1
|
Narita M, Monma N, Chiba K, Suzuki R, Fujita S, Hoshino C, Nakamura K, Sekikawa Y, Ikeda H, Inoue M, Shimbo T, Yamamoto S, Ando S, Takada N, Fujita H. Masqueraders Around Disaster: Clinical Features of Scrub Typhus in Fukushima, Japan. Open Forum Infect Dis 2024; 11:ofae215. [PMID: 38756759 PMCID: PMC11096087 DOI: 10.1093/ofid/ofae215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Background Scrub typhus (ST) is endemic in Fukushima, with the largest number of cases reported in Japan from 2009 to 2010. Although ST is highly treatable, its atypical clinical presentation impedes diagnosis, causing delays in treatment. Methods We review the clinical features of ST in adults from 2008 to 2017 at Ohta Nishinouchi General Hospital in Fukushima, Japan. Results Fifty-five cases (serotype Karp 24, Irie/Kawasaki 21, Hirano/Kuroki 10) of ST were confirmed via serology based on elevated immunoglobulin (Ig)M and IgG and polymerase chain reaction positivity of eschar samples. The mean age was 69 years, and 64% were female. The case fatality rate was 1.8% (1/55). Approximately 70% of cases (38/55) were not diagnosed as ST upon the initial clinic visit. Inappropriate use of antibiotics was identified in 22% of cases (12/55). In terms of atypical clinical features, 1 or more of the manifestations, fever, rash, and eschar, was absent in 31% of cases (17/55). Approximately 11% of cases presented without eschar (6/55; Karp 1, Irie/Kawasaki 1, Hirano/Kuroki 4). Moreover, severe complications were observed with shock and disseminated intravascular coagulation in 7% of cases (4/55), Thus, while 53% of cases presented with the typical triad (29/55), unusual complications and atypical features occurred in 40% (22/55). Conclusions Diagnosis of ST becomes clinically challenging in the absence of typical features. In Fukushima, an endemic area of ST, an atypical presentation involving multisystem disease is common.
Collapse
Affiliation(s)
- Masashi Narita
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Nambu Medical Center & Children's Medical Center, Haebaru, Japan
- Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
- Department of Medicine, Ohta Nishinouch General Hospital, Koriyama, Japan
| | - Naota Monma
- Department of Infection Control, Fukushima Medical University, Fukushima, Japan
| | - Kazuki Chiba
- Fukushima Prefectural Institute of Public Health, Fukushima, Japan
| | - Rie Suzuki
- Fukushima Prefectural Institute of Public Health, Fukushima, Japan
| | - Shohei Fujita
- Fukushima Prefectural Institute of Public Health, Fukushima, Japan
| | | | - Kiwamu Nakamura
- Department of Infection Control, Fukushima Medical University, Fukushima, Japan
| | - Yoshiyuki Sekikawa
- Division of Infectious Diseases, Department of Internal Medicine, Japanese Red Cross Musashino Hospital, Musashino, Japan
| | | | - Minoru Inoue
- Department of Medicine, Ohta Nishinouch General Hospital, Koriyama, Japan
| | - Takuro Shimbo
- Department of Medicine, Ohta Nishinouch General Hospital, Koriyama, Japan
| | - Seigo Yamamoto
- Miyazaki Prefectural Institute for Public Health and Environment, Miyazaki, Japan (former affiliation)
| | - Shuji Ando
- National Institute of Infectious Diseases, Tokyo, Japan
| | - Nobuhiro Takada
- Department of Pathological Sciences, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiromi Fujita
- Institute of Rickettsioses, Kita-Fukushima Medical Center, Fukushima, Japan
| |
Collapse
|
2
|
He J, Wang Y, Liu P, Yin W, Wei X, Sun H, Xu Y, Li S, Soares Magalhaes RJ, Guo Y, Zhang W. Co-effects of global climatic dynamics and local climatic factors on scrub typhus in mainland China based on a nine-year time-frequency analysis. One Health 2022; 15:100446. [PMID: 36277104 PMCID: PMC9582591 DOI: 10.1016/j.onehlt.2022.100446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/04/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background Scrub Typhus (ST) is a rickettsial disease caused by Orientia tsutsugamushi. The number of ST cases has been increasing in China during the past decades, which attracts great concerns of the public health. Methods We obtained monthly documented ST cases greater than 54 cases in 434 counties of China during 2012-2020. Spatiotemporal wavelet analysis was conducted to identify the ST clusters with similar pattern of the temporal variation and explore the association between ST variation and El Niño and La Niña events. Wavelet coherency analysis and partial wavelet coherency analysis was employed to further explore the co-effects of global and local climatic factors on ST. Results Wavelet cluster analysis detected seven clusters in China, three of which are mainly distributed in Eastern China, while the other four clusters are located in the Southern China. Among the seven clusters, summer and autumn-winter peak of ST are the two main outbreak periods; while stable and fluctuated periodic feature of ST series was found at 12-month and 4-(or 6-) month according to the wavelet power spectra. Similarly, the three-character bands were also found in the associations between ST and El Niño and La Niña events, among which the 12-month period band showed weakest climate-ST association and the other two bands owned stronger association, indicating that the global climate dynamics may have short-term effects on the ST variations. Meanwhile, 12-month period band with strong association was found between the four local climatic factors (precipitation, pressure, relative humidity and temperature) and the ST variations. Further, partial wavelet coherency analysis suggested that global climatic dynamics dominate annual ST variations, while local climatic factors dominate the small periods. Conclusion The ST variations are not directly attributable to the change in large-scale climate. The existence of these plausible climatic determinants stimulates the interests for more insights into the epidemiology of ST, which is important for devising prevention and early warning strategies.
Collapse
Affiliation(s)
- Junyu He
- Ocean College, Zhejiang University, Zhoushan, China,Ocean Academy, Zhejiang University, Zhoushan, China
| | - Yong Wang
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Ping Liu
- Department of General Practice, Chinese PLA General Hospital-Sixth Medical Center, Beijing, China
| | - Wenwu Yin
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xianyu Wei
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Hailong Sun
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Yuanyong Xu
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Shanshan Li
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ricardo J. Soares Magalhaes
- Spatial Epidemiology Laboratory, School of Veterinary Science, The University of Queensland, Brisbane, Australia,Child Health Research Center, The University of Queensland, Brisbane, Australia
| | - Yuming Guo
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia,Correspondence to: Y Guo, School of Public Health and Preventive Medicine, Monash University, Level 2, 553 St Kilda Road, Melbourne, VIC 3004, Australia.
| | - Wenyi Zhang
- Chinese PLA Center for Disease Control and Prevention, Beijing, China,Correspondence to: W Zhang, Chinese PLA Center for Disease Control and Prevention, 20 Dong-Da Street, Fengtai District, Beijing 100071, China.
| |
Collapse
|
3
|
Comparison of Lethal and Nonlethal Mouse Models of Orientia tsutsugamushi Infection Reveals T-Cell Population-Associated Cytokine Signatures Correlated with Lethality and Protection. Trop Med Infect Dis 2021; 6:tropicalmed6030121. [PMID: 34287349 PMCID: PMC8293330 DOI: 10.3390/tropicalmed6030121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022] Open
Abstract
The antigenic diversity of Orientia tsutsugamushi as well as the interstrain difference(s) associated with virulence in mice impose the necessity to dissect the host immune response. In this study we compared the host response in lethal and non-lethal murine models of O. tsutsugamushi infection using the two strains, Karp (New Guinea) and Woods (Australia). The models included the lethal model: Karp intraperitoneal (IP) challenge; and the nonlethal models: Karp intradermal (ID), Woods IP, and Woods ID challenges. We monitored bacterial trafficking to the liver, lung, spleen, kidney, heart, and blood, and seroconversion during the 21-day challenge. Bacterial trafficking to all organs was observed in both the lethal and nonlethal models of infection, with significant increases in average bacterial loads observed in the livers and hearts of the lethal model. Multicolor flow cytometry was utilized to analyze the CD4+ and CD8+ T cell populations and their intracellular production of the cytokines IFNγ, TNF, and IL2 (single, double, and triple combinations) associated with both the lethal and nonlethal murine models of infection. The lethal model was defined by a cytokine signature of double- (IFNγ-IL2) and triple-producing (IL2-TNF-IFNγ) CD4+ T-cell populations; no multifunctional signature was identified in the CD8+ T-cell populations associated with the lethal model. In the nonlethal model, the cytokine signature was predominated by CD4+ and CD8+ T-cell populations associated with single (IL2) and/or double (IL2-TNF) populations of producers. The cytokine signatures associated with our lethal model will become depletion targets in future experiments; those signatures associated with our nonlethal model are hypothesized to be related to the protective nature of the nonlethal challenges.
Collapse
|
4
|
Cho H, Kim KS. An Inducible Expression System for Recombinant Sca Proteins with an Autotransporter Domain from Orientia Tsutsugamushi in Escherichia coli. Protein Pept Lett 2021; 28:241-248. [PMID: 32972336 DOI: 10.2174/0929866527666200924144908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/26/2020] [Accepted: 08/30/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Orientia tsutsugamushi (Ot) is an obligate, intracellular, gram-negative bacterium causing scrub typhus. Some of its encoded proteins play key roles in the adhesion and internalization of the Ot strain into host cells and are suitable resources for vaccine development and tools for scrub typhus diagnosis. Surface cell antigen (Sca) proteins, classified as autotransporter (AT) proteins, are one of the largest protein families involved in bacterial pathogenesis and can be promising candidates for vaccine development. These proteins are typically large and contain inhibitory domains; therefore, recombinant proteins without such domains have been evaluated for this purpose. However, the expression for recombinant Sca proteins containing the AT domain, which might largely affect their protective role against scrub typhus, has not been analyzed and optimized. OBJECTIVE In this study, we optimized expression and purification conditions for individual Ot Sca protein fragments [ScaA (27-1461), ScaC (257-526), ScaD (26-998), and ScaE (35-760)] harboring the AT domain. METHODS To this end, we subcloned sequences of codon-optimized DNA encoding Sca protein fragments into the Escherichia coli expression vector. In addition, the expression condition for individual Sca fragments was optimized, and the proteins were purified using one-step Ni-NTA column method. The purified fractions were re-folded by serial dilution method, followed by BCA quantification and densitometric analysis to estimate the yield and purity of proteins. RESULTS We prepared platforms for expression of recombinant Sca protein fragments [ScaA (27-1461), ScaC (257-526), ScaD (26-998), and ScaE (35-760)] containing an AT domain without the signal peptide and transmembrane (TM) domain. The protein yield per liter of culture with >70% of purity was ScaC (257-576), ScaE (35-760), ScaD (26-998), and ScaA (27-1461) in order. CONCLUSION Our results could be used to develop Sca AT-domain based vaccines and tools for scrub typhus diagnosis with rapid and cost-effective ways.
Collapse
Affiliation(s)
- Hyejin Cho
- Department of Chemistry and Chemistry Institute for Functional Materials, Pusan National University, Busan 46241, South Korea
| | - Kwang-Sun Kim
- Department of Chemistry and Chemistry Institute for Functional Materials, Pusan National University, Busan 46241, South Korea
| |
Collapse
|
5
|
Seroprevalence and Clinical Features of Scrub Typhus among Febrile Patients Attending a Referral Hospital in Kathmandu, Nepal. Trop Med Infect Dis 2021; 6:tropicalmed6020078. [PMID: 34068402 PMCID: PMC8163188 DOI: 10.3390/tropicalmed6020078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 01/10/2023] Open
Abstract
(1) Background: Scrub typhus (ST) is endemic to Nepal. It is often underdiagnosed and misdiagnosed due to non-specific clinical presentation coupled with limited microbiological facilities, leading to adverse clinical outcomes. This study aimed to assess the seroprevalence of scrub typhus in febrile patients attending Sukraraj Tropical and Infectious Disease Hospital (STIDH), Nepal, from August 2018 to April 2019. (2) Materials and Method: Blood/serum samples and clinical and demographic data of adult febrile patients (≥19 years) who attended or were referred to the hospital were collected after obtaining written informed consent from the participants excluding immunocompromised individuals. Collected blood/serum samples were subjected to hematological, biochemical, and serological tests. A serological test for scrub typhus was performed using the ImmuneMed scrub typhus rapid diagnostic test kit. Data generated were analyzed using SPSS software version 24.0. (3) Results: Amongst the 2070 febrile patients, 462 (22.3%) were seropositive to at least one etiological agent of febrile illnesses (scrub typhus: 253 cases, dengue: 101 cases, leptospirosis: 9, brucellosis: 52, malaria: 9 and kala-azar: 20 cases). Scrub typhus accounted for 12.2% (n = 253) of total febrile illnesses followed by dengue (4.9%, n = 101). Mixed seropositivity of scrub typhus with dengue, brucellosis, and typhoid was found in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. Among 253 scrub typhus patients, 53.4% were female. Among the 154 patients, the most common symptoms were fever (100%), headache (79.2%), sweating (70.1%), breathing difficulty (51.3%), redness of the eye (43.5%), and pathognomonic eschar was observed in 9.1% patients. Fifty percent of scrub typhus patients had low platelet count and >30% of patients had an elevated level of liver enzymes (such as serum glutamic oxaloacetic transaminase (SGPT) and serum glutamic pyruvic transaminase (SGOT). (4) Conclusion: Scrub typhus is a considerable cause of febrile illness in Nepal. Females apparently have a higher chance of acquiring scrub typhus. ST presents nonspecific clinical presentation. The diagnostic dilemma of typhus patients can be minimized by the early monitoring of ST-associated symptoms. The country's health system needs to be strengthened for early outbreak detection, and immediate response actions against scrub typhus to control the future outbreak of ST.
