Mediterranean spotted fever: case series of 24 years (1989-2012)

Boutonneuse Fever in Southeastern Romania

Boutonneuse fever (BF) is an eruptive disease and is classified as a spotted fever, which is endemic in the Mediterranean basin (i.e., Marseille fever or Mediterranean spotted fever) and the Black Sea, caused by Rickettsia conorii, with dog ticks being a vector (i.e., Rhipicephalus sanguineus). In Romania, although the first reported outbreak of BF occurred during the summer of 1931 in Constanta, the disease was discovered in 1910. Although the disease has occurred most frequently in the two counties of the Dobruja region (Constanta and Tulcea), a region of the Balkan Peninsula, during the last few years, other counties in southeastern Romania have started to report BF cases. In a period of 9 years, 533 cases were registered in Constanta county, while in a period of 11 years, 339 cases were registered in Bucharest county. In this review, we describe the bacterial tick-borne disease caused by R. conorii in southeastern Romania, focusing on its history and epidemiology, pathophysiology, clinical aspects, diagnosis, treatment and preventive measures in the context of climate changes. Although R. conorii is the principal etiologic agent of BF in southeastern Romania, we should take into consideration that other Rickettsia spp. could be present and involved in disease transmission.

Mediterranean spotted fever with multiorgan involvement

A previously well man in his 50s returned to the UK after a trip to the Mediterranean. The day after returning he developed malaise, fevers, rigors and severe headache. He was hospitalised with sepsis, multiorgan involvement, a maculopapular rash and an eschar on each hip. Serology was positive for Rickettsia spp (spotted fever group) with a rise in titre from 1:64 to 1:1024 eight days later. Blood and tissue PCR were also positive for Rickettsia spp. He had cardiac, pulmonary, renal, ocular and neurological involvement. He completed a 14-day course of doxycycline and recovered well. This is a case of likely Mediterranean spotted fever (MSF) caused by Rickettsia conorii, which is endemic to the Mediterranean basin. We highlight the need for awareness and early treatment to prevent severe complications. This case is also the first to describe Purtscher-like retinopathy in the context of likely MSF.

IL-1 Superfamily Member (IL-1A, IL-1B and IL-18) Genetic Variants Influence Susceptibility and Clinical Course of Mediterranean Spotter Fever

Mediterranean Spotted Fever (MSF) is one of the most common spotted fever Rickettsioses. Most cases of MSF follow a benign course, with a minority of cases being fatal. The severity of the infection depends on bacterial virulence, dose and host factors such as effective immune response and genetic background. Herein, we reported data on typing by competitive allele-specific PCR of functionally relevant polymorphisms of genes coding for MyD88 adapter-like (Mal/TIRAP) protein (rs8177374), interleukin(IL)-1 cluster (IL-1A rs1800587, IL-1B rs16944 and rs1143634) and IL-18 (rs187238), which might be crucial for an efficient immune response. The results enlighten the role that IL-1 gene cluster variants might play in susceptibility against Rickettsia conorii infection. In particular, the IL-1A rs1800587TT genotype was significantly increased in patients alone and combined in a haplotype composed by minor alleles rs1800587T, rs16944A and rs1143634A. This result was confirmed using the decision tree heuristic approach. Using this methodology, IL-1A rs1800587TT genotype was the better discrimination key among MSF patients and controls. In addition, the IL-1 gene cluster SNP genotypes containing minor alleles and IL-18 rs187238G positive genotypes were found as associated with risk of severe complications such as sepsis, septic shock, acute respiratory distress syndrome and coma. In conclusion, these data suggest that the evaluation of IL-1A, IL-1B and IL-18 gene SNPs can add useful information on the clinical course of patients affected by Mediterranean Spotted Fever, even if further confirmatory studies will be necessary.

