389 rodents, 33 insectivores, and 2 weasels) were screened for selected zoonotic pathogens. Species-specific DNA fragments of A. phagocytophilum (110 samples), A. platys (68 samples), E. chaffeensis (8 samples), E. ewingii (26 samples), E. canis (51 samples), and Rickettsia sp. (22 samples) were amplified by PCR assay. One hundred thirty small mammals had single infections, while 4, 14, and 21 striped field mice (Apodemus agrarius) had mixed infections of four, three, and two pathogens, respectively. Phylogenetic analysis based on nucleotide sequence comparison also revealed that Korean strains of E. chaffeensis clustered closely with those from China and the United States, while the Rickettsia (rOmpA) sequences clustered within a clade together with a Chinese strain. These results suggest that these agents should be considered in differential diagnosis while examining cases of acute febrile illnesses in humans as well as animals in the ROK.

[Human ehrlichiosis]

BACKGROUND

Human ehrlichiosis is a newly recognized disease. It is a tick-borne disease caused by several bacterial species of the genhus Erlichia. These are small gram-negative pleomorphic cocci, that are obligatory intracellular bacteria. Tick Ixodes is the principle vector in Europe, and Amblyomma amenicanum in the United States. Bacterial organisms replicate in a tick, and are transmited from infected cells in a vector to the blood cells of animals or humans. Human ehrlichiosis is a name for a group of diseases caused by different species of Ehrlichia. One of them is the disease named human monocytic ehrlichiosis, caused by Ehrlichia chaffeensis, and the other is a human granulocytic ehrlichiosis caused by Anaplasma phagocytophilia.

CASE REPORT

We reported a 23-year-old patient admitted for the clinical treatment with the symptoms of high febrility (above 40 degrees C), headache, vomiting, general weakness and exhaustion, but without data on a tick bite. The patient was treated with trimetoprim-sulfamethoxazole for a week when Ehrlichia chaffeensis was confirmed by the immunofluoroscence test, and the therapy contimed with doxacyclin.

CONCLUSION

Human ehrlichiosis is also present in our country, so this disease should be considered everyday, especially in infectology practice.