Diagnosis of spotted fever group Rickettsia infections: the Asian perspective

Challenges in Diagnosing Rickettsial Infection: A Case Report of Rickettsia conorii in a Pediatric Patient in Iran

Mediterranean spotted fever has recently been reported in Iran, yet it continues to be overlooked by healthcare professionals in the country. This case report details a 19-month-old child who presented with fever, edema and skin rashes and was initially misdiagnosed. Subsequent testing revealed a Mediterranean spotted fever infection through IgG seroconversion. Treatment with doxycycline led to the child's full recovery. Rickettsial infections pose a significant public health challenge, particularly in endemic areas, making early intervention essential to avoid severe complications.

Diagnosis of Coxiella burnetii endocarditis by using nanopore targeted sequencing: a case report

BACKGROUND

Infective endocarditis (IE) can be caused by a variety of pathogens, including bacteria, fungi, and atypical pathogens. The diversity of IE manifestations contributes to diagnostic uncertainty, which can lead to missed diagnoses and inappropriate treatment. Diagnosing Coxiella burnetii endocarditis is particularly challenging, as routine blood cultures often yield negative results and echocardiography seldom reveals vegetations. In recent years, the rapid development of sequencing technology provides a new direction for the diagnosis of IE.

CASE PRESENTATION

The present study reports the case of a 57-year-old male patient who was admitted with a diagnosis of severe aortic stenosis. Cardiac computed tomography (CT) angiography revealed a diastolic aortic valve malformation with significant leaflet thickening, calcification and pseudoaneurysm formation, the etiology of which was considered to be due to infectious possibilities. Although clinical suspicion of infective endocarditis was raised, since echocardiogram did not reveal any vegetations and blood cultures were negative, the etiology remained unclear and empirical drug therapy was used. The patient exhibited a severe inflammatory reaction after aortic valve replacement. Samples were sent for pathogenic testing again, including blood cultures and blood nanopore targeted sequencing (NTS). The other tests were all negative, only the NTS detected C. burnetii. After further confirmation, the final diagnosis was C. burnetii infective endocarditis. The patient was subsequently discharged from the hospital after demonstrating improvement with targeted treatment. One month post-discharge, a follow-up examination indicated that he had recovered well.

CONCLUSION

This case study demonstrates the accurate diagnosis and treatment of C. burnetii endocarditis through NTS analysis of blood samples. As a novel technology, NTS may play an important role in the diagnosis of culture-negative infections caused by unidentified pathogens.

SFG and TG seropositivity in Humans suspected of TBD in Yucatan, Mexico

Since 1996, the incidence of rickettsiosis has been increasing in Yucatán, Mexico, but recent prevalence data are lacking. This study aimed to determine exposure to the Spotted Fever Group (SFG) and Typhus Group (TG) in human serum samples suspected of tick-borne diseases (TBD) between 2015 and 2022. A total of 620 samples were analysed using indirect immunofluorescence assay (IFA) to detect IgG antibodies against SFG (Rickettsia rickettsii) and TG (Rickettsia typhi), considering a titer of ≥64 as positive. Results showed that 103 samples (17%) were positive for R. rickettsii and 145 (24%) for R. typhi, while 256 (41%) and 229 (37%) were negative, respectively. There was a cross-reaction in 244 samples (39%). Individuals with contact with vectors, such as ticks, showed significant exposure to fleas (p = 0.0010). The study suggests a high prevalence of rickettsiosis and recommends prospective studies to assess the disease burden and strengthen surveillance and prevention in Yucatán, considering factors like temperature and ecological changes.

Spotted fever diagnosis using molecular methods

Rickettsiosis is a disease caused by bacteria belonging to the genus Rickettsia, and is a potentially fatal zoonotic disease of great medical and veterinary importance. Given the urgent need to develop new diagnostic methods for detecting this disease, the present review aimed to evaluate the number of publications dedicated to the identification of Rickettsia spp. in human samples using molecular methods, such as polymerase chain reaction and its variations. To this end, a bibliographical survey covering articles published in the past ten years was conducted using the PudMed platform with the keywords "spotted fever" and "Rickettsia," both combined with "diagnosis." A growing number of publications in this area reflects an increasing interest in research, especially since 2015. From 2015 to February 2024, several promising results were tested and many studies were able to detect the genetic sequences of interest. Therefore, the absence of a standard diagnosis method highlights the critical need for developing an effective technique capable of accurately detecting the etiological agent and ensuring accurate diagnosis of the disease.

Molecular identification of tick-borne Rickettsia, Anaplasma, Ehrlichia, Babesia, and Colpodella in confiscated Malayan pangolins

The traditional concept of "tonic food" and demand for traditional Chinese medicine make pangolins the largest population of illegally smuggled mammals in the world. Illegal hunting and trade are not only responsible for the sharp decline in pangolin populations but also provide conditions for pathogenic transmission. In 2021, we rescued 21 confiscated unhealthy Malayan pangolins, none of which survived. This study aimed to investigate the reasons for their unexpected deaths and the potential pathogens that may be transmitted during smuggling. Physical examination found that more than 80% pangolins were parasitized with A. javanense ticks. Autopsy and pathological staining analysis revealed multiple organ damage in the deceased pangolins. Pathogens nucleic acid detection of 33 tick samples showed that the positive rate of Rickettsia spp., Anaplasma spp., Ehrlichia spp. Babesia spp., and Colpodella spp. were 90.91%, 6.06%, 6.06%, 15.15% and 18.18%, respectively. Furthermore, pangolin samples were positive for Rickettsia spp. (42.86%, 9/21), Ehrlichia sp. (4.76%, 1/21), and Babesia sp. (4.76%, 1/21). This study confirmed that spotted fever triggered by Rickettsia spp. from A. javanense might accelerate the most death of confiscated pangolins, while Ehrlichia sp., and Babesia sp. infection potentially accelerating a few deaths. Of note, A. javanense ticks carrying Colpodella spp. were detected for the first time in Malayan pangolins. However, whether Colpodella spp. are pathogenic to pangolins is unknown. Further research on the diagnosis, treatment, surveillance, and elimination of ticks and tick-borne diseases in humans, livestock, and wildlife should provide insight into wildlife conservation and zoonotic disease prevention.

Aetiologies of bacterial tick-borne febrile illnesses in humans in Africa: diagnostic limitations and the need for improvement

Tick-borne febrile illnesses caused by pathogens like Anaplasma spp., Bartonella spp., Borrelia spp., Ehrlichia spp., Coxiella burnetii, Francisella tularensis, and Rickettsia spp., are significant health concerns in Africa. The epidemiological occurrence of these pathogens is closely linked to the habitats of their vectors, prevalent in rural and semi-urban areas where humans and livestock coexist. The overlapping clinical presentations, non-specific symptoms, and limited access to commercially available in vitro diagnostics in resource-limited settings exacerbate the complexity of accurate diagnoses. This review aimed to systematically extract and analyze existing literature on tick-borne febrile illnesses in Africa, highlighting the diagnostic challenges and presenting an up-to-date overview of the most relevant pathogens affecting human populations. A comprehensive literature search from January 1990 to June 2024 using databases like PubMed, Cochrane Library, Science Direct, EMBASE, and Google Scholar yielded 13,420 articles, of which 70 met the inclusion criteria. Anaplasma spp. were reported in Morocco, Egypt, and South Africa; Francisella spp. in Kenya and Ethiopia; Ehrlichia spp. in Cameroon; Bartonella spp. in Senegal, Namibia, South Africa, and Ethiopia; Borrelia spp. in Senegal, Gabon, Tanzania, and Ethiopia; Coxiella burnetii in 10 countries including Senegal, Mali, and South Africa; and Rickettsia spp. in 14 countries including Senegal, Algeria, and Uganda. Data were analyzed using a fixed-effect model in R version 4.0.1 and visualized on an African map using Tableau version 2022.2. This review highlights the urgent need for improved diagnostics to better manage and control tick-borne febrile illnesses in Africa.