Tick-Borne Rickettsioses in the Iberian Peninsula

Tick-borne rickettsioses (TBR) are caused by obligate, intracellular bacteria of the spotted-fever group (SFG) of the genus Rickettsia (Order Rickettsiales), transmitted by hard ticks. TBR are one of the oldest known vector-borne zoonoses and pose a threat to both human and animal health, as over the years, new SFG Rickettsia spp. have been reported worldwide with the potential to be human pathogens. In Portugal and Spain, the countries that constitute the Iberian Peninsula, reported TB rickettsiae causing human disease include Rickettsia conorii conorii, Rickettsia conorii israelensis, Rickettsia slovaca, Rickettsia raoultii, Candidatus Rickettsia rioja, Rickettsia sibirica mongolitimonae, and Rickettsia monacensis. An allochthonous case of TBR caused by Rickettsia massiliae, described in Spain, points to the need to monitor disease epidemiology, to predict risks of exposure and spread of disease, and taking into account globalization and climate changes. This review aims to provide up-to-date information on the status of TBR in the Iberian Peninsula, as well as to show the importance of a national and international collaborative epidemiology surveillance network, towards monitoring Rickettsia spp. circulation in both Portugal and Spain.

A case of Mediterranean spotted fever mimicking severe sepsis

Mediterranean spotted fever (MSF) is a tick-borne acute endemic infectious disease caused by Rickettsia conorii. While MSF may progress asymptomatically, it may lead to clinical pictures like severe hemorrhagic fever. In this article, we are presenting an MSF case with signs of high fever, headache, nausea, weakness and generalized maculopapular rash. The diagnosis of the female patient who had a history of contact with a tick-infested dog was confirmed with her clinical and laboratory data. The clinical and laboratory findings of the patient who was given doxycycline by 200 mg/day for 7 days were improved in a short time. Rickettsia conorii serology by indirect immunofluorescence assay method confirmed the diagnosis of MSF. In cases of severe sepsis accompanied by high fever and generalized maculopapular rash where the source of the infection cannot be determined in the short term, carefully questioning exposure to ticks by considering the existing geographical, seasonal and endemic environmental factors may be life-saving in terms of early diagnosis and treatment of MSF, which may become fatal even in the absence of eschars (tache noire). The symptomatology of hemorrhagic fever associated with Rickettsia conorii may be confused with that of sepsis in clinical practice.

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.

Spotted fever diagnosis: Experience from a South Indian center

Spotted fever (SF) is an important treatable cause of acute febrile illness (AFI) with rash and has reemerged in India. A prospective AFI with rash study was undertaken at a South Indian hospital to correlate specific clinical findings with laboratory confirmation of spotted fever. During the study period (December 2017 to May 2019), 175 patients with fever and rash were suspected to have spotted fever. Molecular assays for scrub typhus and spotted fever (47 kDa and ompA qPCR) and serology (IgM ELISA) was performed on the 96 individuals recruited. Laboratory confirmed SF cases (ompA qPCR positive) were 21, whereas laboratory supported SF cases (ompA negative but sero-positive by SF IgM ELISA) were 27. Among the 48 spotted fever (SF) cases, 70% of had maculopapular rash, 12.5% had macular rash, purpuric/petechial rash (severe rash) was seen in 8 patients (16.7%). Presence of rash on the palms and soles was associated with a relative risk (RR) of 4.36 (95% CI: 2.67-7.10; p < 0.001). Our study suggests that ompA qPCR though useful for confirming the diagnosis of spotted fever is not always positive. A positive SF IgM ELISA in febrile individuals with palmo-plantar rash supports the diagnosis of spotted fever especially when other causes of febrile rash have been excluded. Multi-centric prospective studies employing the serological reference standard, IFA (immunofluorescence assay) in addition to the assays used in this study are needed to validate these findings.

Epidemiology, Clinical Aspects, Laboratory Diagnosis and Treatment of Rickettsial Diseases in the Mediterranean Area During COVID-19 Pandemic: A Review of the Literature

The purpose of the present review is to give an update regarding the classification, epidemiology, clinical manifestation, diagnoses, and treatment of the Rickettsial diseases present in the Mediterranean area.

We performed a comprehensive search, through electronic databases (Pubmed – MEDLINE) and search engines (Google Scholar), of peer-reviewed publications (articles, reviews, and books).

