Human infection with Rickettsia sp. related to R. japonica, Thailand

Molecular detection of Rickettsia species in ectoparasites collected from two southern provinces of Cambodia

Arthropod-borne rickettsioses comprise a wide variety of subtypes that are endemic in Cambodia, but there remains very little data on the geographic distribution of the pathogens or their vectors. Surveys were conducted in Koh Kong and Preah Sihanouk Provinces between September 2017 and June 2018 to collect ectoparasites from peridomestic animals and the environment using dragging and flagging methods. Collected ectoparasites were sorted and identified morphologically, then pooled by species, host, and location for molecular detection using Rickettsia genus- and species-specific qPCR and/or multilocus sequence typing (MLST) assays. A total of 14,254 ectoparasites were collected including seven new locality records. Rickettsia species were detected in 35.5% (174/505) of the pools screened representing 3,149 randomly selected ectoparasites from the total collected. Rickettsia asembonensis was detected in 89.6% (147/164) of Rickettsia-positive flea pools and 3.6% (6/164) of the flea pools were positive for both R. asembonensis and Rickettsia felis. Candidatus Rickettsia senegalensis from Ctenocephalides orientis fleas and Rickettsia sp. close to Rickettsia japonica and Rickettsia heilongjiangensis from Haemaphysalis ticks were identified by MLST. This appears to be the first report of these new ectoparasite records and rickettsial species in southern Cambodia, suggesting a potential health risk to military and civilians in this region.

Estimating the Seroprevalence of Scrub Typhus in Nepal

Prior to the devastating earthquake in Nepal in 2015, scrub typhus was not recognized as a highly endemic disease in the country. This contrasted with neighboring India, where scrub typhus is endemic and there have been sporadic outbreaks of severe forms. This discrepancy underscores the limitations in our comprehensive understanding of the scrub typhus epidemiological patterns in Nepal, especially before 2015. To better understand the dynamic and current status of scrub typhus, this study investigated its prevalence among patients with acute febrile illness in two hospitals located in Pokhara city, Kaski district and Bharatpur city, Chitwan district during 2009-2010. Our findings revealed that 31.5% (239 of 759 patients) of the cases were positives for scrub typhus based on serological and pathogen detection assays. These results provide crucial insights into the pre-earthquake endemicity of scrub typhus in Nepal, implying its long-standing presence in the region prior to the significant environmental transformations caused by the 2015 earthquake. This study also emphasizes the need for heightened awareness and improved diagnostic capabilities to effectively manage and control scrub typhus, which remains a significant public health concern in Nepal.

Diagnosing and reintegrating traceability of infectious diseases via metagenomic next-generation sequencing: Study of a severe case of Rickettsia japonica infection

Background

In this study, we present a case of Japanese spotted fever (JSF) caused by Rickettsia japonica and use this case to investigate the process of diagnosing and reintegrating traceability of infectious diseases via metagenomic next-generation sequencing (mNGS).

Methods

From data relating to epidemiological history, clinical and laboratory examinations, and mNGS sequencing, a diagnosis of severe JSF was concluded.

Results

A detailed field epidemiological investigation discovered parasitic Haemaphysalis longicornis from a host animal (dog) in the domicile of the patient, within which R. japonica was detected, along with a diverse array of other potentially pathogenic microorganisms that could cause other infectious diseases.

Conclusion

The mNGS provided an efficient method to diagnose JSF infection. This methodology could also be applied to field epidemiological investigations to establish the traceability of infectious diseases.

Seasonal pattern of questing ticks and prevalence of pathogenic Rickettsia and Anaplasmataceae in Khao Yai national park, Thailand

BACKGROUND

Tick-borne diseases (TBD) are considered neglected diseases in Thailand with disease burden likely underestimated. To assess risk for emerging TBD in Thailand, the seasonality of questing tick and pathogen prevalence were studied in Khao Yai National Park, a top tourist destination.

METHODS

During 2019, questing ticks around tourist attractions were systematically collected bimonthly and analyzed for Rickettsia and Anaplasmataceae bacterial species by polymerase chain reaction and DNA sequencing.

RESULTS

Larvae and nymphs of questing ticks peaked in Khao Yai National Park during the late rainy-winter season, though no specific trends were observed in adult ticks. Winter (November to February) was the highest risk for human tick-bites due to higher numbers of both ticks and visitors. Of the total 5916 ticks analyzed (651 pools), Anaplasma phagocytophilum, Neoehrlichia mikurensis, Ehrlichia ewingii, and Ehrlichia chaffeensis were detected at low rates (≤0.05%). There was a higher prevalence of human rickettsioses (0.2-7%) in ticks surveyed with Rickettsia tamurae, Rickettsia raoultii, and Rickettsia montana the major species. Amblyomma ticks had the highest prevalence of Rickettsia (85%, 35/44 Amblyomma adults), in which only R. tamurae and R. raoultii were found in Amblyomma with mixed species infections common. We report the first detection of R. africae-like and N. mikurensis in Ixodes granulatus adults in Thailand, suggesting I. granulatus as a potential vector for these pathogens.

CONCLUSION

This study demonstrated the risk of emerging TBD in Thailand and underscores the need for tick-bite prevention among tourists in Thailand.