The bacterial patterns suggesting the dynamic features of tick-associated microorganisms in hard ticks

BACKGROUND

Ticks are blood-feeding significant arthropods that can harbour various microorganisms, including pathogens that pose health risks to humans and animals. Tick-symbiont microorganisms are believed to influence tick development, but the intricate interactions between these microbes and the relationships between different tick-borne microorganisms remain largely unexplored.

RESULTS

Based on 111 tick pool samples presenting questing and engorged statuses including 752 questing tick and 1083 engorged tick from cattle and goats, which were collected in two types of geographic landscape (semi-desert and alpine meadow). We observed significant variations in the composition of tick-borne microorganisms across different environments and blood-engorgement statuses, with a pronounced divergence in symbionts compared to environmental bacteria. Metabolic predictions revealed over 90 differential pathways for tick-borne microorganisms in distinct environments and more than 80 metabolic variations in response to varying blood engorgement statuses. Interestingly, nine pathways were identified, particularly related to chorismate synthesis and carbohydrate metabolism. Moreover, microbial network relationships within tick-borne microorganism groups were highly distinct across different environments and blood-engorgement statuses. The microbial network relationships of symbionts involve some pathogenic and environmental microorganisms. Regression modelling highlighted positive correlations between the Coxiella symbiont and related pathogens, while some environmental bacteria showed strong negative correlations with Coxiella abundance. We also identified commensal bacteria/pathogens in bacterial cooccurrence patterns. Furthermore, we tested pathogenic microorganisms of each tick sample analysis revealed that 86.36% (1601/1855) of the tick samples carried one or more pathogenic microorganisms, The total carrier rate of bacterial pathogens was 43.77% ((812/1855). Most blood samples carried at least one pathogenic microorganism. The pathogens carried by the ticks have both genus and species diversity, and Rickettsia species are the most abundant pathogens among all pathogens.

CONCLUSION

Our findings underscore that the bacterial pattern of ticks is dynamic and unstable, which is influenced by the environment factors and tick developmental characteristics.

Epidemiology of Murine Typhus in Taiwan from 2013 to 2020

Murine typhus is a flea-borne disease caused by Rickettsia typhi infection. The disease is a notifiable infectious disease in Taiwan. Specimens from suspected cases are required to be sent to the Taiwan Centers for Disease Control and Prevention for laboratory diagnosis. In this study, 204 cases of murine typhus were identified by bacterial isolation, real-time polymerase chain reaction, or indirect immunofluorescence assay between 2013 and 2020. The average incidence rate was 0.11/100,000 person-years (95% CI: 0.08-0.13). Murine typhus occurred throughout the year, but it was most prevalent in summer (May to August). The majority of patients were males (75%), residents of Kaohsiung city (31%), and worked in agriculture, forestry, fishing, and animal husbandry (27%). Fever was the most common symptom, present in 95.6% of patients, followed by headache (41%), myalgia (33%), and liver dysfunction (33%). Only 13% of patients had a rash. Up to 80% of cases were among hospitalized patients, and 43% of patients developed severe manifestations. Serological assays also indicated coinfection events. Seven patients showed a 4-fold increase in antibody titers against Orientia tsutsugamushi (N = 2), Coxiella burnetii (n = 2), and Leptospira (N = 3). In conclusion, murine typhus is an endemic and important zoonotic rickettsial disease in Taiwan that cannot be ignored. Further epidemiological surveillance and clinical characteristics should be continuously investigated to prevent and control murine typhus.

Grazing system and Hyalomma marginatum tick infestation in cattle with high prevalence of SFG Rickettsia spp

Tick-borne diseases (TBDs) represent a significant portion of infectious diseases of global public health interest. In Italy, knowledge about the occurrence of tick-borne pathogens (TBPs) in ticks parasitizing cattle is scarce. In this research, we focused on ticks infesting Maremmana cattle grazing in open pasture and silvopasture systems. After being morphologically identified, ticks were molecularly tested for the presence of pathogens of the genus Rickettsia. Of the 794 ticks detected, 117 were collected, being the majority Hyalomma marginatum (72.6%), followed by other Hyalomma species (23%), Rhipicephalus turanicus (1.7%), Rh. bursa (0.9%), Hy. lusitanicum (0.9%) and Dermatocentor marginatus (0.9%). All ticks were adults, 58.1% males and 41.8% females. The highest tick prevalence was noted in April for silvopasture system cattle (90%), and in May for open pasture ones (85%). TBPs were detected only in Hy. marginatum, and all belong to Rickettsia spp. of zoonotic interest. In particular, 21/40 (52.5%) ticks scored positive for Rickettsia spp. by gltA gene and of these 15/21 (71.4%) also to spotted fever group (SFG) rickettsiae by ompA gene. Of the total positive specimens, 19 were successfully sequenced and scored Rickettsia aeschilimannii (17/19, 89.5%), R. slovaca (1/19, 5%), and R. massiliae (1/19, 5%). This research highlights the potential impact of grazing systems on cattle parasitization by hard ticks. The molecular investigation of TBPs in ticks collected from Maremmana cattle shed light on the presence of pathogenic bacteria of SFG Rickettsia spp., pointing out the potential risk of TBPs transmission between livestock and humans.

A molecular toolbox for fast and convenient diagnosis of emerging and reemerging bacterial pathogens causing fever of intermediate duration

PURPOSE

Fever of intermediate duration (FID) is defined as a fever in the community without a specific origin or focus, with a duration between 7 and 28 days. FID is often caused by pathogens associated with animal contact or their arthropods parasites, such as ticks, fleas, or lice. The purpose of this work is to design a collection of molecular tools to promptly and accurately detect common bacterial pathogens causing FID, including bacteria belonging to genera Rickettsia, Bartonella, Anaplasma, and Ehrlichia, as well as Coxiella burnetii.

METHODS

Reference DNA sequences from a collection of Rickettsia, Bartonella, Anaplasma, and Ehrlichia species were used to design genus-specific primers and FRET probes targeted to conserved genomic regions. For C. burnetii, primers previously described were used, in combination with a newly designed specific probe. Real-time PCR assays were optimized using reference bacterial genomic DNA in a background of human genomic DNA.

RESULTS

The four real-time PCR assays can detect as few as ten copies of target DNA from those five genera of FDI-causing bacteria in a background of 300 ng of human genomic DNA, mimicking the low microbial load generally found in patient's blood.

CONCLUSION

These assays constitute a fast and convenient "toolbox" that can be easily implemented in diagnostic laboratories to provide timely and accurate detection of bacterial pathogens that are typical etiological causes of febrile syndromes such as FID in humans.

Human spotted fever group Rickettsia seroprevalence and associated epidemiologic factors among diverse, marginalized populations in South Carolina

Illness caused by spotted fever group Rickettsia (SFGR) is increasing nationally, with affluent, white residents most likely to be diagnosed. The common under-representativeness of marginalized populations in research studies and these vulnerable populations' health inequities make veritable epidemiologic risk factor profiling challenging, which inhibits equitable public health intervention. The current study leveraged 749 banked sera and associated surveys from a cross-sectional minority-represented COVID-19 study to perform an SFGR seroprevalence investigation. SFGR titers (1:64, 1:128, 1:256, 1:512, and 1:1024) were measured using commercially available indirect fluorescent antibody slides-SFGR positive cases were defined as titers ≥1:128. Multivariable logistic regression and Getis-Ord-Gi* hotspot analyses were used to identify seropositivity-associated factors and determine seropositive clusters. Among a mostly minority and lower socioeconomic population, a 3.4 % SFGR seropositivity was noted at the ≥1:128 titer level. Male gender (Odds Ratio (OR): 3.20; adjusted Odds Ratio (aOR)s: 3.73), age (aOR: 1.05), any frequency of tick bite (OR: 2.29), and spending time working outdoors (OR: 5.05) were associated with SFGR IgG seropositivity. Moreover, the geospatial analysis showed clusters of seropositivity in areas where previous case reports occurred, suggesting potential endemic foci.