The availability of new diagnostic tools, including Polymerase Chain Reaction and nucleotide sequencing has significantly modified the classification of intracellular bacteria, including the order Rickettsiales with more and more new Rickettsia species recognized as human pathogens. Furthermore, emerging Rickettsia species have been found in several countries and are often associated with unique clinical pictures that may challenge the physician in the early detection of the diseases.

Rickettsial infections include a wide spectrum of clinical presentations ranging from a benign to a potentially life treating disease that requires prompt recognition and proper management. Recently, due to the spread of SARS-CoV-2 infection, the differential diagnosis with COVID-19 is of crucial importance. The correct understanding of the clinical features, diagnostic tools, and proper treatment can assist clinicians in the management of Rickettsioses in the Mediterranean area.

Spatial and temporal trends of Mediterranean spotted fever in Spain, 2005-2015

BACKGROUND

Mediterranean spotted fever (MSF) is a zoonotic disease caused by Rickettsia conorii and transmitted by Rhipicephalus sanguineus sensu lato. The aim of this study is to understand the epidemiology and trends regarding the disease in Spain, based on notifications to the Spanish National Epidemiology Surveillance Network (RENAVE) and the National Hospital Discharge Database (CMBD) between 2005 and 2015.

METHODS

We carried out a retrospective cross-sectional study of the cases and the outbreaks reported to the RENAVE and of those found in the CMBD between January 1^st, 2005 and December 31^st, 2015. We studied the characteristics of the cases and analyzed their spatio-temporal distribution.

RESULTS

1603 cases notified to the RENAVE and 1789 cases registered in the CMBD were analyzed. The most affected group were men between 45 and 64. There were 8 MSF outbreaks during the study period. RENAVE registered lower rates until 2012, when it was decided that MSF in Spain would become a notifiable disease. Across the temporal series we saw that there was seasonality with an increase in cases in summer, and an overall upward trend according to the RENAVE data and descending according to the CMBD. The geographic distribution was heterogeneous throughout the territory, with maximum rates in La Rioja at 1.87 cases and 2.01 cases per 100,000 inhabitants according to the RENAVE and the CMBD, respectively.

CONCLUSIONS

It is of great importance to continue monitoring the disease since it appears to be endemic throughout Spain. There is a need for a common strategy on monitoring and reporting, which would facilitate a more accurate picture on the MSF epidemiological scenario. Entomological information will be of added value.

Under-diagnosis of rickettsial disease in clinical practice: A systematic review

BACKGROUND

Rickettsial diseases present as acute febrile illnesses, sometimes with inoculation eschars.

METHODS

We performed a systematic review of studies published between 1997 and 2017 to assess the underestimation of non-eschar rickettsial disease (NERD) relative to eschar rickettsial disease (ERD), as a cause of acute fever in patients with rickettsial diseases that commonly present with eschar(s): scrub typhus (ST), Mediterranean spotted fever (MSF), and African tick-bite fever. We compared ERD/NERD ratios according to study design: 'complete approach' studies, with testing performed in all patients with 'unspecified febrile illness'; versus 'clinical judgement' studies, with testing performed if patients presented with specific symptoms.

RESULTS

In 'complete approach' studies, ERD/NERD ratios were significantly lower, suggesting a considerable under-diagnosis of NERD in 'clinical judgement' studies. Based on these results, we estimate that the diagnosis of rickettsial disease was missed in 66.5% of patients with ST, and in 57.9% of patients with MSF.

CONCLUSIONS

Study design influences the reported eschar rates in ST and MSF significantly. NERD is likely to be a vastly underdiagnosed entity, and clinicians should consider and test for the disease more often.

PROSPERO REGISTRATION NUMBER

CRD 42016053348.