Collapse
|
6
|
Yang S, Liu X, Gao Y, Chen B, Lu L, Zheng W, Fu R, Yuan C, Liu Q, Li G, Chen H. Spatiotemporal Dynamics of Scrub Typhus in Jiangxi Province, China, from 2006 to 2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094599. [PMID: 33926106 PMCID: PMC8123664 DOI: 10.3390/ijerph18094599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 01/04/2023]
Abstract
Background: Scrub typhus (ST) has become a significant potential threat to public health in Jiangxi. Further investigation is essential for the control and management of the spatiotemporal patterns of the disease. Methods: Time-series analyses, spatial distribution analyses, spatial autocorrelation analysis, and space-time scan statistics were performed to detect spatiotemporal dynamics distribution of the incidence of ST. Results: From 2006 to 2018, a total of 5508 ST cases occurred in Jiangxi, covering 79 counties. The number of ST cases increased continuously from 2006 to 2018, and there was obvious seasonality during the variation process in each year, with a primary peak in autumn (September to October) and a smaller peak in summer (June to August). From 2007 to 2018, the spatial distribution of the ST epidemic was significant heterogeneity, and Nanfeng, Huichang, Xunwu, Anyuan, Longnan, and Xinfeng were hotspots. Seven spatiotemporal clusters were observed using Kulldorff's space-time scan statistic, and the most likely cluster only included one county, Nanfeng county. The high-risk areas of the disease were in the mountainous, hilly region of Wuyi and the southern mountainous region of Jiangxi. Conclusions: Targeted interventions should be executed in high-risk regions for the precise prevention and control of ST.
Collapse
Affiliation(s)
- Shu Yang
- The Collaboration Unit for Field Epidemiology of State Key Laboratory of Infectious Disease Prevention and Control, Nanchang Center for Disease Control and Prevention, Nanchang 330038, China; (S.Y.); (W.Z.); (R.F.); (C.Y.)
| | - Xiaobo Liu
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (X.L.); (Y.G.); (L.L.); (Q.L.)
| | - Yuan Gao
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (X.L.); (Y.G.); (L.L.); (Q.L.)
| | - Baizhou Chen
- School of Geography and Information Engineering, China University of Geosciences, Wuhan 430078, China;
| | - Liang Lu
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (X.L.); (Y.G.); (L.L.); (Q.L.)
| | - Weiqing Zheng
- The Collaboration Unit for Field Epidemiology of State Key Laboratory of Infectious Disease Prevention and Control, Nanchang Center for Disease Control and Prevention, Nanchang 330038, China; (S.Y.); (W.Z.); (R.F.); (C.Y.)
| | - Renlong Fu
- The Collaboration Unit for Field Epidemiology of State Key Laboratory of Infectious Disease Prevention and Control, Nanchang Center for Disease Control and Prevention, Nanchang 330038, China; (S.Y.); (W.Z.); (R.F.); (C.Y.)
| | - Chenying Yuan
- The Collaboration Unit for Field Epidemiology of State Key Laboratory of Infectious Disease Prevention and Control, Nanchang Center for Disease Control and Prevention, Nanchang 330038, China; (S.Y.); (W.Z.); (R.F.); (C.Y.)
| | - Qiyong Liu
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (X.L.); (Y.G.); (L.L.); (Q.L.)
| | - Guichang Li
- State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; (X.L.); (Y.G.); (L.L.); (Q.L.)
- Correspondence: (G.L.); (H.C.)
| | - Haiying Chen
- The Collaboration Unit for Field Epidemiology of State Key Laboratory of Infectious Disease Prevention and Control, Nanchang Center for Disease Control and Prevention, Nanchang 330038, China; (S.Y.); (W.Z.); (R.F.); (C.Y.)
- Correspondence: (G.L.); (H.C.)
| |
Collapse
|
7
|
Genome-Wide Association Study Identifies Eight Novel Loci for Susceptibility of Scrub Typhus and Highlights Immune-Related Signaling Pathways in Its Pathogenesis. Cells 2021; 10:cells10030570. [PMID: 33807835 PMCID: PMC7999653 DOI: 10.3390/cells10030570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Scrub typhus is a fatal zoonotic disease caused by Orientia tsutsugamushi. This disease is accompanied by systemic vasculitis, lymphadenopathy, headache, myalgia, and eschar. In recent studies, a novel strain that is resistant to current medical treatment was identified in Thailand. Thus, the development of new specific drugs for scrub typhus is needed. However, the exact molecular mechanism governing the progression of scrub typhus has not been fully elucidated. To understand disease-related genetic factors and mechanisms associated with the progression of scrub typhus, we performed a genome-wide association study (GWAS) in scrub typhus-infected patients and found a scrub typhus-related signaling pathway by molecular interaction search tool (MIST) and PANTHER. We identified eight potent scrub typhus-related single nucleotide polymorphisms (SNPs) located on the PRMT6, PLGLB2, DTWD2, BATF, JDP2, ONECUT1, WDR72, KLK, MAP3K7, and TGFBR2 genes using a GWAS. We also identified 224 genes by analyzing protein-protein interactions among candidate genes of scrub typhus and identified 15 signaling pathways associated with over 10 genes by classifying these genes according to signaling pathways. The signaling pathway with the largest number of associated genes was the gonadotropin-releasing hormone receptor pathway, followed by the TGF-beta signaling pathway and the apoptosis signaling pathway. To the best of our knowledge, this report describes the first GWAS in scrub typhus.
Collapse
|
8
|
Lee HJ, Park C. Density of Chigger Mites as Tsutsugamushi Vectors Collected from Jinan, Jeollabuk-do. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2020. [DOI: 10.15324/kjcls.2020.52.4.364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hyeok Jae Lee
- Department of Biomedical Laboratory Science, Gwangju Health University, Gwangju, Korea
| | - Chul Park
- Department of Biomedical Laboratory Science, Gwangju Health University, Gwangju, Korea
| |
Collapse
|
9
|
Banerjee A, Kulkarni S. Orientia tsutsugamushi: The dangerous yet neglected foe from the East. Int J Med Microbiol 2020; 311:151467. [PMID: 33338890 DOI: 10.1016/j.ijmm.2020.151467] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 10/06/2020] [Accepted: 11/25/2020] [Indexed: 01/22/2023] Open
Abstract
Orientia tsutsugamushi (OT), the causative agent of the vector-borne Scrub typhus zoonotic disease in humans, is a unique microorganism that exists in the Asia-Pacific region since a long time. In spite of its occurrence, the organism had been neglected until recent years. Humans are the accidental dead-end hosts of O. tsutsugamushi and display manifestations which are both severe and misleading. The vast antigenic diversity of OT and non-pathognomic symptoms of Scrub typhus, create hurdles in the clinical management of the disease and impede the OT-research. Many countries in the Asia-Pacific region have reported the resurgence of OT- infections and have raised concerns for its expanding distribution. This has triggered the development of advanced techniques for diagnosis and research on exploring a successful vaccine candidate to reduce the burden of the disease. Thus, the aim of this systematic review is to provide an update on the recent advances in the OT-research and highlight the key areas that have remained obscure and demand attention.
Collapse
Affiliation(s)
- Anwesha Banerjee
- ICMR-National AIDS Research Institute, Bhosari, Pune, 411026, India
| | - Smita Kulkarni
- ICMR-National AIDS Research Institute, Bhosari, Pune, 411026, India.
| |
Collapse
|
10
|
Kala D, Gupta S, Nagraik R, Verma V, Thakur A, Kaushal A. Diagnosis of scrub typhus: recent advancements and challenges. 3 Biotech 2020; 10:396. [PMID: 32834918 PMCID: PMC7431554 DOI: 10.1007/s13205-020-02389-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
Scrub typhus is a mite-borne, acute febrile illness caused by the bacterium Orientia tsutsugamushi. It is a re-emerging infectious disease of the tsutsugamushi triangle. Scrub typhus is transmitted through bites of contaminated chiggers (larval stage). Diagnosis of scrub typhus is challenging as its symptoms mimic with other acute febrile illnesses. Several methods are effectual for diagnosis of scrub typhus that includes enzyme-linked immunosorbent assay (ELISA), immunofluorescence assay (IFA), immunochromatographic test (ICT), Weil-Felix, polymerase chain reaction (PCR) and loop-mediated isothermal amplification (LAMP). Weil-Felix test was initially used for the diagnosis of scrub typhus in underdeveloped countries but not preferred due to a lack of both specificity and sensitivity. Other immuno-based methods like IFA and ELISA are most outrank for detection of scrub typhus due to their higher sensitivity and specificity, but not vigorous to lay bare the infection at early stages and need the convalescent sampling for verification of positive samples. On another deed, PCR based methods becoming acceptable over era due to its dexterity of early-stage diagnosis with higher specificity and sensitivity but lack its applicability in circumstances of scrub typhus due to the variegated genetic makeup of Orientia tsutsugamushi among its serotypes. The present review focused on various detection methods along with their advantages and disadvantages used in the diagnosis of scrub typhus. A comparison between available methods of diagnosis with challenges in the detection of scrub typhus is also summarized.
Collapse
Affiliation(s)
- Deepak Kala
- Amity Center of Nanotechnology, Amity University, Haryana, 122413 India
| | | | | | | | - Atul Thakur
- Amity Center of Nanotechnology, Amity University, Haryana, 122413 India
| | - Ankur Kaushal
- Amity Center of Nanotechnology, Amity University, Haryana, 122413 India
| |
Collapse
|
11
|
Bahk YY, Jun H, Park SH, Jung H, Jegal S, Kim-Jeon MD, Roh JY, Lee WG, Ahn SK, Lee J, Joo K, Gong YW, Kwon MJ, Kim TS. Surveillance of Chigger Mite Vectors for Tsutsugamushi Disease in the Hwaseong Area, Gyeonggi-do, Republic of Korea, 2015. THE KOREAN JOURNAL OF PARASITOLOGY 2020; 58:301-308. [PMID: 32615743 PMCID: PMC7338901 DOI: 10.3347/kjp.2020.58.3.301] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/20/2020] [Indexed: 11/25/2022]
Abstract
Owing to global climate change, the global resurgence of vector-borne infectious diseases and their potential to inflict widespread casualties among human populations has emerged as a pivotal burden on public health systems. Tsutsugamushi disease (scrub typhus) in the Republic of Korea is steadily increasing and was designated as a legal communicable disease in 1994. The disease is a mite-borne acute febrile disease most commonly contracted from October to December. In this study, we tried to determine the prevalence of tsutsugamushi disease transmitted by chigger mites living on rodents and investigated their target vector diversity, abundance, and distribution to enable the mapping of hotspots for this disease in 2015. A total of 5 species belonging to 4 genera (109 mites): Leptotrombidium scutellare 60.6%, L. pallidum 28.4% Neotrombicula tamiyai 9.2%, Euschoengastia koreaensis/0.9%), and Neoschoengastia asakawa 0.9% were collected using chigger mite collecting traps mimicking human skin odor and sticky chigger traps from April to November 2015. Chigger mites causing tsutsugamushi disease in wild rodents were also collected in Hwaseong for the zoonotic surveillance of the vector. A total of 77 rodents belonging to 3 genera: Apodemus agrarius (93.5%), Crocidura lasiura (5.2%), and Micromys minutus (1.3%) were collected in April, October, and November 2015. The most common mite was L. pallidum (46.9%), followed by L. scutellare (18.6%), and L. orientale (18.0%). However, any of the chigger mite pools collected from rodent hosts was tested positive for Orientia tsutsugamushi, the pathogen of tsutsugamushi disease, in this survey.