Prompt diagnosis and appropriate treatment of Japanese spotted fever: A report of three cases

Background

Japanese Spotted Fever (JSF) is a Spotted Fever Group (SFG) rickettsiosis caused by Rickettsia japonica. More than 300 cases are diagnosed annually in Japan, and the number of reported cases has been increasing. Correct diagnoses depend on the triad of symptoms and signs, including fever, rash, and eschar, which can be seen at the site of vector bites. JSF is not life-threatening if treated appropriately without diagnostic delay but there are some fatal cases every year. This negligence leads to disseminated intravascular coagulation (DIC) and multiple organ failure (MOF), and poor prognoses, consequently. Prompt diagnosis of JSF is difficult when the aforementioned triad of signs and symptoms is not initially present.

Case report

This report describes three JSF cases: an 87-year-old woman with fever, shock, pancytopenia, DIC, and MOF; a 79-year-old man with fever and difficulty in movement; and a 78-year-old man with fever, general fatigue, and appetite loss. All patients had a rash and eschar, which led to prompt diagnosis and appropriate treatment immediately. All patients were treated without any complications.

Why should an emergency physician be aware of this?

As mentioned above, JFS can be fatal with delayed diagnoses and treatment initiations. The key for a prompt diagnosis is to recognize the triad of symptoms and signs, which are not often present initially, and it makes JSF diagnosis challenging. Repeated comprehensive physical examinations are essential for prompt diagnosis and improve prognosis of JSF.

Molecular detection of Rickettsiales and a potential novel Ehrlichia species closely related to Ehrlichia chaffeensis in ticks (Acari: Ixodidae) from Shaanxi Province, China, in 2022 to 2023

Important tick-borne diseases include spotted fever group Rickettsia (SFGR), Anaplasma, and Ehrlichia, which cause harm to animal and human health. Ixodidae are the primary vectors of these pathogens. We aimed to analyze the prevalence and genetic diversity of SFGR, Anaplasma, and Ehrlichia species in the Ixodidae in Shaanxi Province, China. Herein, 1,113 adult Ixodidae ticks were collected from domestic cattle and goats, and detected using nested PCR. A total of four Ixodidae species were collected and Ca. R. jingxinensis (20.58%, 229/1113), A. bovis (3.05%, 34/1113), A. capra (3.32%, 37/1113), A. marginale (0.18%, 2/1113), E. sp. Yonaguni138 (0.18%, 2/1113), and a potent novel Ehrlichia species named E. sp. Baoji96 (0.09%, 1/1113) were detected. A. marginale was detected for the first time in Rhipicephalus microplus. E. sp. Baoji96 was closely related to E. chaffeensis and was first identified in Haemaphysalis longicornis. In addition, co-infection with two Rickettsiales pathogens within an individual tick was detected in 10 (1.54%) ticks. This study provides a reference for the formulation of biological control strategies for ticks and tick-borne diseases in Shaanxi Province, and could lead to an improved control effect.

Anaphylatoxin signaling activates macrophages to control intracellular Rickettsia proliferation

IMPORTANCE

Pathogenic Rickettsia species are extremely dangerous bacteria that grow within the cytoplasm of host mammalian cells. In most cases, these bacteria are able to overpower the host cell and grow within the protected environment of the cytoplasm. However, a dramatic conflict occurs when Rickettsia encounter innate immune cells; the bacteria can "win" by taking over the host, or the bacteria can "lose" if the host cell efficiently fights the infection. This manuscript examines how the immune complement system is able to detect the presence of Rickettsia and alert nearby cells. Byproducts of complement activation called anaphylatoxins are signals that "activate" innate immune cells to mount an aggressive defensive strategy. This study enhances our collective understanding of the innate immune reaction to intracellular bacteria and will contribute to future efforts at controlling these dangerous infections.

Complete genome sequencing and comparative genomic analyses of a new spotted-fever Rickettsia heilongjiangensis strain B8

Rickettsia heilongjiangensis, a tick-borne obligate intracellular bacterium and causative agent of spotted fever in China, has attracted increasing concern regarding its capability in causing human rickettsiosis. Here, we conducted a genomic analysis of a new R. heilongjiangensis strain B8 (B8) isolated from the serum of a patient who had been bitten by a Haemaphysalis longicornis tick in Anhui Province, China. The present study sought to identify exclusive genes that might be associated with the pathogenicity of B8 using comparative genomics. Specifically, the sequences of B8 were assembled into one circular chromosome of 1,275,081 bp and predicted to contain 1447 genes. Comparative genome analyses were performed based on the genome of B8 and 28 spotted fever group (SFG) rickettsial genomes deposited in NCBI. Phylogenomic analyses indicated the B8 strain was clustered within the R. heilongjiangensis species; however, a sum of 112 and 119 B8-unique genes was identified when compared with R. heilongjiangensis and R. japonica strains, respectively. Functional annotation analyses revealed that these B8-unique genes were mainly annotated to defence mechanisms, lipid transport and metabolism, cell wall/membrane/envelope biogenesis. These data indicate B8 rather represents a previously undescribed human-pathogenic SFG rickettsia lineage, which may be an intermediate lineage of R. heilongjiangensis and R. japonica. Overall, this study isolated a new strain of R. heilongjiangensis in East-Central China for the first time, and provided potential B8-unique genetic loci that could be used for the discrimination of B8 from other R. heilongjiangensis and closely related SFG Rickettsial strains.

Complicated Japanese Spotted Fever With Meningitis in an Older Patient: A Case Report

Japanese spotted fever (JSF) poses a significant public health challenge, mainly due to its atypical presentation in specific demographics. This report details a unique case of JSF in an 89-year-old female who was admitted to a rural hospital exhibiting generalized pain and rapid cognitive decline but no rash. Initially misdiagnosed as polymyalgia rheumatica, her condition was complicated by thrombocytopenia and altered mental state, prompting consideration of tick-borne illnesses. Subsequent serological analysis confirmed JSF despite the absence of its hallmark rash. The patient's condition escalated to include bacteremia and aseptic meningitis. Treatment involved a regimen of minocycline and meropenem, along with endoscopic cauterization of a bleeding rectal ulcer. After treatment, the patient showed improvement and was transferred for rehabilitation. This case highlights the criticality of considering JSF in elderly patients within endemic areas, even when classic symptoms like erythema and petechiae are absent. It underscores the necessity for broad diagnostic perspectives, especially in atypical presentations, and the integration of comprehensive care approaches. The involvement of caregivers and relatives in early detection and seeking medical care promptly is crucial. The report illustrates the complexities in diagnosing and managing advanced JSF cases and stresses the importance of early serological testing and adaptive treatment strategies in managing such challenging cases.

A seminested recombinase polymerase amplification assay to detect rickettsial pathogens in clinical samples

Treatment at the early stage of onset is vital for the prognosis of rickettsioses. But the absence of specific clinical symptoms complicates the diagnosis of this condition. Herein we established a seminested recombinase polymerase amplification assay (snRPA-nfo) that enables quick detection and differentiation of rickettsial pathogens in clinical samples with high sensitivity and specificity. The conserved 17-kDa protein gene of Rickettsia sibirica and the 47-kDa protein gene of Orientia tsutsugamushi were targeted for the duplex RPA-nfo assay. The snRPA-nfo assay exhibited an increased LOD in spiked blood samples, up to 1000-fold in comparison to standard RPA-nfo, and a better detection rate (83.3%, 5/6) than TaqMan PCR (16.6%, 1/6, Ct ≤ 35) in clinically confirmed patient blood samples. Thus, snRPA-nfo assay represents a promising alternative to TaqMan PCR in the early diagnosis of rickettsioses for point-of-care testing as well as in resource-limited settings.