Bacterial arthropod-borne diseases in West Africa

Arthropods such as ticks, lice, fleas and mites are excellent vectors for many pathogenic agents including bacteria, protozoa and viruses to animals. Moreover, many of these pathogens can also be accidentally transmitted to humans throughout the world. Bacterial vector-borne diseases seem to be numerous and very important in human pathology, however, they are often ignored and are not well known. Yet they are in a phase of geographic expansion and play an important role in the etiology of febrile episodes in regions of Africa. Since the introduction of molecular techniques, the presence of these pathogens has been confirmed in various samples from arthropods and animals, and more rarely from human samples in West Africa. In this review, the aim is to summarize the latest information about vector-borne bacteria, focusing on West Africa from 2000 until today in order to better understand the epidemiological risks associated with these arthropods. This will allow health and veterinary authorities to develop a strategy for surveillance of arthropods and bacterial disease in order to protect people and animals.

Expression of Rickettsia Adr2 protein in E. coli is sufficient to promote resistance to complement-mediated killing, but not adherence to mammalian cells

Bacteria exposed to host serum are subject to the antibacterial effects to the complement system. However, pathogenic microorganisms have evolved mechanisms of evading this immune attack. We have previously demonstrated that at least two R. conorii antigens, RC1281/Adr1 and OmpB β-peptide, contribute to the evasion of complement-mediated killing by binding the complement regulatory proteins vitronectin and factor H. RC1282/Adr2, a protein related to Adr1, is predicted to share similar structural features, suggesting that this protein may also contribute to evasion of complement-mediated killing. Interestingly, the R. prowazekii Adr1 and Adr2(RP828) proteins were originally found to interact with host cell surface proteins, suggesting their putative roles as adhesins in this pathogenic rickettsial species. In this study, we expressed both R. conorii and R. prowazekii Adr2 on the surface of a non-adherent, serum-sensitive strain of E. coli to examine the potential role of this protein to mediate evasion of complement-mediated killing and adherence to host cells. We demonstrate that, similar to R. conorii Adr1, R. conorii and R. prowazekii Adr2 are sufficient to mediate serum resistance and to promote interaction with the host complement regulator vitronectin. Furthermore, we demonstrate that expression of Adr2 in a non-adherent strain of E. coli is insufficient to mediate adherence to cultured mammalian endothelial cells. Together, our data demonstrate that the R. conorii and R. prowazekii Adr2 protein does not participate in the interactions with mammalian cells, but rather, participates in the evasion of killing by complement.

Mediterranean spotted fever in Spain, 1997-2014: Epidemiological situation based on hospitalization records

Introduction

Mediterranean spotted fever (MSF) is a zoonotic disease caused by Rickettsia conorii. In Spain, deficiencies in the official reporting result in misreporting of this disease. This study aims to describe the clinical and temporal-spatial characteristics of MSF hospitalizations between 1997 and 2014.

Materials and methods

We performed a retrospective descriptive study using the Hospitalization Minimum Data Set (CMBD). All CMBD’s hospital discharges with ICD-9 CM code 082.1 were analyzed. Hospitalization rates were calculated and clinical characteristics were described. Spatial distribution of cases and their temporal behavior were also assessed.

Results

A total of 4,735 hospitalizations with MSF diagnosis were recorded during the study period, out of which 62.2% were male, mean age of 48. Diabetes mellitus, alcohol dependence syndrome, and chronic liver disease occurred in 10.8%, 2.4% and 2.8% hospitalizations, respectively. The median annual hospitalization rate showed a decreasing trend from a maximum of 12.9 in 1997 to a minimum rate of 3.1 in 2014. Most admissions occurred during the summer, showing a significant annual seasonal behavior. Important regional differences were found.

Discussion

Although MSF hospitalization rates have decreased considerably, it remains a public health problem due to its severity and economic impact. Therefore, it would be desirable to improve its oversight and surveillance.

Parasitic zoonoses associated with dogs and cats: a survey of Portuguese pet owners' awareness and deworming practices

Background

Parasitic diseases of companion animals comprise a group of globally distributed and rapidly spreading illnesses that are caused by a wide range of arthropods, helminths and protozoa. In addition to their veterinary importance, many of these parasites can also affect the human population, due to their zoonotic potential. The aim of the present work was to evaluate the knowledge of Portuguese pet owners regarding the zoonotic potential of parasites that dogs and cats can harbour, most common drugs, frequency of use and reasons for endo- and ectoparasite control.

