Rickettsia japonica infections in Huanggang, China, in 2021

Projecting the potential distribution of Rickettsia japonica in China and Asian adjacent regions under climate change using the Maxent model

Objective

To determine the current and future suitable areas of Rickettsia japonica, and to provide a reference for preventing its outbreak and spread.

Methods

Based on the geographic distribution of R. japonica and Haemaphysalis longicornis overlapping data points and information on 56 climatic factors, we utilized the Maxent model to estimate suitable areas for R. japonica in Asian adjacent Regions and China. Model parameter adjustments and the construction of receiver operating characteristic curves were conducted using R 4.3.0 software.

Results

Average precipitation in June (prec6, 28.2%), Temperature Seasonality (bio4, 9.8%) and the minimum temperature in August (tmin8, 9.2%) contributed most to the distribution of R. japonica. The performance metrics for the Maxent model in predicting the distribution of R. japonica are as follows: the Area Under the Curve (AUC) is 0.990, the True Skill Statistic (TSS) is 0.857, and the Kappa statistic is 0.763. Under current climatic conditions, the Asian and adjacent space medium and highly suitable areas for R. japonica are estimated to be 176.78 × 104 km2 and 95.13 × 104 km2, respectively. The highly suitable areas for R. japonica were mainly distributed in east and south Asia. In China, the high suitability areas are mainly distributed in the southeast coastal areas and the Qinling Mountains and Huai River cities. Under future climatic conditions, the Asian and adjacent regions maximum area change rate of R. japonica increased by 118.65%, and that of China increased by 50.42%. Meanwhile, the suitable areas of R. japonica gradually expanding northward in China.

Conclusion

Under global climate change, the suitable area of R. japonica is generally increasing, with a northward shift observed in China. Governments should strengthen monitoring, risk assessment, and response strategies in highly suitable regions, while also preventing the invasion of R. japonica from external source.

Japanese spotted fever in an area endemic to SFTS virus: Case report and review of the literature

RATIONALE

The geographic spread of Japanese spotted fever (JSF) in China is gradually expanding, particularly in regions where severe fever with thrombocytopenia syndrome (SFTS) is highly prevalent, with both diseases sharing similarities in epidemiology and clinical presentation. The microbiological diagnosis of JSF is challenging, compounded by low awareness among healthcare professionals in newly affected areas. Moreover, primary healthcare facilities without polymerase chain reaction (PCR) testing capabilities for SFTS often misdiagnose JSF as SFTS.

PATIENT CONCERNS

All 3 patients had a history of working in the fields, with cold like symptoms in the early fever stages, but the fever did not improve after a few days. The accompanying symptoms were also very different. Physical examination revealed enlarged lymph nodes, different forms of rash, with or without eschar. Laboratory tests showed thrombocytopenia, eosinophilia, elevated lactate dehydrogenase, and transaminase, with 1 patient experiencing renal damage. It is worth noting that these 3 patients reside in an area where SFTS is endemic, and there have been no prior reports of JSF. They exhibited clinical symptoms and laboratory test results closely resembling those of SFTS. Therefore, they were initially misdiagnosed with SFTS in their local hospitals.

DIAGNOSES

The 3 patients who arrived at our hospital 7 days after symptom onset and were subsequently diagnosed with JSF by metagenomic next-generation sequencing (mNGS).

INTERVENTIONS

Doxycycline treatment for 1 week.

OUTCOMES

The patients' symptoms quickly improved with no side effects, and the results of laboratory tests went back to normal.

LESSONS

By comparing the clinical characteristics of JSF patients and SFTS patients comprehensively, we found that APTT and procalcitonin levels may be valuable in assisting in the identification of SFTS and JSF. In all areas where tick-borne diseases are endemic, include SFTS-epidemic areas, we recommend using the Weil-Felix test to screen for potential rickettsiosis in patients presenting with fever and thrombocytopenia with or without rash in primary healthcare settings, as well as simultaneous testing for the SFTS virus and spotted fever group rickettsioses sequence. Additionally, mNGS sequencing should be used to confirm the diagnosis and provide information for epidemiological investigations in patients who are suspected of having spotted fever group rickettsiosis.

Development of an all-in-one real-time PCR assay for simultaneous detection of spotted fever group rickettsiae, severe fever with thrombocytopenia syndrome virus and hantaan virus prevalent in central China