Case report: A case of sepsis caused by rickettsial infection-induced hemophagocytic syndrome

Hemophagocytic lymphohistiocytosis (HLH) is a rare histiocytic disorder characterized by reactive hyperplasia of the mononuclear phagocytic system, which is primarily caused by dysfunction of cytotoxic killer cells and natural killer cells, leading to antigen clearance barriers and the overactivation of the mononuclear phagocytic system due to continuous antigen stimulation. HLH encompasses a group of clinical syndromes marked by the overproduction of inflammatory cytokines. A 68-year-old Chinese man presented with persistent fever, chills, nausea, and vomiting; the patient had no history of any underlying conditions. Laboratory investigations revealed decreased levels of red blood cells, white blood cells, and platelets, along with reduced natural killer cell activity, increased CD25, hyperferritinemia, and the detection of Rickettsia DNA in his blood, meeting the diagnostic criteria of the Histiocyte Society HLH-2004 guidelines. The patient was treated with antibiotics, improving anemia, glucocorticoid therapy, and continuous renal replacement therapy (CRRT), temporarily improving his condition. However, the patient died after 2 years from chronic renal failure caused by septic shock.

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

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

Prevalence of Anaplasma phagocytophilum, Borrelia burgdorferi sensu lato, Rickettsia spp. and Babesia spp. in cattle serum and questing ticks from Belgium

BACKGROUND

Anaplasmosis, borreliosis, rickettsiosis and babesiosis are tick-borne diseases of medical, veterinary and economic importance. In Belgium, little is known on the prevalence of these diseases in animals and previous screenings relate only to targeted geographic regions, clinical cases or a limited number of tested samples. We therefore performed the first nationwide seroprevalence study of Anaplasma spp., A. phagocytophilum, Borrelia spp., Rickettsia spp. and Babesia spp. in Belgian cattle. We also screened questing ticks for the aforementioned pathogens.

METHODS

ELISAs and IFATs were performed on a representative sample set of cattle sera stratified proportionally to the number of cattle herds per province. Questing ticks were collected in areas where the highest prevalence for the forenamed pathogens in cattle serum were observed. Ticks were analyzed by quantitative PCR for A. phagocytophilum (n = 783), B. burgdorferi sensu lato (n = 783) and Rickettsia spp. (n = 715) and by PCR for Babesia spp. (n = 358).

RESULTS

The ELISA screening for antibodies to Anaplasma spp. and Borrelia spp. in cattle sera showed an overall seroprevalence of 15.6% (53/339) and 12.9% (52/402), respectively. The IFAT screening for antibodies against A. phagocytophilum, Rickettsia spp. and Babesia spp. resulted in an overall seroprevalence of 34.2% (116/339), 31.2% (99/317) and 3.4% (14/412), respectively. At the provincial level, the provinces of Liege and Walloon Brabant harboured the highest seroprevalence of Anaplasma spp. (44.4% and 42.7% respectively) and A. phagocytophilum (55.6% and 71.4%). East Flanders and Luxembourg exhibited the highest seroprevalence of Borrelia spp. (32.4%) and Rickettsia spp. (54.8%) respectively. The province of Antwerp showed the highest seroprevalence of Babesia spp. (11%). The screening of field-collected ticks resulted in a prevalence of 13.8% for B. burgdorferi s.l., with B. afzelii and B. garinii being the most common genospecies (65.7% and 17.1%, respectively). Rickettsia spp. was detected in 7.1% of the tested ticks and the only identified species was R. helvetica. A low prevalence was found for A. phagocytophilum (0.5%) and no Babesia positive tick was detected.

CONCLUSIONS

The seroprevalence data in cattle indicate hot spots for tick-borne pathogens in specific provinces and highlights the importance of veterinary surveillance in anticipating the emergence of diseases among humans. The detection of all pathogens, with the exception of Babesia spp. in questing ticks, underlines the need of raising awareness among public and professionals on other tick-borne diseases along with lyme borreliosis.

Imported Rickettsial Infections to the United Kingdom, 2015-2020

OBJECTIVE

The burden of imported rickettsial infection in the UK is not previously described. This retrospective review identifies rickettsial cases diagnosed at the national reference laboratory between 2015-2022.

METHODS

Samples testing positive for spotted fever group, typhus group and scrub typhus IgG/IgM on acute and convalescent blood samples, and/or PCR on tissue/blood were categorised as suspected, confirmed or past infection.

RESULTS

220 patients had rickettsioses, the commonest import was acute spotted fever group infection (61%, 125/205), 54% (62/114) from South Africa. Acute typhus group cases, 60% (40/67) from Southeast Asia. One patient with Rickettsia typhi bacteremia died. Scrub typhus group infections (5%, 10/205) were exclusively from Asia and the Western Pacific regions. Overall, 43% of confirmed cases (39/91) had not received doxycycline prior to results.

CONCLUSIONS

Rickettsial infections are important and under-recognised causes of imported fever in the UK. Thorough history, examination and timely treatment with doxycycline should be considered if there is suspicion of Rickettsia infection before testing.

Diagnosis of Acute Q Fever in a Patient by Using Metagenomic Next-Generation Sequencing: A Case Report

Background

Q fever is a zoonotic disease caused by Coxiella burnetii infection, with domestic ruminants as the main source of infection and tick bites as one of the transmission vectors. The clinical manifestations of Q fever are varied and atypical. For the reason that C. burnetii is a strictly intracellular pathogen, it is difficult to be diagnosed by traditional culture methods. Additionally, serological and molecular diagnostic methods to assist in the diagnosis of Q fever are not routinely performed in most clinical laboratories. Therefore, early and rapid diagnosis of Q fever is a challenge.

Case Presentation

In the present study, a 34-year-old male patient presented with an acute onset and symptoms such as high fever, lethargy, pulmonary infection, and liver damage. In addition, he had a history of tick bites. Despite conducting relevant laboratory and radiological examinations, the etiology remained unknown. Subsequently, we detected the sequence reads of C. burnetii in a venous blood sample using metagenomic next-generation sequencing (mNGS), and the symptoms of patients were significantly improved after timely treatment with the special drug tetracycline. To our knowledge, this is the first report of Q fever associated with C. burnetii detected directly from venous blood sample in Wuhan, China.

Conclusion

Metagenomic next-generation sequencing is a new diagnostic technology that provides rapid and accurate detection of unexplained infections, including Q fever. Its application plays a crucial role in clinical diagnosis for identifying elusive pathogens.

The life cycle of Dermacentor nuttalli from the Qinghai-Tibetan Plateau under laboratory conditions and detection of spotted fever group Rickettsia spp

Dermacentor nuttalli has been a focus of study because tick-borne pathogens have been widely identified in this tick from northern and southwestern China. The aim of this study was to characterize the life cycle of D. nuttalli under laboratory conditions and to detect spotted fever group (SFG) Rickettsia in the midgut and salivary glands of both field-collected and first laboratory generation adults. D. nuttalli ticks were collected in the field on the Qinghai-Tibetan Plateau from March to April 2021 and their life cycle was studied under laboratory conditions. Tick identify was molecularly confirmed, and SFG Rickettsia were detected in the midgut and salivary glands of males and females by PCR targeting different rickettsial genes. The results showed that the life cycle of D. nuttalli under laboratory conditions was completed in an average of 86.1 days. High positivity of Rickettsia spp. was detected in the midgut and salivary glands of both males (92.0%) and females (93.0%) of field-collected D. nuttalli ticks. However, a relatively lower positivity (4.0-6.0%) was detected in first laboratory generation adults. Furthermore, sequencing analysis showed that the Rickettsia sequences obtained in this study shared 98.6 to 100% nucleotide identity with Rickettsia slovaca and Rickettsia raoultii isolated from Dermacentor spp. in China. Phylogenetic analysis of Rickettsia spp. based on the gltA, ompA, ompB and sca4 genes revealed that the Rickettsia sequences obtained could be classified as belonging to R. slovaca and R. raoultii clades. This study described for the first time the life cycle of D. nuttalli from the Qinghai-Tibetan Plateau under laboratory conditions. Two species of SFG Rickettsia were detected in the midgut and salivary glands of males and females in both field-collected and first laboratory-generation adults of D. nuttalli. Our study provides new insights into pathogen detection in ticks in the Qinghai-Tibet Plateau, and the relationships among hosts, ticks, and pathogens.

