A fatal case of Brazilian spotted fever in a non-endemic area in Brazil: the importance of having health professionals who understand the disease and its areas of transmission

Factors associated with the confirmation and death for Brazilian spotted fever in an important endemic area of the State of São Paulo, 2007-2021

BACKGROUND

We evaluated the predictive factors for case confirmation and death from Brazilian spotted fever in an endemic area of Southeastern Brazil.

METHODS

A cross-sectional study was conducted. All suspected cases reported between 2007 and 2021 were analyzed using two logistic regression models.

RESULTS

60 cases were confirmed. Male sex, age group of 40-59 years, tick parasitism, presence of capybaras or horses, exanthema and hospitalization were positively associated with confirmation. Death was associated with a longer period between first symptom-hospitalization and shorter treatment.

CONCLUSIONS

Complete clinical evaluation and information on risk exposure are key to early suspicion, diagnosis, treatment and prevention of deaths.

Capybara Ticks and the Urban Context of Spotted Fever in Brazil: An Overview

Spotted fever is caused by Rickettsia rickettsii and is transmitted through tick’s saliva. Humans, ticks, and capybaras (Hydrochoerus hydrochaeris) are often coexisting in environments that favor the spread of Brazilian spotted fever (BSF). Although capybaras do not transmit R. rickettsii, they can amplify these bacteria among tick vector populations, playing a significant role in the one health approach and epidemiology of the disease. Urban populations of capybaras have increased, especially in Southeast Brazil, as well as the number of cases and lethality of BSF have increased in the country since the 1980s. This expansion is mainly determined by the availability of food and the absence of predators. Thus, urban areas, including parks and university campuses, provide an abundance of food and protection against predators, ensuring the multiplication of the species and increasing the risk of transmission to humans due to the proximity of man with animals in the urban environment. Therefore, this chapter aims to address aspects of spotted fever, considering the many dimensions of the species involved, contributing to public strategies and policies.

Spotted Fever in the Morphoclimatic Domains of Minas Gerais State, Brazil

In Brazil, the tick-borne rickettsiosis known as Spotted Fever (SF) has been recorded from 59% of the Federative Units, however, the knowledge of the epidemiology and dynamics of human infection remains incipient in certain areas, complicating appropriate public health actions to inform the general population and control the disease. Here, we improved the interpretation of epidemiological information of SF cases recorded for an important endemic area. A descriptive epidemiological study was carried out based on records in the SINAN (Notifiable Diseases Information System) SF case databases. Data analysis was performed using Python programming language, Pandas library and Qgis map making. To evaluate the sociodemographic, clinical, assistance, laboratory and epidemiological characteristics, simple and relative nominal values of occurrences, means and standard deviations, and molecular analyzes were performed to identify the bioagent present in biological samples collected during each case investigation. Of the 298 confirmed cases, 98 resulted in death, the number of cases increased from 2011, and the disease scenario had 32.8% lethality. Overall, 207 cases involved men, and lethality was higher in this group. The most affected age group was 30 to 59 years old. The majority of patients reported having had contact with animals such as ticks, capybara and domestic animals such as dogs and cats. The results corroborate existing studies in areas of severe SF cases in Brazil. Despite reports of SF cases from the Cerrado Biome, analyses show that serious cases occur in anthropized areas of the Atlantic Forest biome, and in a transition area between this and the Cerrado. Complex, longitudinal, multidisciplinary studies, with an eco-epidemiological focus, should be carried out to allow the construction of algorithms capable of predicting, in time and space, the risk factors associated with severe cases and deaths from SF, with the aim of avoiding their expansion.

Isolation of Rickettsia rickettsii in Rocky Mountain Spotted Fever Outbreak, Panama

We report new cases of Rocky Mountain spotted fever in patients from Kinkantu, Ngäbe-Bugle indigenous comarca, Panama. We isolated Rickettsia rickettsii in cell culture after intraperitoneal inoculation of guinea pigs with tissues from a deceased patient. Our results indicate that Rocky Mountain spotted fever is emerging in this region.

Biodiversity of Potential Vectors of Rickettsiae and Epidemiological Mosaic of Spotted Fever in the State of Paraná, Brazil