Collapse
Affiliation(s)
- Young Yil Bahk
- Department of Biotechnology, College of Biomedical and Health Science, Konkuk University, Chungju 27478, Korea
| | - Hojong Jun
- Department of Tropical Medicine, Inha University College of Medicine, Incheon 22212, Korea
| | - Seo Hye Park
- Department of Tropical Medicine, Inha University College of Medicine, Incheon 22212, Korea
| | - Haneul Jung
- Department of Tropical Medicine, Inha University College of Medicine, Incheon 22212, Korea
| | - Seung Jegal
- Department of Infectious Diseases Diagnosis, Incheon Metropolitan City Institute of Public Health and Environment, Incheon 22320, Korea
| | - Myung-Deok Kim-Jeon
- Department of Infectious Diseases Diagnosis, Incheon Metropolitan City Institute of Public Health and Environment, Incheon 22320, Korea
| | - Jong Yul Roh
- Division of Vectors and Parasitic Diseases, Korea Centers for Disease Control and Prevention, Osong 28159, Korea
| | - Wook-Gyo Lee
- Division of Vectors and Parasitic Diseases, Korea Centers for Disease Control and Prevention, Osong 28159, Korea
| | - Seong Kyu Ahn
- Department of Tropical Medicine, Inha University College of Medicine, Incheon 22212, Korea
| | - Jinyoung Lee
- Department of Tropical Medicine, Inha University College of Medicine, Incheon 22212, Korea
| | - Kwangsig Joo
- Department of Infectious Diseases Diagnosis, Incheon Metropolitan City Institute of Public Health and Environment, Incheon 22320, Korea
| | - Young Woo Gong
- Department of Infectious Diseases Diagnosis, Incheon Metropolitan City Institute of Public Health and Environment, Incheon 22320, Korea
| | - Mun Ju Kwon
- Department of Infectious Diseases Diagnosis, Incheon Metropolitan City Institute of Public Health and Environment, Incheon 22320, Korea
| | - Tong-Soo Kim
- Department of Tropical Medicine, Inha University College of Medicine, Incheon 22212, Korea
| |
Collapse
|
12
|
Morand S, Chaisiri K, Kritiyakan A, Kumlert R. Disease Ecology of Rickettsial Species: A Data Science Approach. Trop Med Infect Dis 2020; 5:E64. [PMID: 32349270 PMCID: PMC7344507 DOI: 10.3390/tropicalmed5020064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/13/2020] [Accepted: 04/20/2020] [Indexed: 12/15/2022] Open
Abstract
We present an approach to assess the disease ecology of rickettsial species by investigating open databases and by using data science methodologies. First, we explored the epidemiological trend and changes of human rickettsial disease epidemics over the years and compared this trend with knowledge on emerging rickettsial diseases given by published reviews. Second, we investigated the global diversity of rickettsial species recorded in humans, domestic animals and wild mammals, using the Enhanced Infectious Disease Database (EID2) and employing a network analysis approach to represent and quantify transmission ecology of rickettsial species among their carriers, arthropod vectors or mammal reservoirs and humans. Our results confirmed previous studies that emphasized the increasing incidence in rickettsial diseases at the onset of 1970. Using the Global Infectious Diseases and Epidemiology Online Network (GIDEON) database, it was even possible to date the start of this increase of global outbreaks in rickettsial diseases in 1971. Network analysis showed the importance of domestic animals and peridomestic mammals in sharing rickettsial diseases with humans and other wild animals, acting as important hubs or connectors for rickettsial transmission.
Collapse
Affiliation(s)
- Serge Morand
- CNRS ISEM—CIRAD ASTRE—Montpellier University, 34090 Montpellier, France
- Faculty of Veterinary Technology, Kasetsart University, Bangkok 10900, Thailand;
| | - Kittipong Chaisiri
- Department of Helminthology, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;
| | - Anamika Kritiyakan
- Faculty of Veterinary Technology, Kasetsart University, Bangkok 10900, Thailand;
| | - Rawadee Kumlert
- The Office of Disease Prevention and Control 12, Songkhla Province (ODPC12), Department of Disease Control, Ministry of Public Health, Songkhla 90000, Thailand;
| |
Collapse
|
13
|
Heo DH, Kang YM, Song KH, Seo JW, Kim JH, Chun JY, Jun KI, Kang CK, Moon SM, Choe PG, Park WB, Bang JH, Kim ES, Kim HB, Park SW, Oh WS, Kim NJ, Oh MD. Clinical Score System to Differentiate Severe Fever with Thrombocytopenia Syndrome Patients from Patients with Scrub Typhus or Hemorrhagic Fever with Renal Syndrome in Korea. J Korean Med Sci 2020; 35:e77. [PMID: 32193903 PMCID: PMC7086083 DOI: 10.3346/jkms.2020.35.e77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/21/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with high mortality in East Asia. This study aimed to develop, for primary care providers, a prediction score using initial symptoms and basic laboratory blood tests to differentiate between SFTS and other endemic zoonoses in Korea. METHODS Patients aged ≥ 18 years diagnosed with endemic zoonoses during a 3-year period (between January 2015 and December 2017) were retrospectively enrolled from 4 tertiary university hospitals. A prediction score was built based on multivariate logistic regression analyses. RESULTS Of 84 patients, 35 with SFTS and 49 with other endemic zoonoses were enrolled. In multivariate logistic regression analysis, independent predictors of SFTS included neurologic symptoms (odds ratio [OR], 12.915; 95% confidence interval [CI], 2.173-76.747), diarrhea (OR, 10.306; 95% CI, 1.588-66.895), leukopenia (< 4,000/mm³) (OR, 19.400; 95% CI, 3.290-114.408), and normal C-reactive protein (< 0.5 mg/dL) (OR, 24.739; 95% CI, 1.812-337.742). We set up a prediction score by assigning one point to each of these four predictors. A score of ≥ 2 had 82.9% sensitivity (95% CI, 71.7%-87.5%) and 95.9% specificity (95% CI, 88.0%-99.2%). The area under the curve of the clinical prediction score was 0.950 (95% CI, 0.903-0.997). CONCLUSION This study finding suggests a simple and useful scoring system to predict SFTS in patients with endemic zoonoses. We expect this strategic approach to facilitate early differentiation of SFTS from other endemic zoonoses, especially by primary care providers, and to improve the clinical outcomes.
Collapse
Affiliation(s)
- Dae Hyuk Heo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yu Min Kang
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Kyoung Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Jun Won Seo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Han Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - June Young Chun
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kang Il Jun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chang Kyung Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Song Mi Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Won Sup Oh
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Myoung Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
14
|
Yao H, Wang Y, Mi X, Sun Y, Liu K, Li X, Ren X, Geng M, Yang Y, Wang L, Liu W, Fang L. The scrub typhus in mainland China: spatiotemporal expansion and risk prediction underpinned by complex factors. Emerg Microbes Infect 2019; 8:909-919. [PMID: 31233387 PMCID: PMC6598543 DOI: 10.1080/22221751.2019.1631719] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In mainland China, a geographic northward expansion of scrub typhus has been seen, highlighting the need to understand the factors and identify the risk for disease prevention. Incidence data from 1980 to 2013 were used. A Cox proportional hazard model was used to identify drivers for spatial spread, and a boosted regression tree (BRT) model was constructed to predict potential risk areas. Since the 1980s, an invasive expansion from South Natural Foci towards North Natural Foci was clearly identified, with the epidemiological heterogeneity observed between two regions, mainly in spatial distribution, seasonality, and demographic characteristics. Survival analysis disclosed significant factors contributing to the spatial expansion as following: being intersected by freeway (HR = 1.31, 95% CI: 1.11-1.54), coverage percentage of broadleaf forest (HR = 1.10, 95% CI: 1.06-1.15), and monthly average temperature (HR = 1.27, 95% CI: 1.25-1.30). The BRT models showed that precipitation, sunshine hour, temperature, crop field, and relative humidity contributed substantially to the spatial distribution of scrub typhus. A county-scale risk map was created to predict the regions with high probability of the disease. The current study enabled a comprehensive overview of epidemiological characteristics of scrub typhus in mainland China.
Collapse
Affiliation(s)
- Hongwu Yao
- a Department of Infection Management and Disease Control , Chinese PLA General Hospital , Beijing , People's Republic of China
| | - Yixing Wang
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China
| | - Xianmiao Mi
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China
| | - Ye Sun
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China.,c Center for Disease Control and Prevention of the North Military region , Jinan , People's Republic of China
| | - Kun Liu
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China.,d Department of Epidemiology and Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment , School of Public Health, Fourth Military Medical University , Xi'an , People's Republic of China
| | - Xinlou Li
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China.,e PLA Strategic Support Force Characteristic Medical Center , Beijing , People's Republic of China
| | - Xiang Ren
- f Division of Infectious Disease, Key Laboratory of Surveillance and Early-warning on Infectious Disease , Chinese Centre for Disease Control and Prevention , Beijing , People's Republic of China
| | - Mengjie Geng
- f Division of Infectious Disease, Key Laboratory of Surveillance and Early-warning on Infectious Disease , Chinese Centre for Disease Control and Prevention , Beijing , People's Republic of China
| | - Yang Yang
- g Department of Biostatistics , College of Public Health and Health Professions, and Emerging Pathogens Institute, University of Florida , Gainesville , FL , USA
| | - Liping Wang
- f Division of Infectious Disease, Key Laboratory of Surveillance and Early-warning on Infectious Disease , Chinese Centre for Disease Control and Prevention , Beijing , People's Republic of China
| | - Wei Liu
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China.,h Beijing Key Laboratory of Vector Borne and Natural Focus Infectious Diseases , Beijing , People's Republic of China
| | - Liqun Fang
- b The State Key Laboratory of Pathogen and Biosecurity , Beijing Institute of Microbiology and Epidemiology , Beijing , People's Republic of China
| |
Collapse
|
15
|
Lee HJ, Park C. Distribution of Chigger Mites as Tsutsugamushi Vectors Sampled in Seogwipo. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2019. [DOI: 10.15324/kjcls.2019.51.3.344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hyeok Jae Lee
- Department of Clinical Laboratory Science, Gwangju Health Science University, Gwangju, Korea
| | - Chul Park
- Department of Clinical Laboratory Science, Gwangju Health Science University, Gwangju, Korea
| |
Collapse
|
16
|
Heo DH, Hwang JH, Choi SH, Jeon M, Lee JH, Lee JH, Hwang SD, Lee KA, Lee SH, Lee CS. Recent Increase of Human Granulocytic Anaplasmosis and Co-Infection with Scrub Typhus or Korean Hemorrhagic Fever with Renal Syndrome in Korea. J Korean Med Sci 2019; 34:e87. [PMID: 30914905 PMCID: PMC6427050 DOI: 10.3346/jkms.2019.34.e87] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/24/2019] [Indexed: 11/20/2022] Open
Abstract
We report 17 patients with human granulocytic anaplasmosis between January 2015 and September 2018 at two tertiary university hospitals in Korea. Monthly incidence peaked in May and June. Among these patients, we identified three who were co-infected with scrub typhus, and one patient with hemorrhagic fever with renal syndrome.
Collapse
Affiliation(s)
- Dae-Hyuk Heo
- Department of Internal Medicine, Design Hospital, Jeonju, Korea
| | - Joo-Hee Hwang
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Seung Hee Choi
- Department of Industrial Design, Chonbuk National University, Jeonju, Korea
| | - Mir Jeon
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Ju-Hyung Lee
- Department of Preventive Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jae-Hoon Lee
- Department of Internal Medicine, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, Korea
| | - Seon-Do Hwang
- Division of Zoonoses, Center for Immunology and Pathology, Korea National Institute of Health, Korea Centers for Disease Control and Prevention, Cheongju, Korea
- Division of Bacterial Diseases, Center for Laboratory Control of Infectious Diseases, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Kyeong-Ah Lee
- Division of Bacterial Diseases, Center for Laboratory Control of Infectious Diseases, Korea Centers for Disease Control and Prevention, Cheongju, Korea
| | - Seung-Hun Lee
- Division of Zoonoses, Center for Immunology and Pathology, Korea National Institute of Health, Korea Centers for Disease Control and Prevention, Cheongju, Korea
- Yeosu National Quarantine Office, Korea Centers for Disease Control and Prevention, Yeosu, Korea
| | - Chang-Seop Lee
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| |
Collapse
|
17
|
Jan RH, Chen CJ, Hong YR, Lin YL, Chen LK. A surface antigen of Orientia tsutsugamushi activates human monocyte-derived dendritic cells via nuclear factor-kB & p38 mitogen-activated protein kinase pathways. Indian J Med Res 2019; 148:215-224. [PMID: 30381545 PMCID: PMC6206779 DOI: 10.4103/ijmr.ijmr_1417_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background & objectives: Scrub typhus is a chigger-borne disease caused by Orientia tsutsugamushi. The immunological reactions to O. tsutsugamushi infection are not completely understood. In this study, we investigated the response of dendritic cells (DCs) to a major 56-kDa scrub typhus antigen Sta56. Methods: Monocyte-derived human DCs were incubated with different concentrations of recombinant Sta56 and analyzed for maturation based on phagocytic capacity, the ability to induce T-cell proliferation, expression of surface markers, cytokine secretion and activation of toll-like receptor (TLR)-dependent signalling pathways. Results: Treatment of DCs with Sta56 induced cell surface expression of CD80, CD83, CD86 and MHC Class II increased the production of interleukin-12 (IL-12) p40, IL-12 p70 and IL-10 and decreased DC phagocytic capacity. Furthermore, Sta56 increased the ability of DCs to activate T-cell proliferation and interferon-γ secretion. TLR4-specific antibodies neutralized Sta56-elicited effects on DC maturation, suggesting direct interaction between Sta56 and TLR4. Moreover, Sta56 activated nuclear factor (NF)-κB and p38 mitogen-activated protein kinase (MAPK) signalling as evidenced by decrease in Sta56-induced cytokine production and surface marker expression by specific inhibitors helenalin and SB203580, respectively, and increase in IκBα and p38 phosphorylation and NF-κB-DNA binding. Interpretation & conclusions: Our results showed that the surface antigen of O. tsutsugamushi activated DCs through interaction with TLR4 and activation of MAPK and NF-κB signalling, suggesting Sta56 as a potential candidate molecule for the development of vaccine against scrub typhus.