Pathogenicity and virulence of Rickettsia

Rickettsiae include diverse Gram-negative microbial species that exhibit obligatory intracellular lifecycles between mammalian hosts and arthropod vectors. Human infections with arthropod-borne Rickettsia continue to cause significant morbidity and mortality as recent environmental changes foster the proliferation of arthropod vectors and increased exposure to humans. However, the technical difficulties in working with Rickettsia have delayed our progress in understanding the molecular mechanisms involved in rickettsial pathogenesis and disease transmission. Recent advances in developing genetic tools for Rickettsia have enabled investigators to identify virulence genes, uncover molecular functions, and characterize host responses to rickettsial determinants. Therefore, continued efforts to determine virulence genes and their biological functions will help us understand the underlying mechanisms associated with arthropod-borne rickettsioses.

Ticks, Fleas, and Harboured Pathogens from Dogs and Cats in Cyprus

Ticks and fleas are blood-sucking ectoparasites that cause irritation and anaemia to their hosts and act as vectors of pathogens (vector-borne pathogens, VBPs) of relevance for animal and human health. In the present study, tick and flea species in dogs and cats from Cyprus were recorded and VBPs were detected in the collected specimens. Ectoparasites were collected from 220 animals (161 dogs and 59 cats), and a questionnaire including demographic, clinical, and other information was filled out for each animal. The ectoparasites were morphologically identified and the detection of VBPs was performed by PCR-coupled sequencing. Rhipicephalus sanguineus sensu lato was found on 108 dogs and 13 cats, and Ixodes gibbosus on 2 dogs. Ctenocephalides felis was the predominant flea species (on 62 dogs and 45 cats), while one dog and one cat were infested by Ctenocephalides canis and Echidnophaga gallinacea, respectively. The VBPs in ticks were Anaplasma platys, Rickettsia massiliae, Rickettsia conorii, Rickettsia felis, Hepatozoon felis and Hepatozoon canis, while Rickettsia felis, Rickettsia sp., Bartonella koehlerae, Bartonella clarridgeiae, and Bartonella henselae were recorded in fleas. Statistical analysis (chi-square test and multiple univariate generalized linear model) showed that animals up to 6 months of age were less likely to be infested with ticks than older animals, but more likely to be infested with fleas. Ticks were more prevalent in sheltered than in owned animals, while the odds ratio of flea presence was higher in owned animals than those living in shelters. The present study is the first investigation on the occurrence of ticks and fleas in dogs and cats from Cyprus, showing the presence of different VBPs in these important ectoparasites. The results point out the importance of systematic ectoparasite control in dogs and cats.

Biology, Systematics, Microbiome, Pathogen Transmission and Control of Chiggers (Acari: Trombiculidae, Leeuwenhoekiidae) with Emphasis on the United States

Chiggers are the larval stage of Trombiculidae and Leeuwenhoekiidae mites of medical and veterinary importance. Some species in the genus Leptotrombidium and Herpetacarus vector Orientia species, the bacteria that causes scrub typhus disease in humans. Scrub typhus is a life-threatening, febrile disease. Chigger bites can also cause dermatitis. There were 248 chigger species reported from the US from almost every state. However, there are large gaps in our knowledge of the life history of other stages of development. North American wide morphological keys are needed for better species identification, and molecular sequence data for identification are minimal and not clearly matched with morphological data. The role of chiggers in disease transmission in the US is especially understudied, and the role of endosymbionts in Orientia infection are suggested in the scientific literature but not confirmed. The most common chiggers in the eastern United States were identified as Eutrombicula alfreddugesi but were likely misidentified and should be replaced with Eutrombicula cinnabaris. Scrub typhus was originally believed to be limited to the Tsutsugamushi Triangle and the chigger genus, Leptotrombidium, but there is increasing evidence this is not the case. The potential of Orientia species establishing in the US is high. In addition, several other recognized pathogens to infect humans, namely Hantavirus, Bartonella, Borrelia, and Rickettsia, were also detected in chiggers. The role that chiggers play in these disease transmissions in the US needs further investigation. It is possible some of the tick-borne diseases and red meat allergies are caused by chiggers.

Antibody Prevalence and Risk Factors Associated with Rickettsia spp. in a Pediatric Cohort: SFGR Remains Underdiagnosed and Underreported in El Salvador

Spotted fever group rickettsioses (SFGR) are caused by a group of tick-borne pathogens that are increasing in incidence globally. These diseases are typically underreported and undiagnosed in low- and middle-income countries, and thus, have been classified as neglected bacterial pathogens. Countries with high poverty, low human development index score, and limited health infrastructure—like El Salvador in Central America—lack necessary surveillance for SFGR and other tick-borne pathogens. This paucity of baseline SFGR infection prevalence leaves vulnerable populations at risk of misdiagnosis. Further, tick-borne disease burdens in El Salvador are severely limited. To lay the foundation for tick-borne disease epidemiology in El Salvador, our team conducted two different enzyme-linked immunosorbent assays (ELISA) on banked human sera samples from a cohort of approximately 1000 pediatric participants from a high-risk vector-borne disease population. Eleven percent of all tested banked pediatric sera were positive for at least one ELISA assay at the time of enrollment: 10.7% were positive for only IgM antibodies (acute SFGR infection), and 2.5% were positive for IgG antibodies (a past SFGR infection). Older, male, children enrolled during the wet season, with a household history of infectious disease and higher maternal education level had higher odds of SFGR antibodies. Additionally, children from households with domestic poultry birds and previous knowledge of other vector-borne diseases had significantly reduced odds of SFGR antibodies. The large percentage of acute SFGR infections indicates that it continues to remain an underreported and undiagnosed issue in El Salvador and the Central American region. Much is still unknown regarding the complexity of the tick, animal host, and human host ecology transmission cycle of SFGR in El Salvador.

Mediterranean spotted fever-like illness caused by Rickettsia sibirica mongolitimonae, North Macedonia, June 2022

Mediterranean spotted fever-like illness (MSF-like illness) is a tick-borne disease caused by Rickettsia sibirica mongolitimonae first reported in France more than 25 years ago. Until today, more than 50 cases of MSF-like illness have been reported in different regions of Europe and Africa, highlighting variable clinical manifestation. Here we report a case of MSF-like illness following a bite from a Hyalomma tick in the Skopje region of North Macedonia.

Visual closed dumbbell-mediated isothermal amplification (CDA) for on-site detection of Rickettsia raoultii

Spotted fever group (SFG) rickettsioses are important zoonoses, threatening human health seriously and gradually attracting more attention in the world. SFG rickettsiae are classified as neglected pathogens. If these pathogens are detected at all, they are usually recognized very late in the infection through indirect detection of specific antibodies. Previous studies have shown that Rickettsia raoultii (R. raoultii), a member of the SFG rickettsiae, occurs with increasing incidence in remote countries. Therefore, a rapid detection method for R. raoultii is in urgently need. In this study, a R. raoultii diagnosis method by closed dumbbell-mediated isothermal amplification (R-CDA) assay targeting a conserved sequence of the outer membrane protein A (OmpA) gene with high sensitivity and specificity was developed. This assay offered a rapid and simple method for on-site detection of R. raoultii. Firstly, four pairs of R-CDA primers were designed and the optimum primer set was selected to amplify target gene specifically and effectively. Then, a pair of outer primer was designed to accelerate the reaction based on the inner primers to establish the RO-CDA reaction. In addition, the results of real-time amplification curves, melting curves and end-point colorimetric judgements showed that the established visual RO-CDA reaction could accurately detect R. raoultii without cross-reaction with other closely related pathogens. Furthermore, the detection limit of visual RO-CDA assay was 10 copies/μL, which was feasible for on-site detection with merits of easy-operation, rapidity, high sensitivity, and specificity. In conclusion, the developed RO-CDA detection method could be helpful for pathogen screening and epidemic prevention at the point of care.