Spotted Fever Rickettsioses (SFR) are diseases caused by bacteria of the genus Rickettsia, and are transmitted mainly by ticks. Its eco-epidemiological scenarios vary spatially, and may also vary over time due to environmental changes. It is the main disease transmitted by ticks to humans in Brazil, with the state of Paraná (PR) having the sixth highest number of notified incidences in the country. However, information is lacking regarding the SFR disease cycles at likely infection sites within PR. During case investigations or environmental surveillance in PR for SFR, 28,517 arthropods were collected, including species known or potentially involved in the SFR cycles, such as Amblyomma sculptum, Amblyomma aureolatum, Amblyomma ovale, Amblyomma dubitatum, Amblyomma parkeri, Ctenocephalides felis felis, and Rhipicephalus sanguineus sensu lato. From these Rickettsia asembonensis, Rickettsia bellii, Rickettsia felis, Rickettsia parkeri strain Atlantic Rainforest and Candidatus Rickettsia paranaensis were detected. Ectoparasite abundance was found to be related with specific hosts and collection environments. Rickettsiae circulation was observed for 48 municipalities, encompassing 16 Health Regions (HR). As for socio-demographic and assistance indicators, circulation occurred largely in the most urbanized HR, with a higher per capita Gross Domestic Product, lower Family Health Strategy coverage, and with a higher ratio of beds in the Unified Health System per thousand inhabitants. For environmental variables, circulation occurred predominantly in HR with a climatic classified as “subtropical with hot summers” (Cfa), and with forest type phytogeographic formations. In terms of land use, circulation was commonest in areas with agriculture, pasture and fields and forest cover. Rickettsiae were circulating in almost all hydrographic basins of PR state. The results of this study provide the first descriptive recognition of SFR in PR, as well as outlining its eco-epidemiological dynamics. These proved to be quite heterogeneous, and analyzed scenarios showed characteristics strongly-associated with the outbreaks, with cases presenting clinical variation in space, so illustrating the complexity of scenarios in PR state. Due to the diversity of the circumstances surrounding SFR infections in PR, public health initiatives are necessary to foster a better understanding of the dynamics and factors effecting vulnerability to SFR in this Brazilian state.

Two for the price of one: Co-infection with Rickettsia bellii and spotted fever group Rickettsia in Amblyomma (Acari: Ixodidae) ticks recovered from wild birds in Brazil

The bacterium Rickettsia bellii has been detected in 25 species of ticks in the American continents, but its pathogenic potential is considered as undetermined. A possible role for this species in the phenomenon of transovarial exclusion of pathogenic members of the spotted fever group (SFG) of Rickettsia has been suggested and co-infections with pathogenic species have been reported infrequently in both North and South America. Traditional methods for the molecular detection of rickettsial agents in ticks focus largely on the identification of sequences found in SFG Rickettsia, an approach that may overlook the presence of co-infections with R. bellii. Two novel, species-specific polymerase chain reaction (PCR) assays, targeting the genes encoding the surface cell antigen (Sca), autotransporter proteins sca9 and sca14, were developed and validated for the detection of R. bellii using 150 Amblyomma ticks collected from wild birds in Brazil. Co-infection of R. bellii infected ticks was evaluated using a novel PCR assay targeting the ompA sequence characteristic of SFG Rickettsia. Preliminary species-level identification was achieved by restriction fragment length polymorphism (RFLP) analysis and subsequently confirmed by sequencing of amplicons. Nine out of seventy-three Amblyomma longirostre and one of two Amblyomma calcaratum ticks were shown to be co-infected with R. bellii and Rickettsia amblyommatis, while two out of sixty-seven Amblyomma sp. haplotype Nazaré ticks were recorded as co-infected with R. bellii and the Rickettsia parkeri-like bacterium, strain ApPR. Interestingly, our data represent the first records of R. bellii in association with A. calcaratum and Amblyomma sp. haplotype Nazaré. The novel PCR-RFLP systems reported herein, provide an alternative, rapid and cost-efficient (relative to strategies based on sequencing or real-time PCR), approach to evaluate rickettsial co-infection of ticks, a potentially significant phenomenon that has most likely been underestimated to date.

Rickettsia amblyommatis infecting Amblyomma pseudoconcolor in area of new focus of spotted fever in northeast Brazil

In Brazil, active infections of Rickettsia spp. is confirmed in all regions, involving various species of ticks. During investigation of a new focus of Spotted Fever (SF) incidence in the state of Pernambuco, northeastern Brazil, tick species Rhipicephalus sanguineus sensu lato (Latreille), and Amblyomma pseudoconcolor were collected from one Canis familiaris and four Euphractus sexcinctus, respectively, and analized for the presence of rickettsial genes. Ten A. pseudoconcolor ticks (90.9%) were found to be infected with Rickettsia, whereas no evidence of Rickettsia spp. was found in R. sanguineus s. l. Genetic analysis based of five rickettsial genes showed that the detected strain is most closely related to Rickettsia amblyommatis (formerly Candidatus Rickettsia amblyommii). R. amblyommatis was, for the first time, detected in Amblyomma pseudoconcolor and the results pointed to this tick like a potential vector in the enzootic cycle of R. amblyommatis in a typical semiarid Brazilian savannah region. In conclusion, despite the need for further studies to confirm if R. amblyommatis was responsible for the observed case in the state of Pernambuco, the presence of this bacterium during an SF focussed investigation should be a major concern in terms of public health due the capacity of SF for rapid and extensive dispersion within Brazilian territory.