A novel Rickettsia, Candidatus Rickettsia takensis, and the first record of Candidatus Rickettsia laoensis in Dermacentor from Northwestern Thailand

Three hundred and forty-four tick samples were collected from vegetation at Taksin Maharat National Park, Tak province, northwestern Thailand. They were morphologically identified and molecularly confirmed by 16S rRNA and COI genes as Dermacentor laothaiensis (n = 105), D. steini (n = 139), and D. auratus (n = 100). These ticks were examined for the spotted fever group rickettsiae (SFGRs) using PCR and DNA sequencing of six genes; 17-kDa, gltA, 16S rRNA, ompA, ompB, and sca4. Of these ticks, 6.10% (21/344) gave positive results for the presence of SFGRs. Phylogenetic analyses of the SFGRs clearly indicated that a novel genotype assigned as Candidatus Rickettsia takensis was detected in D. laothaiensis (19/105) and at lesser frequency in D. steini (1/139). Furthermore, Candidatus Rickettsia laoensis was also found at a low frequency in D. auratus (1/100), the first record in Thailand. Although, the pathogenicities of these SFGRs remain unknown, our findings suggest potential risks of SFGRs being transmitted via ticks near the border between Thailand and Myanmar, a gateway of daily migrations of local people and visitors both legal and illegal.

A Case of Critical Japanese Spotted Fever in Zhejiang, China

Background

Japanese spotted fever (JSF) is a rare disease, caused by Rickettsia japonica; no case has been reported in Zhejiang Province, China.

Case Presentation

An elderly woman presented to the hospital with abdominal pain and fever. Her condition rapidly worsened with severe complications, such as multiple organ failure and central nervous system damage. The presence of R. japonica was quickly detected by metagenomic next-generation sequencing. On the basis of combined clinical manifestations and laboratory results, critical JSF was diagnosed and treated with doxycycline. The patient showed good prognosis. Typical symptoms (eschar and rash) were not observed in the early stage, consequently increasing the difficulty of clinical diagnosis.

Conclusion

The delay of treatment caused by non-specific symptoms is an important factor affecting the progression of JSF. As an emerging pathogen detection method, mNGS has been successfully applied for disease diagnosis and treatment, and can be an important complement for the diagnosis of this disease.

Molecular Detection of Tick-Borne Bacterial and Protozoan Pathogens in Haemaphysalis longicornis (Acari: Ixodidae) Ticks from Free-Ranging Domestic Sheep in Hebei Province, China

Ticks and tick-borne pathogens significantly threaten human and animal health worldwide. Haemaphysalis longicornis is one of the dominant tick species in East Asia, including China. In the present study, 646 Ha. longicornis ticks were collected from free-ranging domestic sheep in the southern region of Hebei Province, China. Tick-borne pathogens of zoonotic and veterinary importance (i.e., Rickettsia, Anaplasma, Ehrlichia, Borrelia, Theileria, and Hepatozoon spp.) were detected in the ticks using PCR assays and sequence analysis. The prevalence rates of these pathogens were 5.1% (33/646), 15.9% (103/646), 1.2% (8/646), 17.0% (110/646), 0.15% (1/646), and 0.15% (1/646), respectively. For Rickettsia spp., R. japonica (n = 13), R. raoultii (n = 6), and Candidatus R. jingxinensis (n = 14) were detected for the first time in the province, while several Anaplasma spp. were also detected in the ticks, including A. bovis (n = 52), A. ovis (n = 31), A. phagocytophilum (n = 10), and A. capra (n = 10). A putative novel Ehrlichia spp. was also found with a prevalence of 1.2% in the area. The present study provides important data for effectively controlling ticks and tick-borne diseases in the Hebei Province region of China.

Phylogenetic Analysis of Spotted Fever Group Rickettsia Gene from Ticks and Human Patients in Tottori Prefecture, Japan

Background

Japanese spotted fever (JSF) is a tick-borne bacterial febrile disease caused by Rickettsia japonica characterized by fever, rash, and occasional death. The number of patients in Japan and the Tottori Prefecture has been increasing over the past 20 years. Most cases were found in Eastern Tottori; however, the distribution of patients has expanded to the Central and Western regions. Ticks carried by wild animals may be the cause, but the prevalence of R. japonica in ticks has not yet been analyzed.

Methods

Ticks were collected by flagging-dragging from 16 sites in Tottori, Japan. The ticks were morphologically classified and DNA was extracted. The 17-kDa antigen gene was amplified using nested PCR. PCR amplicons from ticks and JSF patients were sequenced and phylogenetically compared.

Results

In total, 177 ticks were collected and identified as Haemahysalis, Ixodes, Amblyomma, and Dermcentor. The Spotted Fever Group Rickettsia (SFGR) was detected in Haemahysalis and Amblyomma spp. using PCR, with positivity rates of 36.8% and 33.3%, respectively. DNA sequencing and phylogenetic analysis revealed that positive ticks harbored R. japonica, P. raoultii, and other Rickettsiae species; however, the patient's samples were restricted to R. japonica. Similar to the incidence of JSF, the rate of R. japonica-positive ticks was higher in the Eastern region; however, R. japonica-positive ticks were also detected in the Western region.

Conclusion

R. japonica sequences had been found in ticks collected in Tottori Prefecture. Ticks harboring R. japonica were found in the Eastern and Western parts of Tottori Prefecture and the sequences were identical to the human cases. Only the R. japonica sequence has been detected in patients with spotted fever symptoms, even though ticks were harboring various SFGRs.

Clinical Forms of Japanese Spotted Fever from Case-Series Study, Zigui County, Hubei Province, China, 2021

We report a case-series study of 5 patients with Japanese spotted fever from the Three Gorges Area in China, including 1 fatal case. Seroprevalence of Rickettsia japonica was ≈21% among the local population. Our report highlights the emerging potential threat to human health of Japanese spotted fever in the area.

Japanese spotted fever with post-infectious encephalitis

Japanese spotted fever (JSF) is a rickettsial disease caused by Rickettsia japonica. To the best of our knowledge, there have only been five reported cases of JSF involving the central nervous system. A 74-year-old man was admitted after 1 week of fever and maculopapular rash. JSF was definitively diagnosed by PCR; however, the patient showed mental disturbance and abnormal behavior. After intravenous immunoglobulin, his mental state and behavior improved. The findings of cerebrospinal fluid analysis, electroencephalography, and ^99 mTcHM-PAO single photon computed emission tomography suggested post-infectious encephalitis. JSF causes post-infectious encephalitis and early treatment is recommended.