Spotted fever group (SFG) rickettsioses are important neglected zoonoses throughout the world, with expanding known distribution, among which R. raoultii is an emerging member. As the clinical symptoms of R. raoultii is similar to other diseases, the accurate diagnosis of the pathogen based on the detection of genome plays a vital role in effective treatment and control at low infection levels. Due to the lack of on-site detection technology of Rickettsia raoultii in remote areas, the pathogen can only be treated in the late infection stage with specific clinical symptoms. Closed dumbbell-mediated isothermal amplification (CDA) is a method that rapidly amplifies nucleic acids under isothermal condition, which can help to resolve the problem of point of care detection for R. raoultii. The established R. raoultii detection approach based on CDA was feasible for on-site detection with merits of easy-operation, rapidity, high sensitivity, and specificity. At last, compared with PCR and LAMP, CDA method is simpler and more efficient to detect R. raoultii, which helps to improve the efficiency of detection and strengthen the prevention and control of this neglected but widely distributed disease.

Incidence of tick-borne spotted fever group Rickettsia species in rodents in two regions in Kazakhstan

Records on the distribution of Rickettsia spp. in their natural hosts in Central Asia are incomplete. Rodents and small mammals are potential natural reservoirs for Rickettsiae in their natural lifecycle. Studies about the maintenance of Rickettsia in wild animals are available for Western nations, but—to our knowledge—no studies and data are available in the Republic of Kazakhstan so far. The first case description of Rickettsioses in Kazakhstan was made in the 1950ies in the Almaty region and now Kyzylorda, East Kazakhstan, Pavlodar and North Kazakhstan are endemic areas. The existence of murine and endemic typhus was proven in arthropod vectors in the regions Kyzylorda and Almaty. Here we show for the first time investigations on tick-borne Rickettsia species detected by a pan-rickettsial citrate synthase gene (gltA) real-time PCR in ear lobes of small mammals (n = 624) in Kazakhstan. From all analysed small mammals 2.72% were positive for Rickettsia raoultii, R. slovaca or R. conorii. Sequencing of the rickettsial gene OmpAIV and the 23S–5S interspacer region revealed a similar heritage of identified Rickettsia species that was observed in ticks in previous studies from the region. In summary, this study proves that rodents in Kazakhstan serve as a natural reservoir of Rickettsia spp.

First detection and molecular identification of a pathogenic spotted fever group Rickettsia, R. massiliae, from Rhipicephalus haemaphysaloides ticks infesting dogs in southern Taiwan

Tick-borne Rickettsia pathogens become an emerging zoonotic infection worldwide. The prevalence and genetic identity of Rickettsia infection was determined firstly in Rhipicephalus haemaphysaloides ticks collected from dogs in southern Taiwan. A total of 141 Rh. haemaphysaloides ticks were examined for Rickettsia infection by nested-PCR assay targeting the citrate synthase (gltA) and outer membrane protein B (ompB) genes of Rickettsia. The Rickettsia infection was detected with a general infection rate of 2.84%, and was detected in male and female ticks with an infection rate of 3.13% and 2.60%, respectively. Genetic relationships were analyzed by comparing the gltA and ompB sequences obtained from 4 Taiwan strains and 15 other strains representing 13 genospecies of Rickettsia. Phylogenetic analyses reveal that all Taiwan strains were genetically affiliated with the R. massiliae (spotted fever group) and can be distinguished from other genospecies of Rickettsia. These results demonstrate the epidemiological significance of a human pathogenic Rickettsia species (R. massiliae) detected in Rh. haemaphysaloides ticks. Further study focused on the vector competence of this tick species may help to illustrate the potential threat for human infection in southern Taiwan.

Clinical Differentiation of Severe Fever with Thrombocytopenia Syndrome from Japanese Spotted Fever

Severe fever with thrombocytopenia syndrome (SFTS) and Japanese spotted fever (JSF; a spotted fever group rickettsiosis) are tick-borne zoonoses that are becoming a significant public health threat in Japan and East Asia. Strategies for treatment and infection control differ between the two; therefore, initial differential diagnosis is important. We aimed to compare the clinical characteristics of SFTS and JSF based on symptomology, physical examination, laboratory data, and radiography findings at admission. This retrospective study included patients with SFTS and JSF treated at five hospitals in Nagasaki Prefecture, western Japan, between 2013 and 2020. Data from 23 patients with SFTS and 38 patients with JSF were examined for differentiating factors and were divided by 7:3 into a training cohort and a validation cohort. Decision tree analysis revealed leukopenia (white blood cell [WBC] < 4000/μL) and altered mental status as the best differentiating factors (AUC 1.000) with 100% sensitivity and 100% specificity. Using only physical examination factors, absence of skin rash and altered mental status resulted in the best differentiating factors with AUC 0.871, 71.4% sensitivity, and 90.0% specificity. When treating patients with suspected tick-borne infection, WBC < 4000/µL, absence of skin rash, and altered mental status are very useful to differentiate SFTS from JSF.

Recent Advances in the Immunologic Method Applied to Tick-Borne Diseases in Brazil

Zoonotic-origin infectious diseases are one of the major concerns of human and veterinary health systems. Ticks, as vectors of several zoonotic diseases, are ranked second only to mosquitoes as vectors. Many ticks’ transmitted infections are still endemic in the Americas, Europe, and Africa and represent approximately 17% of their infectious diseases population. Although our scientific capacity to identify and diagnose diseases is increasing, it remains a challenge in the case of tick-borne conditions. For example, in 2017, 160 cases of the Brazilian Spotted Fever (BSF, a tick-borne illness) were confirmed, alarming the notifiable diseases information system. Conversely, Brazilian borreliosis and ehrlichiosis do not require notification. Still, an increasing number of cases in humans and dogs have been reported in southeast and northeastern Brazil. Immunological methods applied to human and dog tick-borne diseases (TBD) show low sensitivity and specificity, cross-reactions, and false IgM positivity. Thus, the diagnosis and management of TBD are hampered by the personal tools and indirect markers used. Therefore, specific and rapid methods urgently need to be developed to diagnose the various types of tick-borne bacterial diseases. This review presents a brief historical perspective on the evolution of serological assays and recent advances in diagnostic tests for TBD (ehrlichiosis, BSF, and borreliosis) in humans and dogs, mainly applied in Brazil. Additionally, this review covers the emerging technologies available in diagnosing TBD, including biosensors, and discusses their potential for future use as gold standards in diagnosing these diseases.

Diagnostic Value of IgA Antibody Measurement in Tick-Borne Spotted Fever (Astrakhan Rickettsial Fever)

Tick-borne spotted fevers caused by Rickettsia occur worldwide. The symptoms of this bacterial infection are similar to those of viral infection, and thus, diagnostic accuracy has special clinical importance. One of the commonly used methods for the diagnosis of tick-borne spotted fever is enzyme-linked immunosorbent assay (ELISA), which is based on estimation of the presence of specific IgM antibodies in blood. However, IgA analysis has not been used for the diagnosis of rickettsial diseases thus far. We investigated the diagnostic value of IgA antibody determination using patient sera collected in the Astrakhan region of Russia, where an isolated site of Astrakhan rickettsial fever (ARF) caused by Rickettsia conorii subsp. caspia is located. Our investigation was performed on serum samples collected from 185 patients diagnosed with Astrakhan rickettsial fever from May to October 2019. Western blot analysis revealed that specific IgA antibodies, as well as IgM antibodies, from patient sera bind to high-molecular-weight pathogen proteins with similar masses. The obtained data show that the determination of IgM alone allows for serological confirmation of diagnosis in only 46.5% of cases but that the determination of both IgM and IgA increases this rate to 66.5%. Taken together, the findings show an important diagnostic value of IgA evaluation for tick-borne spotted fever rickettsiosis. IMPORTANCE Tick-borne spotted fevers caused by Rickettsia occur worldwide. The symptoms of this bacterial infection are similar to the symptoms of viral infection, and thus, diagnostic accuracy has special clinical importance. The most serious spotted fever group rickettsiosis is Rocky Mountain fever in the United States, which is caused by Rickettsia rickettsii, and disease complications can lead to hemiparesis, blindness, or amputation. Rickettsia conorii subsp. caspia causes a rickettsial spotted fever named Astrakhan rickettsial fever (ARF). One of the commonly used methods for the diagnosis of tick-borne spotted fevers is ELISA, which is based on estimation of the presence of specific IgM antibodies in blood, though IgA has not been used for the diagnosis of rickettsial diseases thus far. In this study, we showed that both IgA and IgM should be analyzed in the blood serum samples of patients to significantly enhance the accuracy of diagnostics of tick-borne spotted fever rickettsiosis.