Central China has been reported to be one of the most important endemic areas of zoonotic infection by spotted fever group rickettsiae (SFGR), severe fever with thrombocytopenia syndrome virus (SFTSV) and hantaan virus (HTNV). Due to similar clinical symptoms, it is challenging to make a definite diagnosis rapidly and accurately in the absence of microbiological tests. In the present study, an all-in-one real-time PCR assay was developed for the simultaneous detection of nucleic acids from SFGR, SFTSV and HTNV. Three linear standard curves for determining SFGR-ompA, SFTSV-L and HTNV-L were obtained within the range of 101-106 copies/μL, with the PCR amplification efficiencies ranging from 93.46% to 96.88% and the regression coefficients R2 of >0.99. The detection limit was 1.108 copies/μL for SFGR-ompA, 1.075 copies/μL for SFTSV-L and 1.006 copies/μL for HTNV-L, respectively. Both the within-run and within-laboratory coefficients of variation on the cycle threshold (Ct) values were within the range of 0.53%-2.15%. It was also found there was no statistical difference in the Ct values between single template and multiple templates (PSFGR-ompA = 0.186, PSFTSV-L = 0.612, PHTNV-L = 0.298). The sensitivity, specificity, positive and negative predictive value were all 100% for determining SFGR-ompA and SFTSV-L, 97%, 100%, 100% and 99.6% for HTNV-L, respectively. Therefore, the all-in-one real-time PCR assay appears to be a reliable, sensitive, rapid, high-throughput and low cost-effective method to diagnose the zoonotic infection by SFGR, SFTSV and HTNV.

Knowledge, attitudes, and practices (KAPs) regarding tick-borne rickettsial disease among medical staff in endemic areas of China

Tick-borne rickettsial disease (TBRD) is a perilous acute infection that often eludes diagnosis in its early stages. The triad of knowledge, attitudes, and practices (KAPs) among medical professionals is key to reducing missed diagnosis rates. Therefore, a meticulous evaluation of KAPs is imperative. This study aimed to delve into the understanding of TBRD and explore the beliefs and practices related to personal prevention methods among individuals in Lu'an, a hotspot for TBRD. During the summer months of 2023, convenience sampling was employed by circulating a confidential questionnaire to 1,206 participants in the endemic regions of China. This questionnaire painted a comprehensive picture of the participants' sociodemographic profiles and their KAPs levels vis-à-vis TBRD. The findings revealed that participants scored a mere 55.78% in knowledge, while their attitudes and practices garnered impressive scores of 90.09% and 90.83%, respectively. Upon further analysis using multiple linear regression, several intriguing patterns emerged. Male participants, employed in the Infectious Disease Department, held vice-senior or higher titles, or had prior medical training demonstrated superior knowledge scores. On the other hand, medical personnel who were younger than 30, possessed graduate degrees or higher qualifications, and had training excelled in attitudes and practices. Notably, when employing the Boston Consulting Group (BCG) matrix, a significant distribution of medical personnel was observed across the four quadrants. Specifically, 37.43%, 13.19%, 19.61%, and 29.77% fell into the first, second, third, and fourth quadrants. This survey underscores the commendable attitudes and practices of medical staff towards TBRD in endemic regions of China. However, their knowledge level remains wanting and demands urgent improvement.

Survey of Rickettsia species in hematophagous arthropods from endemic areas for Japanese spotted fever in China

Japanese spotted fever (JSF) is caused by Rickettsia japonica, mainly vectored by hard ticks. However, whether R. japonica can be transmitted by other arthropods remains unknown. Moreover, it is of interest to investigate whether other Rickettsia species cause spotted fever in endemic areas. In this study, a survey of Rickettsia species was performed in hematophagous arthropods (mosquitoes, tabanids, and ticks) from endemic areas for JSF in Hubei Province, central China. The results showed that the diversity and prevalence of Rickettsia species in mosquitoes are low, suggesting that mosquitoes may not be the vector of zoonotic Rickettsia species. A novel Rickettsia species showed a high prevalence (16.31%, 23/141) in tabanids and was named "Candidatus Rickettsia tabanidii." It is closely related to Rickettsia from fleas and mosquitoes; however, its pathogenicity in humans needs further investigation. Five Rickettsia species were identified in ticks. Rickettsia japonica, the agent of JSF, was detected only in Haemaphysalis longicornis and Haemaphysalis hystricis, suggesting that they may be the major vectors of R. japonica. Notably, two novel species were identified in H. hystricis ticks, one belonging to the spotted fever group and the other potentially belonging to the ancestral group. The latter one named "Candidatus Rickettsia hubeiensis" may provide valuable insight into the evolutionary history of Rickettsia.

A Case of Critical Japanese Spotted Fever in Zhejiang, China

Background

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

Case Presentation

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

Conclusion

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

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

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

Diversity of Rickettsiales bacteria in five species of ticks collected from Jinzhai County, Anhui Province, China in 2021-2022

The order Rickettsiales in the class Alphaproteobacteria comprises vector-borne pathogens of both medical and veterinary importance. Ticks, as a group, are second only to mosquitoes as vectors of pathogens to humans, playing a critical role in the transmission of rickettsiosis. In the present study, 880 ticks collected from Jinzhai County, Lu'an City, Anhui Province, China in 2021-2022 were identified as belonging to five species from three genera. DNA extracted from individual ticks was examined using nested polymerase chain reaction targeting the 16S rRNA gene (rrs), and the gene fragments amplified were sequenced to detect and identify Rickettsiales bacteria in the ticks. For further identification, the rrs-positive tick samples were further amplified by PCR targeting the gltA and groEL gene and sequenced. As a result, 13 Rickettsiales species belonging to the genera Rickettsia, Anaplasma, and Ehrlichia were detected, including three tentative species of Ehrlichia. Our results reveal the extensive diversity of Rickettsiales bacteria in ticks from Jinzhai County, Anhui Province. There, emerging rickettsial species may be pathogenic and cause under-recognized diseases. Detection of several pathogens in ticks that are closely related to human diseases may indicate a potential risk of infection in humans. Therefore, additional studies to assess the potential public health risks of the Rickettsiales pathogens identified in the present study are warranted.