Delayed Tetracycline Initiation Increases Mortality Risk in Patients With Japanese Spotted Fever: Retrospective Analysis Using a National Inpatient Database

Background

This study aimed to determine the relationship between time to tetracycline therapy initiation and disease outcome in patients hospitalized with Japanese spotted fever (JSF).

Methods

Patients with JSF enrolled in the Japanese Diagnosis Procedure Combination database from July 2010 to March 2021 were included in the analysis. Patients who received tetracycline on the day of admission were compared with those who received tetracycline later during their hospital stay using inverse probability of treatment weighting. The primary outcome was in-hospital mortality. Secondary outcomes were total hospitalization cost and length of hospital stay.

Results

A total of 1360 patients were included, of whom 1060 (78%) received tetracycline on the day of admission (early tetracycline group), and 300 (22%) received tetracycline later (delayed tetracycline group). Patients in the delayed tetracycline group had significantly higher in-hospital mortality than those in the early tetracycline group (3.9% vs 1.4%; odds ratio, 2.94; 95% CI, 1.34–6.47), significantly higher hospitalization costs, and longer hospital stays than those in the early tetracycline group.

Conclusions

The prognosis of patients with JSF is worse if tetracycline administration is delayed; therefore, physicians should initiate tetracycline on admission if JSF is suspected as a possible diagnosis.

Effectiveness of fluoroquinolone antimicrobials in addition to tetracyclines for Japanese spotted fever: A retrospective analysis using a national inpatient database

OBJECTIVES

This study aim to evaluate the effectiveness of fluoroquinolone (FQ) antimicrobial therapy in combination with tetracyclines (TCs) in patients with Japanese spotted fever (JSF) using a nationwide inpatient database in Japan.

METHODS

We identified hospitalized patients diagnosed with JSF who were enrolled in the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2021. Patients who received FQ plus TC on the day of admission were compared with patients who received TC alone on the day of admission, using inverse probability of treatment weighting. The primary outcome was in-hospital mortality. Secondary outcomes were in-hospital complications, total hospitalization costs, and length of hospital stay.

RESULTS

We identified 1060 eligible patients. Of these, 434 (41%) received FQ plus TC on the day of admission and 626 (59%) received TC alone on the day of admission. Inverse probability of treatment weighting showed no statistically significant differences between the groups in in-hospital mortality, in-hospital complications, total hospitalization costs, and length of hospital stay.

CONCLUSION

This study did not show any significantly improved effectiveness using FQ antimicrobials in combination with TCs for treating JSF. Clinicians may need to be cautious in administering FQ and TC antimicrobials concomitantly in routine practice.

Risk factors analysis for neglected human rickettsioses in rural communities in Nan province, Thailand: A community-based observational study along a landscape gradient

In this study, we estimated exposure for Scrub typhus (STG), Typhus (TG) and Spotted fever groups (SFG) rickettsia using serology at a fine scale (a whole sub-district administration level) of local communities in Nan Province, Thailand. Geographical characteristics of the sub-district were divided into two landscape types: lowland agricultural area in an urbanized setting (lowland-urbanized area) and upland agricultural area located close to a protected area of National Park (upland-forested area). This provided an ideal contrast between the two landscapes with low and high levels of human-altered habitats to study in differences in disease ecology. In total, 824 serum samples of participants residing in the eight villages were tested by screening IgG ELISA, and subsequently confirmed by the gold standard IgG Immunofluorescent Assay (IFA). STG and TG IgG positivity were highest with seroprevalence of 9.8% and 9.0%, respectively; whereas SFG positivity was lower at 6.9%. Inhabitants from the villages located in upland-forested area demonstrated significantly higher STG exposure, compared to those villages in the lowland-urbanized area (chi-square = 51.97, p < 0.0001). In contrast, TG exposure was significantly higher in those villagers living in lowland-urbanized area (chi-square = 28.26, p < 0.0001). In addition to the effect of landscape types, generalized linear model (GLM) analysis identified socio-demographic parameters, i.e., gender, occupation, age, educational level, domestic animal ownership (dog, cattle and poultry) as influential factors to explain the level of rickettsial exposure (antibody titers) in the communities. Our findings raise the public health awareness of rickettsiosis as a cause of undiagnosed febrile illness in the communities.

Evidence of human exposures to rickettsial pathogens were reported from a cross-sectional study at a whole sub-district scale of local communities in Nan Province, Thailand. Seroprevalence and level of rickettsial exposures demonstrated differences between the habitat types, ecological aspects and socio-demographic factors. In addition, abundance of domestic animals in the community appeared to be one of significant factors influencing levels of human exposure to rickettsial pathogens. Our findings will benefit the local public health by raising awareness of rickettsial infections as one of potential health concerns in the community. Inclusion of rickettsioses in routine laboratory diagnosis would help to differentiate unknown febrile illness and guide appropriate treatment. Further studies are required, particularly in the fields of disease ecology as well as medical and veterinary entomology, in order to better understand epidemiology and potential zoonotic transmission of these neglected rickettsioses in endemic areas.