Case Report: Diagnosis of Acute Q Fever With Aseptic Meningitis in a Patient by Using Metagenomic Next-Generation Sequencing

Query fever (Q fever) is a widespread zoonotic disease caused by the bacterium of Coxiella burnetii (C. burnetii). Its neurological complications are rarely reported. But they may lead to severe consequences. It needs a rapid and accurate detective method to diagnose acute Q fever with neurological presentations in non-epidemic areas urgently. Here, we report an acute Q fever case with aseptic meningitis. The male patient, without any contact history in the epidemic area or with animals, was indicated to exhibit fever and headache symptoms. The cultures of blood, stool, urine, and sputum were all negative. But C. burnetii was repeatedly detected in blood by metagenomic next-generation sequencing (mNGS). He received Doxycycline therapy and quickly returned to normal. Therefore, for the diagnosis and identification of Q fever in non-reporting regions, mNGS has comparative advantages. Secondly, aseptic meningitis may be a direct infection of C. burnetii to central nervous system (CNS) or inflammatory reactions to systemic infection, we recommend detecting mNGS both in blood and cerebrospinal fluid (CSF).

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

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

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

Human infections with neglected vector-borne pathogens in China: A systematic review

Background

Emerging vector-borne pathogens (VBPs) pose a continuous background threat to the global health. Knowledge of the occurrence, distributions and epidemiological characteristics of VBP are lacking in many countries. Outbreaks of novel VBP are of increasing global interest including those arising in China.

Methods

A systematic review of published literature was undertaken to characterize the spectrum of VBPs causing human illness in China. We searched five databases for VBP-related articles in English and Chinese published between January 1980 and June 2021, that excluded those listed in the National Notifiable Diseases Surveillance System of China. The study is registered with PROSPERO, CRD42021259540.

Findings

A total of 906 articles meeting the selection criteria were included in this study. A total of 44,809 human infections with 82 species of VBPs including 40 viruses, 33 bacteria (20 Rickettsiales bacteria, eight Spirochaetales bacteria, and five other bacteria) and nine parasites, were identified in China. Rickettsiales bacteria were the most common and widely distributed pathogens with 18,042 cases reported in 33 provinces by 347 reviewed articles, followed by Spirochaetales bacteria with 15,745 cases in 32 provinces (299 articles), viruses with 8455 cases in 30 provinces (139 articles), other bacteria with 2053 cases in 19 provinces (65 articles), parasites with 514 cases in 17 provinces (44 articles), and multiple pathogens with 3626 cases in 14 provinces (23 articles). Coxiella burnetii, Bartonella henselae and Rickettsia sibirica were the most frequently reported pathogens. A total of 18 new pathogens were reported in China during this period (these also represented their first identification globally). Based on 419 articles with clinical information, a meta-analysis revealed that flu-like illness was the most common manifestation among infections with VBPs.

Interpretation

This review helps improve the understanding of VBPs in China, demonstrating the need to consider a wider surveillance of VBPs in many different settings, thus helping to inform future research and surveillance efforts.

Funding

Natural Science Foundation of China.

Discovering disease-causing pathogens in resource-scarce Southeast Asia using a global metagenomic pathogen monitoring system

SignificanceMetagenomic pathogen sequencing offers an unbiased approach to characterizing febrile illness. In resource-scarce settings with high biodiversity, it is critical to identify disease-causing pathogens in order to understand burden and to prioritize efforts for control. Here, metagenomic next-generation sequencing (mNGS) characterization of the pathogen landscape in Cambodia revealed diverse vector-borne and zoonotic pathogens irrespective of age and gender as risk factors. Identification of key pathogens led to changes in national program surveillance. This study is a "real world" example of the use of mNGS surveillance of febrile individuals, executed in-country, to identify outbreaks of vector-borne, zoonotic, and other emerging pathogens in a resource-scarce setting.

Spotted fever group Rickettsia, Anaplasma and Coxiella-like endosymbiont in Haemaphysalis ticks from mammals in Thailand

Ticks are ectoparasites of vertebrates and vectors of various pathogenic microorganisms. In this study, the presence of bacteria and protozoa was evaluated by PCR and DNA sequencing in 233 mammal ticks collected from 8 provinces in Thailand. Sequence and phylogenetic analyses of partial rickettsial ompA, ompB, sca4 and partial Coxiella 16S rRNA, GroEL, rpoB genes clearly revealed, for the first time, a co-infection of SFG Rickettsia belonging to R. massiliae subgroup and Coxiella-like endosymbiont (CLE), Cox-hein, in a male of Haemaphysalis heinrichi tick infesting Burmese ferret-badger in Loei province. Moreover, a male of H. hystricis tick infesting the same host was infected with another CLE, Cox-hys. Based on the 16S rRNA gene sequence, Anaplasma sp., closely related to Anaplasma bovis was also detected in a male of H. heinrichi infesting the same Burmese ferret-badger. In addition, the third CLE, Cox-asia, found in H. asiatica collected from Asian palm civet in Chiang Rai province, was different from both Cox-hein and Cox-hys. This study provided important data and broadened our knowledge on tick-borne pathogens and endosymbionts in Thailand and Southeast Asia.

Occurrence of tick-borne pathogens in dogs in a coastal region of the state of Ceará, northeastern Brazil

The aim of this study was to determine the occurrence of tick-borne pathogens (Ehrlichia canis, Babesia vogeli, Hepatozoon spp. and Rickettsia spp.) in dogs in Vila de Jericoacoara, coastal region of Ceará, Brazil. Blood samples were collected from 153 animals and analyzed using molecular and serological methods. Sixty animals were found to be infected or exposed to at least one of the pathogens studied. Babesia vogeli was the most prevalent pathogen (15%), followed by E. canis (13.7%) and Hepatozoon spp. (11.8%), which was identified as Hepatozoon canis through sequencing. Twenty dogs (13%) were seroreactive to Rickettsia spp. Rhipicephalus sanguineus sensu lato was observed on 11.8% of the animals. There were associations between age (< 3 years old) and positivity for B. vogeli, and between habitation (stray dogs) and positivity for H. canis. There were also associations between anemia and infection with H. canis, and between leukopenia and exposure to Rickettsia spp. No association was detected between clinical alterations and infection with or exposure to the pathogens studied. The results confirmed that pathogens of veterinary importance are circulating in northeastern Brazil and showed that dogs are exposed to Rickettsia species with zoonotic potential, thus indicating a need for vector control measures.

First detection and genetic identification of Rickettsia infection in Rhipicephalus sanguineus (Acari: Ixodidae) ticks collected from Southern Taiwan

The prevalence and genetic identity of Rickettsia infection in Rhipicephalus sanguineus sensu lato (s.l.) ticks were determined in Taiwan. In total 1153 ticks were examined for Rickettsia infection by PCR assay targeting the citrate synthase gene (gltA) of Rickettsia. The prevalence of Rickettsia infection in R. sanguineus s.l. ticks with a general infection rate of 2.2%, and was detected in nymph, male and female stages of R. sanguineus s.l. ticks with an infection rate of 3.1, 2.0 and 1.1%, respectively. Phylogenetic relationships were analyzed by comparing the gltA sequences obtained from four Taiwan strains and 16 other strains representing 13 genospecies of Rickettsia. Phylogenetic analyses reveal that one Taiwan strain was genetically affiliated with the Japan isolate (GRA-1 strain) which belongs to the spotted fever group (R. parkeri/R. honei) and three Taiwan strains were genetically affiliated with the transitional group of Rickettsia (R. felis). Intra- and inter-species analysis also indicated the genetic distance (GD) of the Taiwan strains with a lower level of GD < 0.011, 0.023 and 0.003 as compared with the type strains of R. parkeri, R. honei and R. felis, respectively. Our findings reveal the first detection of Rickettsia infections (R. parkeri/R. honei and R. felis) in R. sanguineus s.l. ticks of Taiwan. These results also highlight the epidemiological significance of diverse Rickettsia species existed in R. sanguineus s.l. ticks and the potential threat for the geographical transmission of Rickettsia infection in Taiwan.