Methods

Seventy hundred and fifty multiple-choice questionnaires designed to obtain data knowledge about the meaning of zoonosis, knowledge about parasitic diseases and perception regarding their zoonotic potential, as well as the drugs, frequency and reason for deworming their animals were delivered to dog and/or cat owners from non-rural (i.e. urban or semi-urban) and rural parishes who attended veterinary medical centres from continental Portugal.

Results

A total of 536 (71.5 %) questionnaires were retrieved. Two hundred and ninety five (56.5 %) responders had heard of zoonosis/zoonoses, but only 184 (35.2 %) knew their meaning. Tick fever, mange, leishmaniosis and ascaridiosis/roundworms were the parasitic diseases from pets most frequently identified. The number of owners who recognized the different parasitoses, who stated to have heard about zoonoses and who were aware of the potential transmission of parasites from animals to humans was significantly higher in those with intermediate (i.e. ≥9 and ≤ 12 years of schooling) and/or higher academic degree (i.e. licentiate, master’s and/or doctorate degrees). The combinations of febantel-pyrantel-praziquantel (23.5 %) and milbemycin-praziquantel (34.5 %) were the most widely endoparasitic drugs used in dogs and in cats, respectively. The most common ectoparasiticide used in dogs was a combination of imidacloprid-permethrin (33.4 %), while in cats it was imidacloprid (26.3 %) followed by fipronil (25.4 %). The most used treatment schedule against internal and external parasites in dogs and cats was an administration every three months and the main reason to do it was as a prophylactic purpose.

Conclusions

The majority of Portuguese owners that attended veterinarian clinics use endoparasiticides and ectoparasiticides in/on their pets as a prophylactic measure, although in many cases not in the correct schedule of treatment. In addition, most of them are not aware of the possible transmission of parasites from their dogs and cats to themselves, a fact which highlights the important role of veterinarians in the continuous implementation of effective control measures to reduce the risk of parasitic infections in both humans and companion animals.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1533-2) contains supplementary material, which is available to authorized users.

Rickettsioses in Europe

Bacteria of the genera Rickettsia and Orientia (family rickettsiaceae, order rickettsiales) cause rickettsioses worldwide, and are transmitted by lice, fleas, ticks and mites. In Europe, only Rickettsia spp. cause rickettsioses. With improvement of hygiene, the risk of louse-borne rickettsiosis (epidemic typhus) is low in Europe. Nevertheless, recrudescent form of Rickettsia prowazekii infection persists. There could be an epidemic typhus outbreak if a body lice epidemic occurs under unfavorable sanitary conditions. In Europe, endemic typhus or Rickettsia typhi infection, transmitted by rats and fleas, causes febrile illness. At the beginning of this century, flea-borne spotted fever cases caused by Rickettsia felis were diagnosed. Flea-borne rickettsiosis should be suspected after flea bites if fever, with or without rash, is developed. Tick-borne rickettsioses are the main source of rickettsia infections in Europe. Apart from Rickettsia conorii, the Mediterranean Spotted Fever (MSF) agent, other Rickettsia spp. cause MSF-like: Rickettsia helvetica, Rickettsia monacensis, Rickettsia massiliae or Rickettsia aeschlimannii. In the 1990s, two 'new' rickettsioses were diagnosed: Lymphangitis Associated Rickettsiosis (LAR) caused by Rickettsia sibirica mongolitimonae, and Tick-Borne Lymphadenopathy/Dermacentor-Borne-Necrosis-Erythema-Lymphadenopathy/Scalp Eschar Neck Lymphadenopathy (TIBOLA/DEBONEL/SENLAT), caused by Rickettsia slovaca, Candidatus Rickettsia rioja and Rickettsia raoultii. Lastly, European reports about mite-borne rickettsiosis are scarce.