Collapse
Affiliation(s)
- Rong-Hwa Jan
- Institute of Medical Sciences, Tzu Chi University; Department of Pediatrics, Hualien Tzu Chi Hospital, Chia Yi, Taiwan
| | - Chia-Jung Chen
- Department of Nursing, Dalin Tzu Chi Hospital, Chia Yi, Taiwan
| | - Yi-Ren Hong
- Department of Biochemistry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Li Lin
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kuang Chen
- Institute of Medical Sciences, Tzu Chi University, Chia Yi, Taiwan
| |
Collapse
|
18
|
Han YH, Hwang JH, Lee CS. Dissemination of Orientia tsutsugamushi in a Case of Scrub Typhus. Am J Trop Med Hyg 2019; 100:235-236. [PMID: 30795827 PMCID: PMC6367607 DOI: 10.4269/ajtmh.18-0689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yeon-Hee Han
- Cyclotron Research Center, Molecular Imaging and Therapeutic Medicine Research Center, Chonbuk National University Medical School and Hospital, Jeonju, Republic of Korea.,Department of Nuclear Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Joo-Hee Hwang
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea.,Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Chang-Seop Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| |
Collapse
|
19
|
Choi YJ, Lee IY, Song HJ, Kim J, Park HJ, Song D, Jang WJ. Geographical distribution of Orientia tsutsugamushi strains in chiggers from three provinces in Korea. Microbiol Immunol 2018; 62:547-553. [PMID: 30035807 DOI: 10.1111/1348-0421.12639] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/15/2018] [Accepted: 07/12/2018] [Indexed: 11/28/2022]
Abstract
Chiggers were collected from the central and southern parts of South Korea between April and November, 2009 with the aim of investigating the seasonal and geographical distribution of Or. A total of 1136 chiggers were identified. They included eight species belonging to four genera, as follows: Leptotrombidium scutellare (27.2%, n = 309), L. pallidum (54.6%, n = 621), L. orientale (6.25%, n = 71), L. palpale (1.59%, n = 18), L. zetum (2.0%, n = 23), Euschoengastia koreaensis (1.5%, n = 17), Cheladonta ikaoensis (0.08%, n = 1) and Neotrombicula japonica (1.05%, n = 12). The density of L. pallidum was high from April to May, whereas L. scutallare was not found in spring, being observed from October. Serotype-specific nested PCR targeting the 56 kDa protein gene and sequencing analysis identified that the strains of 1136 O. tsutsugamushi in the chiggers as Boryong (6.8%), Kanda (0.4%), Oishi (0.3%), Jecheon (0.1%), Youngworl (0.1%) and Wonju (0.1%). Our findings indicate that L. pallidum and L. scutellare are dominant species in Korea and have geographical and seasonal variations.
Collapse
Affiliation(s)
- Yeon-Joo Choi
- Department of Microbiology, College of Medicine, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 143 701, Korea
| | - In-Yong Lee
- Department of Environmental Medical Biology, College of Medicine, Yonsei University, 50 Yonsei-ro, Seoul 120 752, Korea
| | - Hyeon-Je Song
- Department of Clinical Pathology, Gwangju Health College, 73 Bungmun Dae-ro, Gwangju 506 701, Korea
| | - Jeoungyeon Kim
- Department of Microbiology, College of Medicine, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 143 701, Korea
| | - Hye-Jin Park
- Department of Microbiology, College of Medicine, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 143 701, Korea
| | - Dayoung Song
- Department of Microbiology, College of Medicine, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 143 701, Korea
| | - Won-Jong Jang
- Department of Microbiology, College of Medicine, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 143 701, Korea
| |
Collapse
|
20
|
Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM. A review of the global epidemiology of scrub typhus. PLoS Negl Trop Dis 2017; 11:e0006062. [PMID: 29099844 PMCID: PMC5687757 DOI: 10.1371/journal.pntd.0006062] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/15/2017] [Accepted: 10/21/2017] [Indexed: 12/18/2022] Open
Abstract
Scrub typhus is a serious public health problem in the Asia-Pacific area. It threatens one billion people globally, and causes illness in one million people each year. Caused by Orientia tsutsugamushi, scrub typhus can result in severe multiorgan failure with a case fatality rate up to 70% without appropriate treatment. The antigenic heterogeneity of O. tsutsugamushi precludes generic immunity and allows reinfection. As a neglected disease, there is still a large gap in our knowledge of the disease, as evidenced by the sporadic epidemiologic data and other related public health information regarding scrub typhus in its endemic areas. Our objective is to provide a systematic analysis of current epidemiology, prevention and control of scrub typhus in its long-standing endemic areas and recently recognized foci of infection.
Collapse
Affiliation(s)
- Guang Xu
- Department of Pathology, The University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - David H. Walker
- Department of Pathology, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Daniel Jupiter
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Peter C. Melby
- Department of Internal Medicine, Division of Infectious Diseases, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Christine M. Arcari
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas, United States of America
| |
Collapse
|
21
|
Huang XD, Cheng P, Zhao YQ, Li WJ, Zhao JX, Liu HM, Kou JX, Gong MQ. Chigger Mite (Acari: Trombiculidae) Survey of Rodents in Shandong Province, Northern China. THE KOREAN JOURNAL OF PARASITOLOGY 2017; 55:555-559. [PMID: 29103271 PMCID: PMC5678473 DOI: 10.3347/kjp.2017.55.5.555] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 09/08/2017] [Accepted: 10/11/2017] [Indexed: 11/23/2022]
Abstract
Chigger mites are parasites of rodents and other vertebrates, invertebrates, and other arthropods, and are the only vectors of scrub typhus, in addition to other zoonoses. Therefore, investigating their distribution, diversity, and seasonal abundance is important for public health. Rodent surveillance was conducted at 6 districts in Shandong Province, northern China (114–112°E, 34–38°N), from January to December 2011. Overall, 225/286 (78.7%) rodents captured were infested with chigger mites. A total of 451 chigger mites were identified as belonging to 5 most commonly collected species and 3 genera in 1 family. Leptotrombidium scutellare and Leptotrombidium intermedia were the most commonly collected chigger mites. L. scutellare (66.2%, 36.7%, and 49.0%) was the most frequently collected chigger mite from Apodemus agrarius, Rattus norvegicus, and Microtus fortis, respectively, whereas L. intermedia (61.5% and 63.2%) was the most frequently collected chigger mite from Cricetulus triton and Mus musculus, respectively. This study demonstrated a relatively high prevalence of chigger mites that varied seasonally in Shandong Province, China.
Collapse
Affiliation(s)
- Xiao-Dan Huang
- Shandong Academy of Medicine Sciences, Shandong Institute of Parasitic Diseases, Jining, Shandong Province 272033, People's Republic of China
| | - Peng Cheng
- Shandong Academy of Medicine Sciences, Shandong Institute of Parasitic Diseases, Jining, Shandong Province 272033, People's Republic of China
| | - Yu-Qiang Zhao
- Shandong Academy of Medicine Sciences, Shandong Institute of Parasitic Diseases, Jining, Shandong Province 272033, People's Republic of China
| | - Wen-Juan Li
- Institute of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining, Shandong Province 272067, People's Republic of China
| | - Jiu-Xu Zhao
- Jining Health School, Jining, Shandong Province 272031, People's Republic of China
| | - Hong-Mei Liu
- Shandong Academy of Medicine Sciences, Shandong Institute of Parasitic Diseases, Jining, Shandong Province 272033, People's Republic of China
| | - Jing-Xuan Kou
- Shandong Academy of Medicine Sciences, Shandong Institute of Parasitic Diseases, Jining, Shandong Province 272033, People's Republic of China
| | - Mao-Qing Gong
- Shandong Academy of Medicine Sciences, Shandong Institute of Parasitic Diseases, Jining, Shandong Province 272033, People's Republic of China
| |
Collapse
|
22
|
A Case of Scrub Typhus Related Encephalopathy Presenting as Rapidly Progressive Dementia. Dement Neurocogn Disord 2017; 16:83-86. [PMID: 30906376 PMCID: PMC6427984 DOI: 10.12779/dnd.2017.16.3.83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/13/2017] [Accepted: 09/13/2017] [Indexed: 11/27/2022] Open
Abstract
Background An infection known to be a major cause of mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). Rapidly progressive dementia is a neurological condition in which dementia progresses in a short period of time. Case Report We report on a 78-year-old woman presenting with a rapid decline in cognitive function resulting from a scrub typhus infection. Diffusion weighted images showed a signal intensity at the splenium, and subcortical white matter of both hemispheres suggesting MERS. On the neuropsychological test, the patient showed frontal executive dysfunction. Conclusions This case suggests that diagnosticians should consider the possibility that a MERS patient with a rapidly cognitive decline could have a scrub typhus infection because early diagnosis of scrub typhus is very important in this aspect of the treatment.
Collapse
|
23
|
Lee HS, Sunwoo JS, Ahn SJ, Moon J, Lim JA, Jun JS, Lee WJ, Lee ST, Jung KH, Park KI, Jung KY, Lee SK, Chu K. Central Nervous System Infection Associated with Orientia tsutsugamushi in South Korea. Am J Trop Med Hyg 2017; 97:1094-1098. [PMID: 28820719 DOI: 10.4269/ajtmh.17-0077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Orientia tsutsugamushi is a major cause of vector-borne infection in Asia. Prompt recognition and appropriate treatment are crucial because of its potentially fatal complications and lack of response to beta-lactam antibiotics. The present study retrospectively evaluated the clinical characteristics and laboratory findings of 16 patients with scrub typhus-related central nervous system (CNS) infections. Single titers ≥ 1:40 of total serum antibodies against O. tsutsugamushi detected by an indirect immunofluorescent assay were considered as positive results. The median age was 35.5 (range, 14-72) years, and 10 (62.5%) patients were female. The most common symptoms were headache (81.3%) and fever (81.3%). Eschar formation was found in three (18.8%) patients. Among patients with encephalitis, seizures and altered consciousness occurred in five (83.3%) and four (66.7%) patients, respectively. An abnormal liver function was noted in seven (43.8%) patients. The median antibody titer was 1:120 (range, 1:40-1:2,560). Typical cerebrospinal fluid profiles were lymphocytic pleocytosis, mild protein elevations, and normal glucose levels. All patients received an empirical treatment with doxycycline and most (93.8%) of them recovered without neurological sequelae. None of the patients reported side effects of the doxycycline treatment. An empirical treatment with doxycycline is needed in patients with CNS infections in scrub typhus endemic areas.
Collapse
Affiliation(s)
- Han Sang Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jun-Sang Sunwoo
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Seon-Jae Ahn
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jung-Ah Lim
- Department of Neurology, National Center for Mental Health, An affiliate of the Ministry for Health & Welfare, Seoul, South Korea
| | - Jin-Sun Jun
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| |
Collapse
|
24
|
Sun Y, Wei YH, Yang Y, Ma Y, de Vlas SJ, Yao HW, Huang Y, Ma MJ, Liu K, Li XN, Li XL, Zhang WH, Fang LQ, Yang ZC, Cao WC. Rapid increase of scrub typhus incidence in Guangzhou, southern China, 2006-2014. BMC Infect Dis 2017; 17:13. [PMID: 28056840 PMCID: PMC5216553 DOI: 10.1186/s12879-016-2153-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the last decade, scrub typhus (ST) has been emerging or re-emerging in some areas of Asia, including Guangzhou, one of the most affected endemic areas of ST in China. METHODS Based on the data on all cases reported in Guangzhou from 2006 to 2014, we characterized the epidemiological features, and identified environmental determinants for the spatial distribution of ST using a panel negative binomial model. RESULTS A total of 4821 scrub typhus cases were reported in Guangzhou during 2006-2014. The annual incidence increased noticeably and the increase was relatively high and rapid in rural townships and among elderly females. The majority of cases (86.8%) occurred during May-October, and farmers constituted the majority of the cases, accounting for 33.9% in urban and 61.6% in rural areas. The number of housekeeper patients had a rapid increment in both rural and urban areas during the study period. Atmospheric pressure and relative humidity with lags of 1 or 2 months, distributions of broadleaved forest and rural township were identified as determinants for the spatiotemporal distribution of scrub typhus. CONCLUSION Our results indicate that surveillance and public education need to be focused on the elderly farmers in rural areas covered with broadleaf forest in southern China.