Fatal case of spotted fever in a patient from Northeastern Brazil

Spotted fevers are diseases caused by bacterial agents belonging to the spotted-fever (SF) group of the genus Rickettsia. The first documented case of SF in Pernambuco State, Northeast Brazil, was reported here. Also, it is the first case described of fatal SF in Northeast region of Brazil. The patient was a resident of Arcoverde municipality and the probable site of infection lies in Sertania municipality, both in Pernambuco State, a semi-arid region of Brazil. The patient had not visited other areas where SF is endemic. The patient showed clinical manifestations and epidemiological exposure compatible with SF, and the infection was confirmed by molecular biology techniques.

Timeliness in the notification of spotted fever in Brazil: Evaluating compulsory reporting strategies and digital disease detection

Spotted fever is caused by rickettsia species, and is the most important tick-borne disease. In Brazil, it requires national compulsory notification to the Ministry of Health. Since 2007, all suspected cases of spotted fever have been integrated into the Notifiable Diseases Information System (SINAN). In this descriptive study we evaluate the timeliness (expressed in number of days between time of clinical suspicion and reporting) of the compulsory notification of spotted fever cases in SINAN and the strategy for digital disease detection (DDD). This study analysed the information from the SINAN and from the digital detection strategy used by ProMED-Português. Results show that detection by the SINAN system was more efficient than Promed-Português, reporting 90.4% of evaluated suspected cases 20.5days earlier. The surveillance strategy based on the mandatory case reporting using SINAN has proven to be more timely, but DDD can be considered as a complementary strategy providing a more disseminate epidemiological information to wide range readership globally.

Descriptions of two new cases of Rocky Mountain spotted fever in Panama, and coincident infection with Rickettsia rickettsii in Rhipicephalus sanguineus s.l. in an urban locality of Panama City, Panama

The clinical and pathologic characterisation of two fatal cases of tick-borne rickettsiosis in rural (El Valle) and urban (City of Panama) Panama are described. Clinical and autopsy findings were non-specific, but the molecular analysis was used to identify Rickettsia rickettsii in both cases. No ticks were collected in El Valle, while in the urban case, R. rickettsii was detected in Rhipicephalus sanguineus s.l., representing the first molecular finding in this tick in Panama and Central America.

Rickettsia rickettsii infecting Rhipicephalus sanguineus sensu lato (Latreille 1806), in high altitude atlantic forest fragments, Ceara State, Brazil

In Brazil, Spotted Fever (SF) is caused by Rickettsia rickettsii and Rickettsia parkeri strain Atlantic Forest. In recent years, several human cases of a milder SF have been reported from the Maciço de Baturité region of Ceará State. Previous studies in this region found R. parkeri strain Atlantic Forest to be present in Rhipicephalus sanguineus sensu lato and Amblyomma ovale ticks. The present study isolated and identified the Rickettsia spp. present in this new endemic area in Brazil. In March 2015, R. sanguineus s.l. and A. ovale were collected in rural areas of the Maciço de Baturité region, and subjected to the isolation technique. A bacterium was isolated from one R. sanguineus s.l., which phylogenetic analysis clustered to the R. rickettsii group. In conclusion, R. rickettsii bacteria is circulating in the studied area and may in future have an impact on the clinical diagnoses and consequently cause changes in the profile of the disease in the region. In addition, we suggest the increase of epidemiological and environmental surveillance in the area, in order to prevent Brazilian Spotted Fever cases.

Predictive Factors for Fatal Tick-Borne Spotted Fever in Brazil

In Brazil, two pathogenic Rickettsia species have been identified causing tick-borne spotted fever (SF). The aetiological agent Rickettsia rickettsii causes serious illness, particularly in the south-eastern region of the country. Moreover, the Rickettsia sp. strain Atlantic Rainforest cause milder clinical manifestations in south-eastern, south and north-east regions. This study has sought to analyse predictive factors for fatal SF. A case-control study was performed using disease notification records in Brazil. The cases included were individuals with laboratory confirmation and fatal progression of SF, while the controls included individuals with SF who were cured. A total of 386 cases and 415 controls were identified (1 : 1.1), and the cases and controls were similar in age. The factors identified as being protective against death were reported presence of ticks (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.41-0.88), residing in urban areas (OR, 0.47, 95% CI, 0.31-0.74) and presenting lymphadenopathy (OR, 0.43; 95% CI, 0.23-0.82). Males exhibited a greater chance of death (OR, 1.57; 95% CI, 1.13-2.18), as did patients who were hospitalized (OR, 10.82; 95% CI, 6.38-18.35) and who presented hypotension or shock (OR, 10.80; 95% CI, 7.33-15.93), seizures (OR, 11.24; 95% CI, 6.49-19.45) and coma (OR of 15.16; 95% CI, 8.51-27.02). The study demonstrates the severity profile of the SF cases, defined either as the frequency of hospitalization (even in cases that were cured) or as the increased frequency of the clinical complications typically found in critical patients. Opportune clinical diagnosis, a careful evaluation of the epidemiological aspects of the disease and adequate care for patients are determining factors for reducing SF fatality rates.