The Bacterial Community in Questing Ticks From Khao Yai National Park in Thailand

Ticks are known vectors for a variety of pathogens including bacteria, viruses, fungi, and parasites. In this study, bacterial communities were investigated in active life stages of three tick genera (Haemaphysalis, Dermacentor, and Amblyomma) collected from Khao Yai National Park in Thailand. Four hundred and thirty-three questing ticks were selected for pathogen detection individually using real-time PCR assays, and 58 of these were subjected to further metagenomics analysis. A total of 62 ticks were found to be infected with pathogenic bacteria, for a 14.3% prevalence rate, with Amblyomma spp. exhibiting the highest infection rate (20.5%), followed by Haemaphysalis spp. (14.5%) and Dermacentor spp. (8.6%). Rickettsia spp. were the most prevalent bacteria (7.9%) found, followed by Ehrlichia spp. (3.2%), and Anaplasma spp. and Borrelia spp. each with a similar prevalence of 1.6%. Co-infection between pathogenic bacteria was only detected in three Haemaphysalis females, and all co-infections were between Rickettsia spp. and Anaplasmataceae (Ehrlichia spp. or Anaplasma spp.), accounting for 4.6% of infected ticks or 0.7% of all examined questing ticks. The prevalence of the Coxiella-like endosymbiont was also investigated. Of ticks tested, 65.8% were positive for the Coxiella-like endosymbiont, with the highest infection rate in nymphs (86.7%), followed by females (83.4%). Among tick genera, Haemaphysalis exhibited the highest prevalence of infection with the Coxiella-like endosymbiont. Ticks harboring the Coxiella-like endosymbiont were more likely to be infected with Ehrlichia spp. or Rickettsia spp. than those without, with statistical significance for Ehrlichia spp. infection in particular (p-values = 0.003 and 0.917 for Ehrlichia spp. and Rickettsia spp., respectively). Profiling the bacterial community in ticks using metagenomics revealed distinct, predominant bacterial taxa in tick genera. Alpha and beta diversities analyses showed that the bacterial community diversity and composition in Haemaphysalis spp. was significantly different from Amblyomma spp. However, when examining bacterial diversity among tick life stages (larva, nymph, and adult) in Haemaphysalis spp., no significant difference among life stages was detected. These results provide valuable information on the bacterial community composition and co-infection rates in questing ticks in Thailand, with implications for animal and human health.

Amplicon-Based Next Generation Sequencing for Rapid Identification of Rickettsia and Ectoparasite Species from Entomological Surveillance in Thailand

BACKGROUND

Next generation sequencing (NGS) technology has been used for a wide range of epidemiological and surveillance studies. Here, we used amplicon-based NGS to species identify Rickettsia and their arthropod hosts from entomological surveillance.

METHODS

During 2015-2016, we screened 1825 samples of rodents and ectoparasites collected from rodents and domestic mammals (dog, cat, and cattle) across Thailand for Rickettsia. The citrate synthase gene was amplified to identify Rickettsia to species, while the Cytochrome Oxidase subunit I (COI) and subunit II (COII) genes were used as target genes for ectoparasite identification. All target gene amplicons were pooled for library preparation and sequenced with Illumina MiSeq platform.

RESULT

The highest percentage of Rickettsia DNA was observed in fleas collected from domestic animals (56%) predominantly dogs. Only a few samples of ticks from domestic animals, rodent fleas, and rodent tissue were positive for Rickettisia DNA. NGS based characterization of Rickettsia by host identified Rickettsia asembonensis as the most common bacteria in positive fleas collected from dogs (83.2%) while "Candidatus Rickettsia senegalensis" was detected in only 16.8% of Rickettsia positive dog fleas. Sequence analysis of COI and COII revealed that almost all fleas collected from dogs were Ctenocephalides felis orientis. Other Rickettsia species were detected by NGS including Rickettsia heilongjiangensis from two Haemaphysalis hystricis ticks, and Rickettsia typhi in two rodent tissue samples.

CONCLUSION

This study demonstrates the utility of NGS for high-throughput sequencing in the species characterization/identification of bacteria and ectoparasite for entomological surveillance of rickettsiae. A high percentage of C. f. orientis are positive for R. asembonensis. In addition, our findings indicate there is a risk of tick-borne Spotted Fever Group rickettsiosis, and flea-borne murine typhus transmission in Tak and Phangnga provinces of Thailand.

Detection of Multiple Intracellular Bacterial Pathogens in Haemaphysalis flava Ticks Collected from Hedgehogs in Central China

Tickborne intracellular bacterial pathogens including Anaplasma, Coxiella burnetti, Ehrlichia, and Rickettsia cause emerging infectious diseases worldwide. PCR was used to amplify the genes of these pathogens in Haemaphysalis flava ticks collected from hedgehogs in Central China. Among 125 samples including 20 egg batches, 24 engorged females, and 81 molted male and female adult ticks, the DNA sequences and phylogenetic analysis showed that the minimum infection rate of the ticks was 4% (5/125) for A. bovis, 3.2% (4/125) for C. burnetti, 9.6%, (12/125) for E. ewingii, and 5.6% for Rickettsia including R.japonica (3.2%, 4/125) and R. raoultii (2.4%, 3/125), respectively. The prevalence of these pathogens was significantly higher in dead engorged females (83.3%, 20/24) than in eggs (5%, 1/20) and molted ticks (8.6%, 7/81). Our study indicated that H. flava ticks could be infected with multiple species of tickborne pathogens including Anaplasma, C. burnetti, Ehrlichia, and Rickettsia in Central China, and the prevalence of these pathogens was reduced during transovarial and transstadial transmission in ticks, suggesting that ticks may not be real reservoirs but only vectors for these tickborne pathogens.

Impact of C-Reactive Protein Levels on Differentiating of Severe Fever With Thrombocytopenia Syndrome From Japanese Spotted Fever

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging viral hemorrhagic fever in China, Korea, and Japan. Japanese spotted fever (JSF), which belongs to spotted fever group rickettsioses, is also endemic to Western Japan. Patients with SFTS and those with JSF display many of the same clinical manifestations. Sudden fever, rash, tick bite, and neurological and gastrointestinal symptoms may be seen in both infections, but the frequency and severity of each disease have not been compared and studied. Because laboratory confirmation of pathogens takes time, it is important to predict diagnosis of SFTS vs JSF based on the features of the clinical characteristics at the initial presentation, particularly in primary care settings.