Collapse
Affiliation(s)
- Ye Sun
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China.,Center for Disease Control and Prevention of Jinan Military Region, Shandong Province, Jinan, 250014, People's Republic of China
| | - Yue-Hong Wei
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, 510440, People's Republic of China
| | - Yang Yang
- Department of Biostatistics, College of Public Health and Health Professions, and Emerging Pathogens Institute, University of Florida, 32311, Florida, USA
| | - Yu Ma
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, 510440, People's Republic of China
| | - Sake J de Vlas
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, 999025, Rotterdam, The Netherlands
| | - Hong-Wu Yao
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China
| | - Yong Huang
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, 510440, People's Republic of China
| | - Mai-Juan Ma
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China
| | - Kun Liu
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China
| | - Xiao-Ning Li
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, 510440, People's Republic of China
| | - Xin-Lou Li
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China
| | - Wen-Hui Zhang
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China
| | - Li-Qun Fang
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China.
| | - Zhi-Cong Yang
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, 510440, People's Republic of China.
| | - Wu-Chun Cao
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, 20 Dong-Da Street, Fengtai District, Beijing, 100071, People's Republic of China.
| |
Collapse
|
25
|
Ha NY, Shin HM, Sharma P, Cho HA, Min CK, Kim HI, Yen NTH, Kang JS, Kim IS, Choi MS, Kim YK, Cho NH. Generation of protective immunity against Orientia tsutsugamushi infection by immunization with a zinc oxide nanoparticle combined with ScaA antigen. J Nanobiotechnology 2016; 14:76. [PMID: 27887623 PMCID: PMC5124320 DOI: 10.1186/s12951-016-0229-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/17/2016] [Indexed: 01/31/2023] Open
Abstract
Background Zinc oxide nanoparticle (ZNP) has been applied in various biomedical fields. Here, we investigated the usage of ZNP as an antigen carrier for vaccine development by combining a high affinity peptide to ZNP. Results A novel zinc oxide-binding peptide (ZBP), FPYPGGDA, with high affinity to ZNP (Ka = 2.26 × 106 M−1) was isolated from a random peptide library and fused with a bacterial antigen, ScaA of Orientia tsutsugamushi, the causative agent of scrub typhus. The ZNP/ZBP-ScaA complex was efficiently phagocytosed by a dendritic cell line, DC2.4, in vitro and significantly enhanced anti-ScaA antibody responses in vivo compared to control groups. In addition, immunization with the ZNP/ZBP-ScaA complex promoted the generation of IFN-γ-secreting T cells in an antigen-dependent manner. Finally, we observed that ZNP/ZBP-ScaA immunization provided protective immunity against lethal challenge of O. tsutsugamushi, indicating that ZNP can be used as a potent adjuvant when complexed with ZBP-conjugated antigen. Conclusions ZNPs possess good adjuvant potential as a vaccine carrier when combined with an antigen having a high affinity to ZNP. When complexed with ZBP-ScaA antigen, ZNPs could induce strong antibody responses as well as protective immunity against lethal challenges of O. tsutsugamushi. Therefore, application of ZNPs combined with a specific soluble antigen could be a promising strategy as a novel vaccine carrier system.
Collapse
Affiliation(s)
- Na-Young Ha
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Mu Shin
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Endemic Disease, Seoul National University Medical Research Center and Bundang Hospital, Seoul, Republic of Korea
| | - Prashant Sharma
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Ah Cho
- Department of Materials Science and Engineering, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Chan-Ki Min
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong-Il Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nguyen Thi Hai Yen
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae-Seung Kang
- Department of Microbiology, Inha University School of Medicine, Incheon, Republic of Korea
| | - Ik-Sang Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Institute of Endemic Disease, Seoul National University Medical Research Center and Bundang Hospital, Seoul, Republic of Korea
| | - Myung-Sik Choi
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Institute of Endemic Disease, Seoul National University Medical Research Center and Bundang Hospital, Seoul, Republic of Korea
| | - Young Keun Kim
- Department of Materials Science and Engineering, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea.
| | - Nam-Hyuk Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea. .,Institute of Endemic Disease, Seoul National University Medical Research Center and Bundang Hospital, Seoul, Republic of Korea.
| |
Collapse
|
26
|
Jang MS, Kim CM, Kim DM, Yoon NR, Han MA, Kim HK, Oh WS, Yoon HJ, Wie SH, Hur J. Comparison of Preferred Bite Sites Between Mites and Ticks on Humans in Korea. Am J Trop Med Hyg 2016; 95:1021-1025. [PMID: 27645781 DOI: 10.4269/ajtmh.16-0186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 08/16/2016] [Indexed: 11/07/2022] Open
Abstract
Identification of mite and tick bite sites provides important clinical information. The predominant mite species in Korea associated with scrub typhus are Leptotrombidium pallidum and Leptotrombidium scutellare The most abundant tick species is Haemaphysalis longicornis To date, there has been no comparative study on preferred bite sites between mites and ticks in humans. This study included a review of medical records and a field study. For mite bite sites, eschars were checked on 506 patients with scrub typhus, confirmed by indirect immunofluorescence assay or nested polymerase chain reaction on the 56-kDa type-specific antigen gene of Orientia tsutsugamushi Tick bite sites were identified and marked on a diagram for 91 patients who experienced tick bites within the previous year through a field epidemiological investigation. The mite and tick bite sites in Koreans were compared. The most frequently observed mite bite sites were the anterior chest, including the axillae (29.1%) and the abdominal region, including the inguinal area (26.1%). Tick bite sites were most frequent on the lower extremities (33.0%), followed by the abdominal region, including the inguinal area (26.4%), and upper extremities (26.4%). The distribution was significantly different between mite and tick bite sites (P < 0.001). There was a statistically significant difference in the mite bite (P = 0.001), but not tick bite sites (P = 0.985), between men and women. This is the first report on the differences between tick and mite bite sites, and may help clinicians reach a rapid diagnosis of mite- or tick-borne infection.
Collapse
Affiliation(s)
- Mi-Sun Jang
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Choon-Mee Kim
- Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea
| | - Dong-Min Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, South Korea.
| | - Na Ra Yoon
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Hyun-Kuk Kim
- Department of Pulmonary and Critical Care Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Won Sup Oh
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Hee-Jung Yoon
- Department of Infectious Diseases, Seoul Metropolitan Government Seobuk Hospital, Seoul, Korea
| | - Seong-Heon Wie
- Department of Internal Medicine, St. Vincent's Hospital, School of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University, College of Medicine, Daegu, South Korea
| |
Collapse
|
27
|
Abstract
The obligate intracellular bacterium Orientia tsutsugamushi is responsible for more than one million cases of scrub typhus annually throughout the Asia-Pacific region. Human infection occurs via the bite of the larval form (chigger) of several species of trombiculid mites. While in some patients the result of infection is a mild, febrile illness, others experience severe complications, which may even be fatal. This review discusses the genome and biology of the causative agent, the changing epidemiology of scrub typhus, the challenges of its diagnosis, and current treatment recommendations.
Collapse
Affiliation(s)
- Sunil Thomas
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania USA
| |
Collapse
|
28
|
Spatiotemporal Dynamics of Scrub Typhus Transmission in Mainland China, 2006-2014. PLoS Negl Trop Dis 2016; 10:e0004875. [PMID: 27479297 PMCID: PMC4968795 DOI: 10.1371/journal.pntd.0004875] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 07/04/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Scrub typhus is endemic in the Asia-Pacific region including China, and the number of reported cases has increased dramatically in the past decade. However, the spatial-temporal dynamics and the potential risk factors in transmission of scrub typhus in mainland China have yet to be characterized. OBJECTIVE This study aims to explore the spatiotemporal dynamics of reported scrub typhus cases in mainland China between January 2006 and December 2014, to detect the location of high risk spatiotemporal clusters of scrub typhus cases, and identify the potential risk factors affecting the re-emergence of the disease. METHOD Monthly cases of scrub typhus reported at the county level between 2006 and 2014 were obtained from the Chinese Center for Diseases Control and Prevention. Time-series analyses, spatiotemporal cluster analyses, and spatial scan statistics were used to explore the characteristics of the scrub typhus incidence. To explore the association between scrub typhus incidence and environmental variables panel Poisson regression analysis was conducted. RESULTS During the time period between 2006 and 2014 a total of 54,558 scrub typhus cases were reported in mainland China, which grew exponentially. The majority of cases were reported each year between July and November, with peak incidence during October every year. The spatiotemporal dynamics of scrub typhus varied over the study period with high-risk clusters identified in southwest, southern, and middle-eastern part of China. Scrub typhus incidence was positively correlated with the percentage of shrub and meteorological variables including temperature and precipitation. CONCLUSIONS The results of this study demonstrate areas in China that could be targeted with public health interventions to mitigate the growing threat of scrub typhus in the country.
Collapse
|
29
|
Wu YC, Qian Q, Magalhaes RJS, Han ZH, Haque U, Weppelmann TA, Hu WB, Liu YX, Sun YS, Zhang WY, Li SL. Rapid Increase in Scrub Typhus Incidence in Mainland China, 2006-2014. Am J Trop Med Hyg 2015; 94:532-6. [PMID: 26711517 DOI: 10.4269/ajtmh.15-0663] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/06/2015] [Indexed: 11/07/2022] Open
Abstract
Scrub typhus is a vector-borne disease, which has recently reemerged in China. In this study, we describe the distribution and incidence of scrub typhus cases in China from 2006 to 2014 and quantify differences in scrub typhus cases with respect to sex, age, and occupation. The results of our study indicate that the annual incidence of scrub typhus has increased during the study period. The number of cases peaked in 2014, which was 12.8 times greater than the number of cases reported in 2006. Most (77.97%) of the cases were reported in five provinces (Guangdong, Yunnan, Anhui, Fujian, and Shandong). Our study also demonstrates that the incidence rate of scrub typhus was significantly higher in females compared to males (P < 0.001) and was highest in the 60-69 year age group, and that farmers had a higher incidence rate than nonfarmers (P < 0.001). Different seasonal trends were identified in the number of reported cases between the northern and southern provinces of China. These findings not only demonstrate that China has experienced a large increase in scrub typhus incidence, but also document an expansion in the geographic distribution throughout the country.
Collapse
Affiliation(s)
- Yi-Cheng Wu
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Quan Qian
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Ricardo J Soares Magalhaes
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Zhi-Hai Han
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Ubydul Haque
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Thomas A Weppelmann
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Wen-Biao Hu
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Yun-Xi Liu
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Yan-Song Sun
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Wen-Yi Zhang
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| | - Shen-Long Li
- Institute of Disease Control and Prevention Academy of Military Medical Science, Beijing, People's Republic of China; School of Veterinary Science, Centre for Children's Health Research, University of Queensland, Brisbane, Australia; Navy General Hospital of People's Liberation Army, Beijing, People's Republic of China; Emerging Pathogens Institute, University of Florida, Gainesville, Florida; Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China; Academy of Military Medical Science, Beijing, People's Republic of China
| |
Collapse
|
30
|
Jeung YS, Kim CM, Yun NR, Kim SW, Han MA, Kim DM. Effect of Latitude and Seasonal Variation on Scrub Typhus, South Korea, 2001-2013. Am J Trop Med Hyg 2015; 94:22-5. [PMID: 26503283 DOI: 10.4269/ajtmh.15-0474] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 08/20/2015] [Indexed: 11/07/2022] Open
Abstract
In South Korea, scrub typhus is one of the most common rickettsial diseases. The number of scrub typhus patients has increased in South Korea, a total of 69,210 cases were reported from 2001 to 2013. The seasonality and relation of scrub typhus cases to latitude were analyzed in this article using data obtained from the National Notifiable Diseases Surveillance System website of the Korea Centers for Disease Control and Prevention. The incidence of scrub typhus tended to increase in the later months of the year, especially in October-December. In general, lower latitudes were associated with a later peak incidence. Our results suggest for the first time that the monthly observed incidence tended to increase in the later months of the year as the latitude decreased, and on a yearly basis in Korea.
Collapse
Affiliation(s)
- Ye Sul Jeung
- School of Medicine, Chosun University, Gwangju, South Korea; Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea; Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, South Korea; Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, South Korea; Department of Preventive Medicine, School of Medicine, Chosun University, Gwangju, South Korea
| | - Choon-Mee Kim
- School of Medicine, Chosun University, Gwangju, South Korea; Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea; Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, South Korea; Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, South Korea; Department of Preventive Medicine, School of Medicine, Chosun University, Gwangju, South Korea
| | - Na Ra Yun
- School of Medicine, Chosun University, Gwangju, South Korea; Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea; Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, South Korea; Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, South Korea; Department of Preventive Medicine, School of Medicine, Chosun University, Gwangju, South Korea
| | - Seok-Won Kim
- School of Medicine, Chosun University, Gwangju, South Korea; Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea; Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, South Korea; Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, South Korea; Department of Preventive Medicine, School of Medicine, Chosun University, Gwangju, South Korea
| | - Mi Ah Han
- School of Medicine, Chosun University, Gwangju, South Korea; Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea; Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, South Korea; Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, South Korea; Department of Preventive Medicine, School of Medicine, Chosun University, Gwangju, South Korea
| | - Dong-Min Kim
- School of Medicine, Chosun University, Gwangju, South Korea; Premedical Science, College of Medicine, Chosun University, Gwangju, South Korea; Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, South Korea; Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, South Korea; Department of Preventive Medicine, School of Medicine, Chosun University, Gwangju, South Korea
| |
Collapse
|
31
|
Park JH, Kim SJ, Youn SK, Park K, Gwack J. Epidemiology of scrub typhus and the eschars patterns in South Korea from 2008 to 2012. Jpn J Infect Dis 2015; 67:458-63. [PMID: 25410561 DOI: 10.7883/yoken.67.458] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In South Korea, scrub typhus is the most common acute febrile illness in autumn. We analyzed scrub typhus cases reported from 2008 to 2012 to describe the epidemiology of scrub typhus as well as eschar patterns. A total of 30,478 cases were reported from 2008 to 2012; the incidence rates were higher in the southern and western regions of South Korea. The common clinical symptoms of confirmed scrub typhus cases from 2010 to 2012 were fever/chills (95.2%), eschars (78.9%), and myalgia (61.7%). The primary sites of eschars were the lower extremities (19.0%), abdomen/waist (13.4%), and axilla (11.5%) in men and the shoulder/frontal chest (15.1%), lower extremities (14.5%), and abdomen/waist (13.6%) in women. Regardless of gender, eschars tended to be more on the lower extremities among the leisure activities group. Among the occupational farm work group, who usually lived in rural areas, eschars appeared most frequently on the abdomen/waist in men and on the shoulder/frontal chest in women. Eschar patterns were influenced by gender and activities. These results could facilitate the prevention of scrub typhus and clarify the current status of scrub typhus in South Korea.