Identification of Bacterial Communities and Tick-Borne Pathogens in Haemaphysalis spp. Collected from Shanghai, China

Ticks can carry and transmit a large number of pathogens, including bacteria, viruses and protozoa, posing a huge threat to human health and animal husbandry. Previous investigations have shown that the dominant species of ticks in Shanghai are Haemaphysalis flava and Haemaphysalis longicornis. However, no relevant investigations and research have been carried out in recent decades. Therefore, we investigated the bacterial communities and tick-borne pathogens (TBPs) in Haemaphysalis spp. from Shanghai, China. Ixodid ticks were collected from 18 sites in Shanghai, China, and identified using morphological and molecular methods. The V3-V4 hypervariable regions of the bacterial 16S rRNA gene were amplified from the pooled tick DNA samples and subject to metagenomic analysis. The microbial diversity in the tick samples was estimated using the alpha diversity that includes the observed species index and Shannon index. The Unifrac distance matrix as determined using the QIIME software was used for unweighted Unifrac Principal coordinates analysis (PCoA). Individual tick DNA samples were screened with genus-specific or group-specific nested polymerase chain reaction (PCR) for these TBPs and combined with a sequencing assay to confirm the results of the V3-V4 hypervariable regions of the bacterial 16S rRNA gene. We found H. flava and H. longicornis to be the dominant species of ticks in Shanghai in this study. Proteobacteria, Firmicutes, Bacteroidetes and Actinobacteria are the main bacterial communities of Haemaphysalis spp. The total species abundances of Proteobacteria, Firmicutes and Bacteroidetes, are 48.8%, 20.8% and 18.1%, respectively. At the level of genus analysis, H. longicornis and H. flava carried at least 946 genera of bacteria. The bacteria with high abundance include Lactobacillus, Coxiella, Rickettsia and Muribaculaceae. Additionally, Rickettsia rickettsii, Rickettsia japonica, Candidatus Rickettsia jingxinensis, Anaplasma bovis, Ehrlichia ewingii, Ehrlichia chaffeensis, Coxiella spp. and Coxiella-like endosymbiont were detected in Haemaphysalis spp. from Shanghai, China. This study is the first report of bacterial communities and the prevalence of some main pathogens in Haemaphysalis spp. from Shanghai, China, and may provide insights and evidence for bacterial communities and the prevalence of the main pathogen in ticks. This study also indicates that people and other animals in Shanghai, China, are exposed to several TBPs.

Detection and phylogenetic analysis of tick-borne bacterial and protozoan pathogens in a forest province of eastern China

Ticks, as obligate blood-sucking ectoparasites, feed on a broad range of vertebrates and transmit a great diversity of pathogenic microorganisms. Some tick-borne pathogens (TBPs) are endemic in China, whereas epidemiological studies are limited in Jiangxi, a forest province located in eastern China. Here, we have determined the positivity rates of TBPs in humans, rodents, dogs, goats and ticks, and performed the molecular characterization of TBPs in Jiangxi province. We found a high positivity rate of TBPs in the collected samples, demonstrating 23 (12.92%) samples positive for more than one TBPs. Of those, 11 (6.18%) samples were positive for Rickettsia spp., six (3.37%) Ehrlichia spp./Anaplasma spp., one (0.56%) Bartonella spp., two (1.12%) Borrelia spp., and five (2.81%) Babesia spp. The positivity rates of TBPs varied among ticks, animals, and humans as follow: goats (14/37, 37.84%), ticks (8/35, 22.86%), and dogs (1/11, 9.09%). Humans and rodents were negative for TBP presence. Phylogenetic analyses of these TBP sequences revealed the presence of Rickettsia japonica, Ehrlichia minasensis, and an unclassified Babesia spp. in goats, and Anaplasma phagocytophilum, Borrelia valaisiana, and an unclassified Bartonella spp. in ticks. Furthermore, R. japonica infection was exclusively found in goats with the positivity rate of 29.73%. Our study is the first report of R. japonica in goats around the world. These findings suggest high TBP positivity rates among goats, ticks, and dogs, and diverse TBPs in goats and ticks in the studied sites. Therefore, our results underscore the urgent need to assess TBP-tick-vertebrate-environment interactions and the risk of tick borne disease exposure in humans in the future.