Methods

We conducted a case series review at 4 medical facilities in Miyazaki, Japan. Based on the medical records, clinical and laboratory characteristics were compared between patients with SFTS and those with JSF.

Results

Eighty-one patients were enrolled in this study, including 41 with SFTS and 40 with JSF. The absence of rash (P < .001), leukopenia (P < .001), and normal C-reactive protein (CRP) levels (P < .001) were the variables distinguishing SFTS from JSF. Normal CRP levels (≤1.0 mg/dL) had a 95% sensitivity (84%–99%) and 97% specificity (87%–100%) for SFTS, with a positive likelihood ratio of 37.1 (5.35–257).

Conclusions

Normal serum CRP levels were shown to differentiate SFTS from JSF with a very high probability.

Spotted Fever Group Rickettsia Infection of Cats and Cat Fleas in Northeast Thailand

Rickettsia species cause rickettsioses, which are zoonotic diseases found worldwide, and are transmitted by arthropods such as lice, fleas, ticks, and mites. In Thailand, flea infestations are common among cats and dogs. This study aimed at determining the exposure to spotted fever group rickettsiae (SFGR) of cats in surrounding areas of Rajabhat Maha Sarakham University, Muang district, Maha Sarakham province and rickettsial infection among cat fleas, Ctenocephalides felis, collected from dogs of the surrounding area of Waeng Noi district, Khon Kaen province. Forty-two cat sera were assessed for IgG antibody titers against SFGR by a group-specific enzyme-linked immunosorbent assay. The prevalence of seroreactive cats was 4.76% (2/42). DNA preparations from 23 individual cat fleas from three dogs were assessed by Rickettsia genus-specific, group-specific, and species-specific quantitative real-time PCR (qPCR) assays. Positive results were confirmed by ompB gene fragment sequencing. Twenty-one of 23 cat fleas were positive for Rickettsia asembonensis, and the other two DNA preparations were negative for rickettsial DNA. This study's finding indicates that companion cats and dogs in Northeast Thailand are exposed to SFGR and that exposure may be due to infection with R. asembonensis, an organism known to infect humans, monkeys, and dogs. Clinicians for humans and animals in Northeast Thailand should be aware of rickettsial infections among their patients.

An overview of rickettsiae in Southeast Asia: Vector-animal-human interface

Rickettsioses are emerging, and re-emerging diseases caused by obligate intracellular arthropod-borne bacteria that infect humans and animals worldwide. Various rickettsiae such as Orientia, Rickettsia, Anaplasma and Ehrlichia have been circulated in companion, domesticated and wild animals through bites of infected ticks, fleas, lice or mites. This review summarizes the infections of rickettsiae, including the newly discovered regional species Rickettsia thailandii, Candidatus Rickettsia sepangensis, Candidatus Rickettsia johorensis, Candidatus Rickettsia laoensis, Candidatus Rickettsia mahosotii, Candidatus Rickettsia khammouanensis, Candidatus Anaplasma pangolinii, and other novel genotypes in vectors, humans and animals in Southeast Asia. Issues on some unidentified rickettsiae that elicit immune responses and production of antibodies that are cross-reactive with the antigens used are discussed. Knowledge gaps which required attention are also identified in this review.

Rickettsia japonica Infections in Humans, Xinyang, China, 2014-2017

During 2014–2017, we screened for Rickettsia japonica infection in Xinyang, China, and identified 20 cases. The major clinical manifestations of monoinfection were fever, asthenia, myalgia, rash, and anorexia; laboratory findings included thrombocytopenia and elevated hepatic aminotransferase concentrations. Physicians in China should consider R. japonica infection in at-risk patients.

Rickettsia japonica and Novel Rickettsia Species in Ticks, China

PCR amplification indicated the minimum infection rate of Rickettsia spp. was 0.66% in Haemaphysalis longicornis ticks collected from Shandong Province, China. Phylogenetic analysis based on the rrs, gltA, ompA, and ompB genes indicated that the ticks carried R. japonica, Candidatus Rickettsia longicornii, and a novel Rickettsia species related to R. canadensis.

Diagnosis of spotted fever group Rickettsia infections: the Asian perspective

Spotted fever group rickettsiae (SFG) are a neglected group of bacteria, belonging to the genus Rickettsia, that represent a large number of new and emerging infectious diseases with a worldwide distribution. The diseases are zoonotic and are transmitted by arthropod vectors, mainly ticks, fleas and mites, to hosts such as wild animals. Domesticated animals and humans are accidental hosts. In Asia, local people in endemic areas as well as travellers to these regions are at high risk of infection. In this review we compare SFG molecular and serological diagnostic methods and discuss their limitations. While there is a large range of molecular diagnostics and serological assays, both approaches have limitations and a positive result is dependent on the timing of sample collection. There is an increasing need for less expensive and easy-to-use diagnostic tests. However, despite many tests being available, their lack of suitability for use in resource-limited regions is of concern, as many require technical expertise, expensive equipment and reagents. In addition, many existing diagnostic tests still require rigorous validation in the regions and populations where these tests may be used, in particular to establish coherent and worthwhile cut-offs. It is likely that the best strategy is to use a real-time quantitative polymerase chain reaction (qPCR) and immunofluorescence assay in tandem. If the specimen is collected early enough in the infection there will be no antibodies but there will be a greater chance of a PCR positive result. Conversely, when there are detectable antibodies it is less likely that there will be a positive PCR result. It is therefore extremely important that a complete medical history is provided especially the number of days of fever prior to sample collection. More effort is required to develop and validate SFG diagnostics and those of other rickettsial infections.

Rickettsia japonica Infections in Humans, Zhejiang Province, China, 2015

We investigated 16 Japanese spotted fever cases that occurred in southeastern China during September–October 2015. Patients had fever, rash, eschar, and lymphadenopathy. We confirmed 9 diagnoses and obtained 2 isolates with high identity to Rickettsiajaponica strain YH. R. japonica infection should be considered for febrile patients in China.