Collapse
Affiliation(s)
- Ji-Hyuk Park
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention
| | | | | | | | | |
Collapse
|
32
|
Park SW, Ha NY, Ryu B, Bang JH, Song H, Kim Y, Kim G, Oh MD, Cho NH, Lee JK. Urbanization of scrub typhus disease in South Korea. PLoS Negl Trop Dis 2015; 9:e0003814. [PMID: 26000454 PMCID: PMC4441427 DOI: 10.1371/journal.pntd.0003814] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 05/05/2015] [Indexed: 01/19/2023] Open
Abstract
Background Scrub typhus is an endemic disease in Asia. It has been a rural disease, but indigenous urban cases have been observed in Seoul, South Korea. Urban scrub typhus may have a significant impact because of the large population. Methods Indigenous urban scrub typhus was epidemiologically identified in Seoul, the largest metropolitan city in South Korea, using national notifiable disease data from 2010 to 2013. For detailed analysis of clinical features, patients from one hospital that reported the majority of cases were selected and compared to a historic control group. Chigger mites were prospectively collected in the city using a direct chigger mite-collecting trap, and identified using both phenotypic and 18S rDNA sequencing analyses. Their infection with Orientia tsutsugamushi was confirmed by sequencing the 56-kDa antigen gene. Results Eighty-eight cases of urban scrub typhus were determined in Seoul. The possible sites of infection were mountainous areas (56.8%), city parks (20.5%), the vicinity of one’s own residence (17.0%), and riversides (5.7%). Eighty-seven chigger mites were collected in Gwanak mountain, one of the suspected infection sites in southern Seoul, and seventy-six (87.4%) of them were identified as Helenicula miyagawai and eight (9.2%) as Leptotrombidium scutellare. Pooled DNA extracted from H. miyagawai mites yielded O. tsutsugamushi Boryong strain. Twenty-six patients from one hospital showed low APACHE II score (3.4 ± 2.7), low complication rate (3.8%), and no hypokalemia. Conclusions We identified the presence of indigenous urban scrub typhus in Seoul, and a subgroup of them had mild clinical features. The chigger mite H. miyagawai infected with O. tsutsugamushi within the city was found. In endemic area, urban scrub typhus needs to be considered as one of the differential febrile diseases and a target for prevention. Scrub typhus is one of the high burdened infectious diseases in endemic rural areas. Our study showed that the disease could be endemic in urban areas. Indigenous urban scrub typhus may also have significant impact in terms of a disease burden and differential diagnosis. A low rate of characteristic eschar and skin rash may make the clinical suspicion more troublesome. Scrub typhus is the 3rd most frequent notifiable infectious disease in South Korea. Seoul is a densely populated capital city located in northwestern South Korea. We epidemiologically identified indigenous urban cases. A subgroup of them showed mild clinical characteristics. Direct mite collection from a suspected infection site, Mt. Gwanak in Seoul, showed that Helenicula miyagawai (87.4%) and Leptotrombidium scutellare (9.2%) were the dominant species. In addition, O. tsutsugamushi-specific gene, tsa56, was identified in a fraction of the collected H. miyagawai. The 18S rDNA sequencing of the chigger mites was complementarily helpful for the differentiation of species. Our data are from one region, but urban scrub typhus is likely a scenario in endemic areas. Urban areas should be included as possible locations for scrub typhus.
Collapse
Affiliation(s)
- Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Boramae Medical Center, Seoul, Republic of Korea
| | - Na-Young Ha
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine and Bundang Hospital, Seoul, Republic of Korea
| | - Boyeong Ryu
- Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea
- Seoul Center for Infectious Disease Control, Seoul, Republic of Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Boramae Medical Center, Seoul, Republic of Korea
- Seoul Center for Infectious Disease Control, Seoul, Republic of Korea
| | - Hoyeon Song
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine and Bundang Hospital, Seoul, Republic of Korea
| | - Yuri Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine and Bundang Hospital, Seoul, Republic of Korea
| | - Gwanghun Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine and Bundang Hospital, Seoul, Republic of Korea
| | - Myoung-don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Seoul Center for Infectious Disease Control, Seoul, Republic of Korea
| | - Nam-Hyuk Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine and Bundang Hospital, Seoul, Republic of Korea
- * E-mail: (NHC); (JkL)
| | - Jong-koo Lee
- Seoul Center for Infectious Disease Control, Seoul, Republic of Korea
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail: (NHC); (JkL)
| |
Collapse
|
33
|
Lee HW, Cho PY, Moon SU, Na BK, Kang YJ, Sohn Y, Youn SK, Hong Y, Kim TS. Current situation of scrub typhus in South Korea from 2001-2013. Parasit Vectors 2015; 8:238. [PMID: 25928653 PMCID: PMC4416255 DOI: 10.1186/s13071-015-0858-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/13/2015] [Indexed: 11/20/2022] Open
Abstract
Background The bacteria Orientia tsutsugamushi is the causative agent of scrub typhus, mite-borne disease, which causes an acute febrile illness in patients. An epidemiologic study was conducted to understand the characteristics of scrub typhus in South Korea. Findings Reporting of tsutsugamushi disease is mandatory in South Korea since 1994. To investigate the prevalence of tsutsugamushi disease from 2001 to 2013, medical records from the Korea Center for Disease Control and Prevention were reviewed. In total, 70,914 cases were reported during 2001–2013. Of these, 37.16% (26,349) were male and 62.84% (44,565) were female. The highest number of cases was in the 60–69-year-old age group (19,484; 27.48%), and 72.22% (51,212) were in the 50–79-year-old age group. There were 65,100 cases (91.80%) reported during October (24,964; 35.20%) and November (40,136; 56.60%). An almost four-fold increase in the number of patients was observed in 2013 (10,485 cases) compared to 2001 (2,637 cases). The highest number of patients was reported in the Jeonbuk (9,425; 13.29%) and lowest in the Jeju (362; 0.51%). Conclusions A rapid increase in the incidence of patients with tsutsugamushi disease was observed in most areas from 2001 to 2013, with the majority of cases reported in the western and southern coast.
Collapse
Affiliation(s)
- Hyeong-Woo Lee
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA.
| | - Pyo Yun Cho
- Departments of Parasitology and Tropical Medicine, Inha University School of Medicine, Incheon, 400-712, Republic of Korea.
| | - Sung-Ung Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, 463-939, Korea.
| | - Byoung-Kuk Na
- Department of Parasitology and Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, 660-751, Korea.
| | - Yoon-Joong Kang
- Department of Biomedical Science, Jungwon University, Goesan, Chungbuk, 367-805, Republic of Korea.
| | - Youngjoo Sohn
- Department of Anatomy, College of Korean Medicine, Institute of Korean Medicine, Kyung Hee University, Seoul, 130-701, Korea.
| | - Seung-Ki Youn
- Department of Epidemiology, National Institute of Health, Osong, 363-951, Republic of Korea.
| | - Yeongseon Hong
- Department of Public Health, Sahmyook University, Seoul, 139-742, Republic of Korea.
| | - Tong-Soo Kim
- Departments of Parasitology and Tropical Medicine, Inha University School of Medicine, Incheon, 400-712, Republic of Korea.
| |
Collapse
|
34
|
Coincidence between geographical distribution of Leptotrombidium scutellare and scrub typhus incidence in South Korea. PLoS One 2014; 9:e113193. [PMID: 25500568 PMCID: PMC4264734 DOI: 10.1371/journal.pone.0113193] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 09/04/2014] [Indexed: 11/19/2022] Open
Abstract
To clarify the geographical distribution of scrub typhus vectors in Korea, a survey of larval trombiculid mites was conducted from 2005 to 2007 by collecting wild small mammals twice a year (spring and autumn) at 24 sites nationwide. A total of 67,325 mites representing 4 genera and 14 species were collected from 783 trapped rodents, corresponding to a chigger index (number of chigger mites per rodent) of 86.0. The predominant mite species were Leptotrombidium pallidum (52.6%), Leptotrombiduim scutellare (27.1%), Leptotrombidium palpale (8.2%), Leptotrombidium orientale (5.6%), and Neotrombicula tamiyai (1.7%). However, the proportions of L. scutellare in southern areas, including endemic provinces such as Jeollabuk-Do (34.3%), Jeollanam-Do (49.0%), and Gyeongsangnam-Do (88%), were relatively higher than in central Korean regions where L. pallidum was predominant. In autumn, the ratio of L. scutellare increased to 42% while the ratio of L. pallidum decreased. The geographical distribution map of the L. scutellare chigger index was identical to the incidence pattern of scrub typhus, whereas those of overall mites and L. pallidum showed no relationship with case incidence patterns. Distribution mapping analysis shows an identical geographical distribution of L. scutellare and epidemic incidence of scrub typhus in South Korea. L. pallidum could be another vector at all other parts of the Korean peninsula, including the eastern and northern regions that have a low level of scrub typhus incidence.
Collapse
|
35
|
Jung HC, Chon SB, Oh WS, Lee DH, Lee HJ. Etiologies of acute undifferentiated fever and clinical prediction of scrub typhus in a non-tropical endemic area. Am J Trop Med Hyg 2014; 92:256-61. [PMID: 25448236 DOI: 10.4269/ajtmh.14-0377] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Scrub typhus usually presents as acute undifferentiated fever. This cross-sectional study included adult patients presenting with acute undifferentiated fever defined as any febrile illness for ≤ 14 days without evidence of localized infection. Scrub typhus cases were defined by an antibody titer of a ≥ fourfold increase in paired sera, a ≥ 1:160 in a single serum using indirect immunofluorescence assay, or a positive result of the immunochromatographic test. Multiple regression analysis identified predictors associated with scrub typhus to develop a prediction rule. Of 250 cases with known etiology of acute undifferentiated fever, influenza (28.0%), hepatitis A (25.2%), and scrub typhus (16.4%) were major causes. A prediction rule for identifying suspected cases of scrub typhus consisted of age ≥ 65 years (two points), recent fieldwork/outdoor activities (one point), onset of illness during an outbreak period (two points), myalgia (one point), and eschar (two points). The c statistic was 0.977 (95% confidence interval = 0.960-0.994). At a cutoff value ≥ 4, the sensitivity and specificity were 92.7% (79.0-98.1%) and 90.9% (86.0-94.3%), respectively. Scrub typhus, the third leading cause of acute undifferentiated fever in our region, can be identified early using the prediction rule.
Collapse
Affiliation(s)
- Ho-Chul Jung
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Bin Chon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won Sup Oh
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong-Hyun Lee
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
36
|
Wei Y, Luo L, Jing Q, Li X, Huang Y, Xiao X, Liu L, Wu X, Yang Z. A city park as a potential epidemic site of scrub typhus: a case-control study of an outbreak in Guangzhou, China. Parasit Vectors 2014; 7:513. [PMID: 25403988 PMCID: PMC4240828 DOI: 10.1186/s13071-014-0513-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/31/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Scrub typhus is an important public health problem in China, especially in Guangzhou city. Typical outbreaks of scrub typhus have been previously reported in rural areas, affecting mainly farmers. We describe an atypical outbreak of the disease with case fatalities, from a park in Haizhu District, Guangzhou, that could turn out to be a potential scrub typhus epidemic site. METHODS From May 2012 to June 2012, a case-control study was conducted to identify source and risk factors of this outbreak. Reported cases of scrub typhus in Xiaogang Park were confirmed by Weil-Felix test or a nested polymerase chain reaction (NPCR). Controls were matched with their neighbors by gender and age. Multivariate conditional logistic regression was used to identify risk factors and protective factors. RESULTS A total of 29 cases were confirmed by Weil-Felix test, including 4 deaths by both Weil-Felix test and NPCR. All patients presented with fever (100%), while 28 (96.6%) cases had eschars, 10 (34.5%) headache, 10 (34.5%) chills, 6 (20.7%) lymphadenopathy, 5 (17.2%) rash, 2 (6.9%) vomiting and 1 (3.5%) presented with conjunctival congestion. The proportion of cases with activity history in Xiaogang Park was much higher than the control group (72.4% vs 24.1%, P < 0.001), and morning exercise in park or field was also as a risk factor for scrub typhus (adjusted OR = 3.0, 95% CI: 1.1-8.2). Four factors were significantly associated with the risk of developing scrub typhus: sitting on the lawn (adjusted OR = 8.0, 95% CI: 1.4-44.5), close contact with rats (adjusted OR = 3.3, 95% CI: 1.2-9.6), sitting near the rat holes (OR = 6.8, 95% CI: 1.2-38.1) and wearing long-sleeved clothing when outside (adjusted OR = 0.3, 95% CI: 0.1-0.7). CONCLUSIONS We confirmed an atypical outbreak of scrub typhus in a park in Guangzhou city, which has the potential to develop into an important epidemic site. This public health risk should not be neglected and requires more attention from authorities.
Collapse
Affiliation(s)
- Yuehong Wei
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Lei Luo
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Qinlong Jing
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Xiaoning Li
- School of Public Health, Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China.
| | - Yong Huang
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Xincai Xiao
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Lan Liu
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Xinwei Wu
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| | - Zhicong Yang
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China.
| |
Collapse
|
37
|
Min CK, Kwon YJ, Ha NY, Cho BA, Kim JM, Kwon EK, Kim YS, Choi MS, Kim IS, Cho NH. Multiple Orientia tsutsugamushi ankyrin repeat proteins interact with SCF1 ubiquitin ligase complex and eukaryotic elongation factor 1 α. PLoS One 2014; 9:e105652. [PMID: 25166298 PMCID: PMC4148323 DOI: 10.1371/journal.pone.0105652] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/22/2014] [Indexed: 11/30/2022] Open
Abstract
Background Orientia tsutsugamushi, the causative agent of scrub typhus, is an obligate intracellular bacterium. Previously, a large number of genes that encode proteins containing eukaryotic protein-protein interaction motifs such as ankyrin-repeat (Ank) domains were identified in the O. tsutsugamushi genome. However, little is known about the Ank protein function in O. tsutsugamushi. Methodology/Principal Findings To characterize the function of Ank proteins, we investigated a group of Ank proteins containing an F-box–like domain in the C-terminus in addition to the Ank domains. All nine selected ank genes were expressed at the transcriptional level in host cells infected with O. tsutsugamushi, and specific antibody responses against three Ank proteins were detected in the serum from human patients, indicating an active expression of the bacterial Ank proteins post infection. When ectopically expressed in HeLa cells, the Ank proteins of O. tsutsugamushi were consistently found in the nucleus and/or cytoplasm. In GST pull-down assays, multiple Ank proteins specifically interacted with Cullin1 and Skp1, core components of the SCF1 ubiquitin ligase complex, as well as the eukaryotic elongation factor 1 α (EF1α). Moreover, one Ank protein co-localized with the identified host targets and induced downregulation of EF1α potentially via enhanced ubiquitination. The downregulation of EF1α was observed consistently in diverse host cell types infected with O. tsutsugamushi. Conclusion/Significance These results suggest that conserved targeting and subsequent degradation of EF1α by multiple O. tsutsugamushi Ank proteins could be a novel bacterial strategy for replication and/or pathogenesis during mammalian host infection.
Collapse
Affiliation(s)
- Chan-Ki Min
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ye-Jin Kwon
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Na-Young Ha
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bon-A Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jo-Min Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Kyung Kwon
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon-Sook Kim
- Divisions of Infectious Diseases, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Myung-Sik Choi
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ik-Sang Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam-Hyuk Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Endemic Disease, Seoul National University Medical Research Center and Bundang Hospital, Seoul, Republic of Korea
- * E-mail:
| |
Collapse
|
38
|
Griffith M, Peter JV, Karthik G, Ramakrishna K, Prakash JAJ, Kalki RC, Varghese GM, Chrispal A, Pichamuthu K, Iyyadurai R, Abraham OC. Profile of organ dysfunction and predictors of mortality in severe scrub typhus infection requiring intensive care admission. Indian J Crit Care Med 2014; 18:497-502. [PMID: 25136187 PMCID: PMC4134622 DOI: 10.4103/0972-5229.138145] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background and Aims: Scrub typhus, a zoonotic rickettsial infection, is an important reason for intensive care unit (ICU) admission in the Indian subcontinent. We describe the clinical profile, organ dysfunction, and predictors of mortality of severe scrub typhus infection. Materials and Methods: Retrospective study of patients admitted with scrub typhus infection to a tertiary care university affiliated teaching hospital in India during a 21-month period. Results: The cohort (n = 116) aged 40.0 ± 15.2 years (mean ± SD), presented 8.5 ± 4.4 days after symptom onset. Common symptoms included fever (100%), breathlessness (68.5%), and altered mental status (25.5%). Forty-seven (41.6%) patients had an eschar. Admission APACHE-II score was 19.6 ± 8.2. Ninety-one (85.2%) patients had dysfunction of 3 or more organ systems. Respiratory (96.6%) and hematological (86.2%) dysfunction were frequent. Mechanical ventilation was required in 102 (87.9%) patients, of whom 14 (12.1%) were solely managed with non-invasive ventilation. Thirteen patients (11.2%) required dialysis. Duration of hospital stay was 10.7 ± 9.7 days. Actual hospital mortality (24.1%) was less than predicted APACHE-II mortality (36%; 95% Confidence interval 32-41). APACHE-II score and duration of fever were independently associated with mortality on logistic regression analysis. Conclusions: In this cohort of severe scrub typhus infection with multi-organ dysfunction, survival was good despite high severity of illness scores. APACHE-II score and duration of fever independently predicted mortality.
Collapse
Affiliation(s)
- Mathew Griffith
- Department of Internal Medicine, University of Colorado, Colorada, USA
| | - John Victor Peter
- Department of Critical Care, Associate Professor, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Gunasekaran Karthik
- Department of Critical Care, Registrar, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Kartik Ramakrishna
- Department of Critical Care, Registrar, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | - Rajamanickam C Kalki
- Department of Critical Care, Registrar, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - George M Varghese
- Department of Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Anugragh Chrispal
- Department of Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Critical Care, Associate Professor, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Ramya Iyyadurai
- Department of Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | |
Collapse
|
39
|
Wei Y, Huang Y, Luo L, Xiao X, Liu L, Yang Z. Rapid increase of scrub typhus: an epidemiology and spatial-temporal cluster analysis in Guangzhou City, Southern China, 2006-2012. PLoS One 2014; 9:e101976. [PMID: 25006820 PMCID: PMC4090214 DOI: 10.1371/journal.pone.0101976] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 06/13/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Scrub typhus has been increasingly reported in Southern China, and public health authorities are concerned about its increased incidence. Additionally, little evidence is available on the epidemiology of scrub typhus in Southern China. This study aims to analyze the epidemiological and geographic features of ST in Guangzhou City, Southern China, to guide the future prevention efforts. METHODS Scrub typhus surveillance data in Guangzhou City during 2006-2012 were obtained from the Chinese National Communicable Disease Surveillance Network. We first conducted a descriptive analysis to analyze the epidemiological features of scrub typhus. Then we used space-time scan statistic based on a discrete Poisson model to detect and evaluate high-risk spatial-temporal clusters of scrub typhus. RESULTS There were 4,001 cases of scrub typhus in Guangzhou City during the study period. The incidence of scrub typhus increased from 3.29 per 100,000 in 2006 to 9.85 per 100,000 in 2012. A summer peak was observed in June and July with a second peak in September and October except year 2009 and 2011. The majority of the cases (71.4%) were among persons aged ≥40 years, and female incidence was higher than male incidence in persons ≥50 years. In the space-time analysis, high-risk clusters were concentrated in rural areas in Guangzhou City. Over the past 7 years, Haizhu District, an urban area, was found to be a high-risk cluster for the first time in 2012. CONCLUSION The resurgence of scrub typhus epidemics in Guangzhou population in 2012 necessitates more effective measures for minimizing future epidemics. Consideration of high-risk population and historical spatial-temporal clusters may help prevent scrub typhus. The risk of scrub typhus in urban areas should not be neglected and needs more attention from public health authorities.
Collapse
Affiliation(s)
- Yuehong Wei
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, China
| | - Yong Huang
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, China
| | - Lei Luo
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, China
| | - Xincai Xiao
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, China
| | - Lan Liu
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, China
| | - Zhicong Yang
- Guangzhou Center for Disease Control and Prevention, Guangdong Province, Guangzhou, China
- * E-mail:
| |
Collapse
|
40
|
Jang MO, Kim JE, Kim UJ, Ahn JH, Kang SJ, Jang HC, Jung SI, Park KH. Differences in the clinical presentation and the frequency of complications between elderly and non-elderly scrub typhus patients. Arch Gerontol Geriatr 2013; 58:196-200. [PMID: 24268946 DOI: 10.1016/j.archger.2013.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 10/25/2013] [Accepted: 10/26/2013] [Indexed: 01/18/2023]
Abstract
Age can affect the clinical features and severity of infectious disorders, such as scrub typhus. We performed this study to examine differences between elderly and non-elderly scrub typhus patients, and to identify risk factors predictive of disease outcomes. This retrospective study included patients admitted to a tertiary hospital with scrub typhus between 2001 and 2011. A total of 615 patients were enrolled in this study, 328 of which were >65 years of age. Of the elderly patients, 46.0% (151/328) experienced at least one complication compared to only 23.0% (66/287) in younger patients. A linear trend was observed between age and complication rates (p=0.002). The most common complication in elderly patients was acute kidney injury (75, 22.9%). Treatment failure was reported in 10 elderly patients (3.0%) compared to one non-elderly patient (0.3%). Mental confusion and dyspnea of clinical manifestations at admission were common in elderly patients. Frequency of fever, rash, and eschar were similar in both groups. The following four factors were significantly associated with severe scrub typhus in elderly patients: (1) white blood cell (WBC) counts>10,000/mm(3) (OR=2.569, CI=1.298-5.086), (2) MDRD GFR<60mL/min (OR=3.525, CI=1.864-6.667), (3) albumin≤3.0g/dL (OR=4.976, CI=2.664-9.294), and (4) acute physiology and chronic health evaluation II (APACHE II) score>10 points (OR=3.304, CI=1.793-60.87). Complications and mortality were more common in elderly patients, often associated with delays in diagnosis and treatment.
Collapse
Affiliation(s)
- Mi-Ok Jang
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Ji Eun Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Uh Jin Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Joon Hwan Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Seung-Ji Kang
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Hee-Chang Jang
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Sook-In Jung
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea.
| |
Collapse
|
41
|
Li T, Yang Z, Wang M. SCRUB TYPHUS RAPIDLY INCREASED IN GUANGZHOU, SOUTHERN CHINA, 20072012. Rev Inst Med Trop Sao Paulo 2013. [DOI: 10.1590/s0036-46652013000400015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
42
|
Kuo CC, Huang JL, Shu PY, Lee PL, Kelt DA, Wang HC. Cascading effect of economic globalization on human risks of scrub typhus and tick-borne rickettsial diseases. ECOLOGICAL APPLICATIONS : A PUBLICATION OF THE ECOLOGICAL SOCIETY OF AMERICA 2012; 22:1803-1816. [PMID: 23092017 DOI: 10.1890/12-0031.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The increase in global travel and trade has facilitated the dissemination of disease vectors. Globalization can also indirectly affect vector-borne diseases through the liberalization of cross-border trade, which has far-reaching, worldwide effects on agricultural practices and may in turn influence vectors through the modification of the ecological landscape. While the cascading effect of economic globalization on vector-borne diseases, sometimes acting synergistically with regional agricultural policy, could be substantial and have significant economic, agricultural, and public health implications, research into this remains very limited. We evaluated how abandonment of rice paddies in Taiwan after joining the World Trade Organization, along with periodic plowing, an agricultural policy to reduce farm pests in abandoned fields can unexpectedly influence risks to diseases transmitted by ticks and chiggers (larval trombiculid mites), which we collected from their small-mammal hosts. Sampling was limited to abandoned (fallow) and plowed fields due to the challenge of trapping small mammals in flooded rice paddies. Striped field mice (Apodemus agrarius) are the main hosts for both vectors. They harbored six times more ticks and three times more chiggers in fallow than in plowed plots. The proportion of ticks infected with Rickettsia spp. (etiologic agent of spotted fever) was three times higher in fallow plots, while that of Orientia tsutsugamushi (scrub typhus) in chiggers was similar in both treatments. Fallow plots had more ground cover and higher vegetation than plowed ones. Moreover, ticks and chiggers in both field types were dominated by species known to infest humans. Because ticks and chiggers should exhibit very low survival in flooded rice paddies, we propose that farm abandonment in Taiwan, driven by globalization, may have inadvertently led to increased risks of spotted fever and scrub typhus. However, periodic plowing can unintentionally mitigate vector burdens. Economic globalization can have unexpected consequences on disease risk through modification of the agricultural landscape, but the outcome may also be influenced by agricultural policies, calling for further research on vector-borne diseases and their control from broader perspectives.