Japanese Spotted Fever in Eastern China, 2013

We isolated Rickettsia japonica from a febrile patient in Lu'an City, China, in 2013. Subsequently, we found an R. japonica seroprevalence of 54.8% (494/902) in the rural population of Anhui Province and an R. japonica prevalence in Haemaphysalis longicornis ticks of 0.5% (5/935). R. japonica and its tick vector exist in China.

Distribution of Rickettsia spp. in Ticks from Northwestern and Southwestern Provinces, Republic of Korea

This study was done to characterize distribution of Rickettsia spp. in ticks in the northwestern and southwestern provinces in the Republic of Korea. A total of 2,814 ticks were collected between May and September 2009. After pooling, 284 tick DNA samples were screened for a gene of Rickettsia-specific 17-kDa protein using nested PCR (nPCR), and produced 88 nPCR positive samples. Of these positives, 75% contained 190-kDa outer membrane protein gene (ompA), 50% 120-kDa outer membrane protein gene (ompB), and 64.7% gene D (sca4). The nPCR products of ompA, ompB, and sca4 genes revealed close relatedness to Rickettsia japonica, R. heilongjiangensis, and R. monacensis. Most Rickettsia species were detected in Haemaphysalis longicornis. This tick was found a dominant vector of rickettsiae in the study regions in the Republic of Korea.

Diversity of Rickettsiae in Feeding and Questing Ticks Collected From a Malaysian Forest Reserve Area

High seropositivity to Rickettsia conorii and Rickettsia felis has been reported in Malaysian indigenous community living in settlements adjacent to forest areas. The current study was conducted to determine the type and distribution of rickettsiae in feeding and questing ticks that were collected from a forest reserve area at Kuala Lompat in Pahang, Malaysia. Using PCR assays targeting citrate synthase (gltA), outer membrane protein A (ompA) and B (ompB) genes, rickettsiae were detected from approximately one-third of 98 ticks (mainly Dermacentor and Haemaphysalis spp.) collected from the forest reserve. BLAST analysis reveals the predominance of Rickettsia sp. RF2125 in both feeding and questing ticks and Rickettsia sp. TCM1 in the questing ticks. Sequences exhibiting close genetic relationship with Rickettsia raoultii, Rickettsia tamurae, Rickettsia heilongjiangensis, and Rickettsia asiatica were also detected from the ticks. This study highlights the diversity of rickettsial species and potential tick vectors which may contribute to the high seropositivity observed among the local communities.

Distribution of tick-borne diseases in Japan: Past patterns and implications for the future

The rapid geographical spread of tick-borne diseases (TBDs) worldwide has recently provoked significant concerns amongst public health authorities. Tick-borne pathogens are maintained in enzootic cycles involving ticks and wild animal hosts, with epizootic spread to other mammals, including livestock and humans. Despite the increasing public health concern, current TBD diagnostic tests and treatments are inadequate, and predictive models of future risks posed by TBDs are limited by the heterogeneity of environmental, vector, and host factors, even in neighboring regions. In recent years, infections resulting in severe fever with thrombocytopenia syndrome (SFTS), Japanese spotted fever, and the scrub typhus pathogens have been reported frequently in addition to traditional TBDs in Japan. The Japanese archipelago is extremely elongated from north to south and its climate varies considerably, creating remarkable regional differences in tick species. The importance of continuous surveillance of TBDs has been growing in terms of geopathology - studies dealing with the relationships between geographic factors and the causes of specific diseases - in Japan and neighboring areas among eastern Asian countries, including China and Korea. In this review, we summarize detailed information regarding the history and epidemic status of human TBDs in Japan.

Phylogenetic studies of bacteria (Rickettsia, Coxiella, and Anaplasma) in Amblyomma and Dermacentor ticks in Thailand and their co-infection

In this study, we attempted to detect Rickettsia, Coxiella and Anaplasma bacteria in one hundred and fourteen-Dermacentor and thirty three-Amblyomma unfed adult ticks that were collected from under leaves along animal trails at different places across Thailand. PCR amplification was used to identify bacterial infection with general conserved sequences of bacteria. The results revealed single infection in Amblyomma testudinarium ticks with Rickettsia (24%) and Coxiella (6%). Anaplasma bacteria were often detected in Dermacentor auratus ticks (32%). Coxiella spp. were detected in Dermacentor atrosignatus (6%) and D. auratus ticks (3%) in this study. Moreover, we found co-infection by Coxiella and Rickettsia bacteria (39%) in Am. testudinarium. In contrast, D. atrosignatus ticks were co-infected with Coxiella and Anaplasma bacteria (3%) and Dermacentor compactus ticks were co-infected with Rickettsia and Anaplasma spp. (25%). Interestingly, Am. testudinarium ticks (12%) were found for the first time to exhibit triple infection by these three bacteria. Phylogenetic studies showed the rickettsiae from ticks causing both single and multiple infections had sequence similarity with spotted fever group rickettsial strains, including Rickettsia massilliae, R. raoultii and R. tamurae. In addition, the phylogenetic analysis of the 16S rRNA gene of Coxiella bacteria showed that they were closely grouped with Coxiella endosymbionts in both Dermacentor and Amblyomma. Moreover, the Anaplasma identified in a D. auratus tick was grouped in the same clade with the pathogenic bacterium Anaplasma phagocytophilum. Bacterial co-infections in Dermacentor and Amblyomma ticks may cause co-transmission of some tick-borne microorganisms (pathogen and endosymbiont, whether enhance or reduce) in humans and animals and they could affect medical and veterinary health.