Collapse
Affiliation(s)
- Chi-Chien Kuo
- Department of Wildlife, Fish, and Conservation Biology, University of California, One Shields Avenue, Davis, California 95616, USA
| | | | | | | | | | | |
Collapse
|
43
|
Cho BA, Ko Y, Kim YS, Kim S, Choi MS, Kim IS, Kim HR, Cho NH. Phenotypic characterization of peripheral T cells and their dynamics in scrub typhus patients. PLoS Negl Trop Dis 2012; 6:e1789. [PMID: 22905277 PMCID: PMC3419201 DOI: 10.1371/journal.pntd.0001789] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 07/10/2012] [Indexed: 11/26/2022] Open
Abstract
Background Scrub typhus, caused by Orientia tsutsugamushi infection, is one of the main causes of febrile illness in the Asia-Pacific region. Although cell-mediated immunity plays an important role in protection, little is known about the phenotypic changes and dynamics of leukocytes in scrub typhus patients. Methodology/Principal Findings To reveal the underlying mechanisms of immunological pathogenesis, we extensively analyzed peripheral blood leukocytes, especially T cells, during acute and convalescent phases of infection in human patients and compared with healthy volunteers. We observed neutrophilia and CD4+ T lymphopenia in the acute phase of infection, followed by proliferation of CD8+ T cells during the convalescent phase. Massive T cell apoptosis was detected in the acute phase and preferential increase of CD8+ T cells with activated phenotypes was observed in both acute and convalescent phases, which might be associated or correlated with elevated serum IL-7 and IL-15. Interestingly, peripheral Treg cells were significantly down-regulated throughout the disease course. Conclusions/Significance The remarkable decrease of CD4+ T cells, including Treg cells, during the acute phase of infection may contribute to the loss of immunological memory that are often observed in vaccine studies and recurrent human infection. Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi infection. It has been estimated that one billion people are at risk and one million new cases arise each year in Asian-pacific region. Despite of aggressive attempts to develop a prophylactic vaccine against scrub typhus during the last several decades, all approaches have failed to generate long lasting immunity. In addition, little is known about the immunological pathogenesis of scrub typhus. To understand the pathogenic mechanisms of this infectious disease, we extensively analyzed peripheral leukocytes, especially T cells, in Korean scrub typhus patients and compared with healthy volunteers. We observed neutrophilia and CD4+/T lymphopenia in the acute phase of infection, followed by proliferation of CD8+ T cells during the convalescent phase. Massive T cell apoptosis was detected in the acute phase and a preferential increase of CD8+ T cells with activated phenotypes was observed in both acute and convalescent phases. The remarkable decrease of CD4+ T cells, including Treg cells, during the acute phase of infection may contribute to the loss of immunological memory and generate helpless but unregulated cytotoxic T cell responses observed in vaccine studies and recurrent human infection.
Collapse
Affiliation(s)
- Bon-A Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anatomy, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Endemic Disease, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Youngho Ko
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon-Sook Kim
- Divisions of Infectious Diseases, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Sanguk Kim
- Department of Life Science and School of Interdisciplinary Bioscience and Bioengineering, Pohang University of Science and Technology, Pohang, Kyungbuk, Republic of Korea
| | - Myung-Sik Choi
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ik-Sang Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hang-Rae Kim
- Department of Anatomy, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail: (NHC); (HRK)
| | - Nam-Hyuk Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Endemic Disease, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Bundang Hospital, Seoul, Republic of Korea
- * E-mail: (NHC); (HRK)
| |
Collapse
|
44
|
Detection of antibodies against Orientia tsutsugamushi Sca proteins in scrub typhus patients and genetic variation of sca genes of different strains. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2012; 19:1442-51. [PMID: 22787193 DOI: 10.1128/cvi.00285-12] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Scrub typhus, caused by Orientia tsutsugamushi infection, is one of the main causes of acute febrile illness in the Asian-Pacific region. Although early diagnosis and immediate antibiotic treatment are critical for reducing disease severity and mortality, current diagnostic methods using serological and molecular approaches have some limitations in sensitivity and applicability in clinical laboratories. In this study, we identified and characterized O. tsutsugamushi surface cell antigen (sca) family genes encoding autotransporter proteins in order to test them as novel diagnostic targets. We evaluated antibody responses against the Sca proteins in scrub typhus patient sera and examined the genetic diversity of these genes in different strains after PCR amplification. Specific antibody responses against ScaA and ScaC were observed in patients with high indirect immunofluorescence assay titers (≥1:640), whereas specific responses against ScaB and ScaE were relatively low. Genetic analysis using genomic DNAs revealed the sca genes to be quite variable among the different strains. In contrast to scaA, scaC, and scaD, which were detected in all of the tested strains, scaB and scaE were amplified differentially from the different strains, suggesting a differential presence of the genes in the genomes. Among the members of the gene family, the sequence of scaC is the most highly conserved between the different strains, and the size of scaD is the most variable due to the presence of different numbers of internal repeat sequences. These results suggest that the sca genes of O. tsutsugamushi may be valuable targets for use in combination with classical assay methods for scrub typhus diagnosis.
Collapse
|
45
|
Scrub typhus: pathophysiology, clinical manifestations and prognosis. ASIAN PAC J TROP MED 2012; 5:261-4. [PMID: 22449515 DOI: 10.1016/s1995-7645(12)60036-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/27/2012] [Accepted: 03/15/2012] [Indexed: 01/10/2023] Open
Abstract
Scrub typhus is a zoonosis caused by the pathogen Orientia tsutsugamushi (O. tsutsugamushi). The disease has significant prevalence in eastern and Southeast Asia. Usually presenting as an acute febrile illness, the diagnosis is often missed because of similarities with other tropical febrile infections. Many unusual manifestations are present, and these are described in this review, together with an outline of current knowledge of pathophysiology. Awareness of these unusual clinical manifestations will help the clinician to arrive at an early diagnosis, resulting in early administration of appropriate antibiotics. Prognostic indicators for severe disease have not yet been clearly established.
Collapse
|
46
|
Park SW, Lee CS, Lee CK, Kwak YG, Moon C, Kim BN, Kim ES, Kang JM, Oh MD. Severity predictors in eschar-positive scrub typhus and role of serum osteopontin. Am J Trop Med Hyg 2011; 85:924-30. [PMID: 22049051 DOI: 10.4269/ajtmh.2011.11-0134] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We prospectively evaluated severity predictors in terms of host, microorganism, and treatment factors in 153 eschar-positive scrub typhus patients. Severity was assessed with the Acute Physiology and Chronic Health Evaluation (APACHE) II score (< 10 versus ≥ 10) and predefined criteria of severe complications. Genotypes of Orientia tsutsugamushi were determined. Independent risk factors for severity (APACHE II score ≥ 10) were old age, diabetes mellitus, serum osteopontin > 100 ng/mL, and a group of underlying diseases (congestive heart failure, cerebrovascular disease, chronic liver disease, bronchial asthma, and chronic obstructive lung diseases). Anemia (≤ 10 g/dL) and C-reactive protein > 10 mg/dL were indicators of current severity. Neither the delay in antibiotics administration nor strain types (Boryong, Taguchi, or Kanda/Kawasaki) contributed to the severity. The risk factors for severe complications were similar. Serum osteopontin > 100 ng/mL had a negative predictive value of 96% for severe complications. This marker can be used to rule out severe disease status.
Collapse
Affiliation(s)
- Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Kuo CC, Huang JL, Ko CY, Lee PF, Wang HC. Spatial analysis of scrub typhus infection and its association with environmental and socioeconomic factors in Taiwan. Acta Trop 2011; 120:52-8. [PMID: 21703220 DOI: 10.1016/j.actatropica.2011.05.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/09/2011] [Accepted: 05/29/2011] [Indexed: 12/01/2022]
Abstract
We analyzed the spatial distribution of human cases of scrub typhus on the main island of Taiwan from 2003 to 2008 and implemented an island-wide survey of scrub typhus vectors (trombiculid chiggers) in 2007 and 2008. The standardized incidence rate 'SIR' incorporating inter-district variations in population, gender and age was correlated with environmental and socioeconomic variables. Higher incidence and SIR rates were clustered in the less developed, mountainous regions of central and eastern Taiwan. Higher SIRs were also associated with a higher proportion of dry-field farmers in the population, a higher normalized difference vegetation index (NDVI) and lower mean annual temperature, but was not associated with rainfall. Small mammal hosts in high-SIR districts harbored more chiggers and had higher rates of seropositivity against Orientia tsutsugamushi Hyashi, the etiologic agent of scrub typhus, compared to low-SIR districts. The concurrence of a higher proportion of dry-field farmers and higher NDVI has likely led to the clustering of scrub typhus in the mountainous regions of Taiwan. Further individual-level study of the risk factors associated with scrub typhus, and a better understanding of the effect of environmental factors on chigger abundance, should help to prevent scrub typhus in Taiwan.
Collapse
Affiliation(s)
- Chi-Chien Kuo
- Research and Diagnostic Center, Centers for Disease Control, Department of Health, Taipei, Taiwan, ROC
| | | | | | | | | |
Collapse
|
48
|
An autotransporter protein from Orientia tsutsugamushi mediates adherence to nonphagocytic host cells. Infect Immun 2011; 79:1718-27. [PMID: 21282412 DOI: 10.1128/iai.01239-10] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Orientia tsutsugamushi, the causative agent of scrub typhus, is an obligate intracellular pathogen whose mechanism of cellular adhesion and invasion is poorly characterized. Bioinformatic analyses of two O. tsutsugamushi genomes revealed the presence of a group of genes that encode autotransporter proteins. In this study, we identified 10 autotransporter gene products and categorized them into five groups of orthologs (ScaA to ScaE) based on their sequence similarities. Sequence homology was highest between members of ScaC group, suggesting the functional conservation of bacterium-host interactions. ScaC was actively expressed on the surface of O. tsutsugamushi and induced antibody responses in scrub typhus patients. Experiments using microbeads conjugated to recombinant ScaC or a surrogate Escherichia coli expression system showed that ScaC was sufficient to mediate attachment to, but not invasion of, nonphagocytic mammalian cells. In addition, preincubation of host cells with recombinant ScaC significantly inhibited their interaction with O. tsutsugamushi. Finally, fibronectin was identified as a potential receptor for ScaC by using yeast two-hybrid screening, and this was confirmed using a glutathione S-transferase (GST) pulldown assay. Taken together, these results demonstrate that ScaC is involved in the interaction of O. tsutsugamushi with mammalian host cells and suggest that ScaC may play a critical role in bacterial pathogenesis.
Collapse
|
49
|
Kim S, Kim JS, Lee H. Epidemiological characteristics of scrub typhus in Korea, 2009. Osong Public Health Res Perspect 2010; 1:55-60. [PMID: 24159441 PMCID: PMC3766886 DOI: 10.1016/j.phrp.2010.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 10/12/2010] [Accepted: 10/22/2010] [Indexed: 11/10/2022] Open
Abstract
Objectives Currently, the incidence of scrub typhus has increased in urban areas. In this study, we described the epidemiological characteristics of scrub typhus cases reported in the urban areas of Korea in 2009. Methods We analysed the case investigation reports of scrub typhus cases that were collected in Korea in 2009. Specially, the different risk factors such as fieldwork and outdoor activity were compared to urban and rural areas, and six urban cities. Statistical analysis was performed using χ2 test. Results A total of 4,461 cases (including 1,663 suspected cases) were analysed in this study. Among these, the case reports of 4,254 cases had complete addresses. The cases with outdoor activities were 720 (85.2%) in urban areas. In Daegu and Daejeon, the number of cases participated in outdoor activities was 32 (34.4%) and 23 (31.5%), respectively. In other urban areas, cases with outdoor activities were more than 85%. Conclusion The most common infection risk factor was outdoor activity in urban areas. However, the proportion and distribution of outdoor activities were different in urban areas. These results will be used to establish strategies for effective prevention and management in urban areas.
Collapse
Affiliation(s)
- Sunja Kim
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Seoul, Korea
| | | | | |
Collapse
|
50
|
Park SW, Lee CK, Kwak YG, Moon C, Kim BN, Kim ES, Kang JM, Lee CS. Antigenic drift of Orientia tsutsugamushi in South Korea as identified by the sequence analysis of a 56-kDa protein-encoding gene. Am J Trop Med Hyg 2010; 83:930-5. [PMID: 20889895 DOI: 10.4269/ajtmh.2010.09-0791] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
This study was performed to determine the nationwide antigenic diversity of Orientia tsutsugamushi in South Korea. Sequence analysis was performed around variable domains I and II of a 56-kDa protein-encoding gene. We used eschar to overcome the disadvantages of conventional serotyping. The serological passive hemagglutination assay (PHA) was assessed based on the genotyping results. We analyzed 153 isolates from scrub typhus patients in major endemic areas and found that Boryong was the major strain (68.6%). New strains were also identified: Taguchi (19.6%), Kanda/Kawasaki (9.2%), and UAP7 (1.3%). PHA yielded significantly fewer positive results among Kawasaki strains (P < 0.001), which are not included in the PHA antigen panel. In South Korea, Boryong was still the predominant strain, but the sequence analysis identified new changes in minor strains (30.1%). This antigenic drift had a negative effect on the PHA results. Periodic surveillance of the contemporary strains using sequence analysis is needed.
Collapse
Affiliation(s)
- Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine and Boramae Medical Center, Seoul, Republic of Korea.
| | | | | | | | | | | | | | | |
Collapse
|