Extremely Low Genomic Diversity of Rickettsia japonica Distributed in Japan

Rickettsiae are obligate intracellular bacteria that have small genomes as a result of reductive evolution. Many Rickettsia species of the spotted fever group (SFG) cause tick-borne diseases known as “spotted fevers”. The life cycle of SFG rickettsiae is closely associated with that of the tick, which is generally thought to act as a bacterial vector and reservoir that maintains the bacterium through transstadial and transovarial transmission. Each SFG member is thought to have adapted to a specific tick species, thus restricting the bacterial distribution to a relatively limited geographic region. These unique features of SFG rickettsiae allow investigation of how the genomes of such biologically and ecologically specialized bacteria evolve after genome reduction and the types of population structures that are generated. Here, we performed a nationwide, high-resolution phylogenetic analysis of Rickettsia japonica, an etiological agent of Japanese spotted fever that is distributed in Japan and Korea. The comparison of complete or nearly complete sequences obtained from 31 R. japonica strains isolated from various sources in Japan over the past 30 years demonstrated an extremely low level of genomic diversity. In particular, only 34 single nucleotide polymorphisms were identified among the 27 strains of the major lineage containing all clinical isolates and tick isolates from the three tick species. Our data provide novel insights into the biology and genome evolution of R. japonica, including the possibilities of recent clonal expansion and a long generation time in nature due to the long dormant phase associated with tick life cycles.

Rickettsial seropositivity in the indigenous community and animal farm workers, and vector surveillance in Peninsular Malaysia

Rickettsioses are emerging zoonotic diseases that are often neglected in many countries in Southeast Asia. Rickettsial agents are transmitted to humans through exposure to infected arthropods. Limited data are available on the exposure of indigenous community and animal farm workers to the aetiological agents and arthropod vectors of rickettsioses in Peninsular Malaysia. Serological analysis of Rickettsia conorii and Rickettsia felis was performed for 102 individuals from the indigenous community at six rural villages and 87 workers from eight animal farms in Peninsular Malaysia in a cross-sectional study. The indigenous community had significantly higher seropositivity rates for R. conorii (P<0.001) and R. felis (P<0.001), as compared to blood donors from urban (n=61). Similarly, higher seropositivity rates for R. conorii (P=0.046) and R. felis (P<0.001) were noted for animal farm workers, as compared to urban blood donors. On the basis of the sequence analysis of gltA, ompA and ompB, various spotted fever group rickettsiae closely related to R. raoultii, R. heilongjiangensis, R. felis-like organisms, R. tamurae, Rickettsia sp. TCM1, R. felis, Rickettsia sp. LON13 and R. hulinensis were identified from tick/flea samples in animal farms, indigenous villages and urban areas. This study describes rickettsial seropositivity of the Malaysian indigenous community and animal farm workers, and provides molecular evidence regarding the presence of rickettsial agents in ticks/fleas infesting domestic animals in Peninsular Malaysia.

Molecular evidence of Rickettsia spp. in ixodid ticks and rodents in suburban, natural and rural habitats in Slovakia

BACKGROUND

Natural foci of tick-borne spotted fever group (SFG) rickettsiae of public health concern have been found in Slovakia, but the role of rodents in their circulation is unclear. Ticks (Ixodes ricinus, Ixodes trianguliceps, Dermacentor marginatus, Dermacentor reticulatus, Haemaphysalis concinna and Haemaphysalis inermis) and tissues of rodents (Apodemus flavicollis, Apodemus sylvaticus, Myodes glareolus, Microtus arvalis, Microtus subterraneus and Micromys minutus) were examined for the presence of SFG rickettsiae and Coxiella burnetii by molecular methods. Suburban, natural and rural habitats were monitored to acquire information on the role of ticks and rodents in the agents' maintenance in various habitat types of Slovakia.

RESULTS

The overall prevalence of rickettsial infection in questing I. ricinus and D. marginatus was 6.6% and 21.4%, respectively. Rickettsia helvetica, R. monacensis and non-identified rickettsial species were detected in I. ricinus, whereas R. slovaca and R. raoultii were identified in D. marginatus. Rickettsia spp.-infected I. ricinus occurred during the whole tick questing period. Rickettsia helvetica dominated (80.5%) followed by R. monacensis (6.5%). The species were present in all studied habitats. Rickettsia slovaca (66.7%) and R. raoultii (33.3%) were identified in D. marginatus from the rural habitat. Apodemus flavicollis was the most infested rodent species with I. ricinus, but My. glareolus carried the highest proportion of Rickettsia-positive I. ricinus larvae. Only 0.5% of rodents (A. flavicollis) and 5.2% of engorged I. ricinus removed from My. glareolus, A. flavicollis and M. arvalis were R. helvetica- and R. monacensis-positive. Coxiella burnetii was not detected in any of the tested samples. We hypothesize that rodents could play a role as carriers of infected ticks and contribute to the maintenance of rickettsial pathogens in natural foci.

CONCLUSIONS

Long-term presence of SFG Rickettsia spp. was confirmed in questing ticks from different habitat types of Slovakia. The results suggest a human risk for infection with the pathogenic R. helvetica, R. monacensis, R. slovaca and R. raoultii.

Syndromic classification of rickettsioses: an approach for clinical practice

Rickettsioses share common clinical manifestations, such as fever, malaise, exanthema, the presence or absence of an inoculation eschar, and lymphadenopathy. Some of these manifestations can be suggestive of certain species of Rickettsia infection. Nevertheless none of these manifestations are pathognomonic, and direct diagnostic methods to confirm the involved species are always required. A syndrome is a set of signs and symptoms that characterizes a disease with many etiologies or causes. This situation is applicable to rickettsioses, where different species can cause similar clinical presentations. We propose a syndromic classification for these diseases: exanthematic rickettsiosis syndrome with a low probability of inoculation eschar and rickettsiosis syndrome with a probability of inoculation eschar and their variants. In doing so, we take into account the clinical manifestations, the geographic origin, and the possible vector involved, in order to provide a guide for physicians of the most probable etiological agent.

Rickettsial infections in Southeast Asia: implications for local populace and febrile returned travelers

Rickettsial infections represent a major cause of non-malarial febrile illnesses among the residents of Southeast Asia and returned travelers from that region. There are several challenges in recognition, diagnosis, and management of rickettsioses endemic to Southeast Asia. This review focuses on the prevalent rickettsial infections, namely, murine typhus (Rickettsia typhi), scrub typhus (Orientia tsutsugamushi), and members of spotted fever group rickettsiae. Information on epidemiology and regional variance in the prevalence of rickettsial infections is analyzed. Clinical characteristics of main groups of rickettsioses, unusual presentations, and common pitfalls in diagnosis are further discussed. In particular, relevant epidemiologic and clinical aspects on emerging spotted fever group rickettsiae in the region, such as Rickettsia honei, R. felis, R. japonica, and R. helvetica, are presented. Furthermore, challenges in laboratory diagnosis and management aspects of rickettsial infections unique to Southeast Asia are discussed, and data on emerging resistance to antimicrobial drugs and treatment/prevention options are also reviewed.

Update on tick-borne rickettsioses around the world: a geographic approach

Tick-borne rickettsioses are caused by obligate intracellular bacteria belonging to the spotted fever group of the genus Rickettsia. These zoonoses are among the oldest known vector-borne diseases. However, in the past 25 years, the scope and importance of the recognized tick-associated rickettsial pathogens have increased dramatically, making this complex of diseases an ideal paradigm for the understanding of emerging and reemerging infections. Several species of tick-borne rickettsiae that were considered nonpathogenic for decades are now associated with human infections, and novel Rickettsia species of undetermined pathogenicity continue to be detected in or isolated from ticks around the world. This remarkable expansion of information has been driven largely by the use of molecular techniques that have facilitated the identification of novel and previously recognized rickettsiae in ticks. New approaches, such as swabbing of eschars to obtain material to be tested by PCR, have emerged in recent years and have played a role in describing emerging tick-borne rickettsioses. Here, we present the current knowledge on tick-borne rickettsiae and rickettsioses using a geographic approach toward the epidemiology of these diseases.

Old and new tick-borne rickettsioses

The field of rickettsiology is rapidly evolving. Rickettsiae are small Gram-negative bacteria that can be transmitted to humans by arthropods. In most cases they are transmitted transovarially in the arthropod; human beings are incidental hosts. In recent years the use of cell culture and molecular biology has profoundly changed our knowledge of rickettsiae and has led to the description of several new species. New rickettsial diseases have been found in three main situations: firstly, in places where no new species have been identified, typical rickettsial symptoms have been observed (Japan, China); secondly, typical rickettsioses have been found to be caused by different organisms - in such cases a new Rickettsia species has been misdiagnosed as a previously identified bacterium (for example, R. parkeri was confused with R. rickettsii); thirdly, atypical clinical symptoms have been found to be caused by rickettsial organisms such as R. slovaca. These findings challenge the old dogma that only one tick-borne rickettsiosis is prevalent in one geographical area. Many Rickettsia spp. have been identified in ticks, but have not yet been implicated in human pathology. These rickettsiae should be considered as potential pathogens. All known or suspected rickettsial diseases should be treated (including in children) with doxycycline.

Complete genomic DNA sequence of the East Asian spotted fever disease agent Rickettsia japonica

Rickettsia japonica is an obligate intracellular alphaproteobacteria that causes tick-borne Japanese spotted fever, which has spread throughout East Asia. We determined the complete genomic DNA sequence of R. japonica type strain YH (VR-1363), which consists of 1,283,087 base pairs (bp) and 971 protein-coding genes. Comparison of the genomic DNA sequence of R. japonica with other rickettsiae in the public databases showed that 2 regions (4,323 and 216 bp) were conserved in a very narrow range of Rickettsia species, and the shorter one was inserted in, and disrupted, a preexisting open reading frame (ORF). While it is unknown how the DNA sequences were acquired in R. japonica genomes, it may be a useful signature for the diagnosis of Rickettsia species. Instead of the species-specific inserted DNA sequences, rickettsial genomes contain Rickettsia-specific palindromic elements (RPEs), which are also capable of locating in preexisting ORFs. Precise alignments of protein and DNA sequences involving RPEs showed that when a gene contains an inserted DNA sequence, each rickettsial ortholog carried an inserted DNA sequence at the same locus. The sequence, ATGAC, was shown to be highly frequent and thus characteristic in certain RPEs (RPE-4, RPE-6, and RPE-7). This finding implies that RPE-4, RPE-6, and RPE-7 were derived from a common inserted DNA sequence.

Rickettsia sp. closely related to Rickettsia raoultii (Rickettsiales: Rickettsiaceae) in an Amblyomma helvolum (Acarina: Ixodidae) tick from a Varanus salvator (Squamata: Varanidae) in Thailand

An engorged female Amblyomma helvolum Koch tick was removed from an adult Varanus salvator Laurenti lizard during field collection in Thailand. After using polymerase chain reaction to amplify three genes (16S rDNA, gltA, and OmpA), we discovered the presence of a Rickettsia sp. of the Spotted Fever Group. Phylogenetic analysis revealed that this Rickettsia sp. is closely related to Rickettsia raoultii Mediannikov. Therefore, we report herein for the first time the detection of a novel Spotted Fever Group Rickettsia in an Amblyomma helvolum from a Varanus salvator in Thailand.

Severe murine typhus with shock and acute respiratory failure in a Japanese traveler after returning from Thailand

We treated a case of severe murine typhus in a Japanese traveler after returning from Thailand. Although the disease is typically self-limited or mild, the patient showed shock and multiple organ failure including acute respiratory distress syndrome. Then the patient fully recovered following intensive care and administration of antirickettsial medicines.