Molecular Evidence for Flea-Borne Rickettsiosis in Febrile Patients from Madagascar

Rickettsiae may cause febrile infections in humans in tropical and subtropical regions. From Madagascar, no molecular data on the role of rickettsioses in febrile patients are available. Blood samples from patients presenting with fever in the area of the capital Antananarivo were screened for the presence of rickettsial DNA. EDTA (ethylenediaminetetraacetic acid) blood from 1020 patients presenting with pyrexia > 38.5 °C was analyzed by gltA-specific qPCR. Positive samples were confirmed by ompB-specific qPCR. From confirmed samples, the gltA amplicons were sequenced and subjected to phylogenetic analysis. From five gltA-reactive samples, two were confirmed by ompB-specific qPCR. The gltA sequence in the sample taken from a 38-year-old female showed 100% homology with R. typhi. The other sample taken from a 1.5-year-old infant was 100% homologous to R. felis. Tick-borne rickettsiae were not identified. The overall rate of febrile patients with molecular evidence for a rickettsial infection from the Madagascan study site was 0.2% (2/1020 patients). Flea-borne rickettsiosis is a rare but neglected cause of infection in Madagascar. Accurate diagnosis may prompt adequate antimicrobial treatment.

Frequency of antibodies and seroconversion against Rickettsia spp in patients consulting health institutions in the department of Caldas, Colombia, 2016-2019

Introduction: Rickettsioses are zoonotic diseases transmitted by arthropods acting as vectors and reservoirs. Disease symptoms are nonspecific and, therefore, their clinical diagnosis is difficult. Indirect immunofluorescence (IFA) is the gold standard assay for diagnosis. The interest for conducting studies on these pathologies has resurfaced in Colombia since 2001; besides, previous studies have evidenced cases of rickettsiosis in the north of the department of Caldas. Objective: To establish the frequency of antibodies and seroconversion against Rickettsia spp. In patients consulting health institutions in Caldas, Colombia, from 2016 to 2019. Materials and methods: We conducted a quantitative, observational, and descriptive study on a non-probabilistic sample of 175 patients with symptoms compatible with rickettsiosis who consulted in different municipalities of Caldas, Colombia; IFA was performed to detect antibodies in the acute and convalescent phases against Rickettsia rickettsii, Rickettsia typhi, and Rickettsia felis. Results: The average age of the patients was 31 years. The municipalities with the highest proportion of seropositive cases were Belalcázar, Chinchiná, Filadelfia, La Dorada, La Merced, and Manizales; 66% of patients owned pets and 12% reported arthropod bites. The most frequent signs and symptoms were headache (69.7%), arthromyalgia (60%), and fever (58.2%). IgG seroprevalence was 60% for R. rickettsii, 47.9% for R. typhi, and, and 24% for R. felis. Eight patients presented seroconversion. Conclusion: We found evidence of the circulation of Rickettsia species from the spotted fever group and the typhus group associated with human cases in Caldas.

An Update on the Laboratory Diagnosis of Rickettsia spp. Infection

Rickettsia species causing human illness are present globally and can cause significant disease. Diagnosis and identification of this intracellular bacteria are challenging with many available diagnostic modalities suffering from several shortcomings. Detection of antibodies directed against Rickettsia spp. via serological methods remains widely used with a broad range of sensitivity and specificity values reported depending on the assay. Molecular methods, including polymerase chain reaction (PCR) testing, enables species-specific identification with a fast turnaround time; however, due to resource requirements, use in some endemic settings is limited. Reports on the use of next-generation sequencing (NGS) and metagenomics to diagnose Rickettsia spp. infection have been increasing. Despite offering several potential advantages in the diagnosis and surveillance of disease, genomic approaches are currently only limited to reference and research laboratories. Continued development of Rickettsia spp. diagnostics is required to improve disease detection and epidemiological surveillance, and to better understand transmission dynamics.

A case of tick-transmitted Q fever in Lishui, China diagnosed by next-generation sequencing

Q fever is a zoonotic disease caused by Coxiella burnetii. Most patients have non-specific symptoms at onset. In addition, routine diagnostic tests for C. burnetii are not sensitive, and the bacterium cannot grow in general culture medium. The diagnosis of Q fever therefore poses a challenge. This case study describes a man with a clear history of tick bite who had recurrent fever, pneumonia, and liver damage. Routine tests and bacterial cultures failed to clarify the pathogeny, but laboratory and imaging data suggested infection. After routine tests were exhausted, we detected the presence of C. burnetii in a whole blood sample using next-generation sequencing (NGS). To our knowledge, this is the first report of Q fever associated with Coxiella burnetii detected directly from blood samples in Lishui, China. NGS has revolutionized the diagnosis of infectious diseases, especially those caused by rare or newly discovered pathogens, and patient responses have finally proved its substantial benefits. NGS has important clinical significance for the early diagnosis of chronic Q fever. This proof-of-concept study is worthy of promotion in clinical practice.

Mediterranean Spotted Fever: Current Knowledge and Recent Advances

Mediterranean spotted fever (MSF) is an emerging tick-borne rickettsiosis of the spotted fever group (SFG), endemic in the Mediterranean basin. By virtue of technological innovations in molecular genetics, it has been determined that the causative agent of MSF is Rickettsia conorii subspecies conorii. The arthropod vector of this bacterium is the brown dog tick Rhipicephalus sanguineus. The true nature of the reservoir of R. conorii conorii has not been completely deciphered yet, although many authors theorize that the canine population, other mammals, and the ticks themselves could potentially contribute as reservoirs. Typical symptoms of MSF include fever, maculopapular rash, and a characteristic eschar ("tache noire"). Atypical clinical features and severe multi-organ complications may also be present. All of these manifestations arise from the disseminated infection of the endothelium by R. conorii conorii. Several methods exist for the diagnosis of MSF. Serological tests are widely used and molecular techniques have become increasingly available. Doxycycline remains the treatment of choice, while preventive measures are focused on modification of human behavior and vector control strategies. The purpose of this review is to summarize the current knowledge on the epidemiology, pathogenesis, clinical features, diagnosis, and treatment of MSF.

First Molecular Evidence of Pathogens in Fleas Collected from Dogs in Northern Vietnam

Fleas are considered as hosts for a wide range of pathogens that cause emerging and re-emerging zoonotic diseases worldwide. Data on fleas and flea-borne pathogens (FBPs) in the international literature are limited in Vietnam. This study aimed to investigate the species of fleas and the presence of pathogens of interest in fleas in northern Vietnam using PCR and sequence analysis. Out of 200 dogs enrolled in this study, 20% were infested by the flea species Ctenocephalides felis felis. In total, 62 fleas (35 females and 27 males) collected from domestic dogs were molecularly screened for the detection of pathogens. Out of the screened fleas, 39 were positive for Rickettsia felis (62.9%), 9 for Candidatus Mycoplasma hemobos (14.52%), and 6 for Mycoplasma wenyonii (9.68%). This study shows the first molecular detection of the above-mentioned pathogens in fleas collected from the studied areas and the potential risk of infection with examined FBPs in northern Vietnam.

Spotted fever diagnosis: Experience from a South Indian center

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

Seroprevalence of Spotted Fever Group Rickettsiae in extensively managed sheep and goats in Nigeria, West Africa

Sheep and goats raised extensively are frequently infested by Ixodid ticks that may act as vectors or reservoirs of Spotted Fever Group Rickettsiae (SFGR). A study to determine the seroprevalence of SFGR infection in 300 sheep and goats in Plateau State, Nigeria was conducted from September to November, 2018 using the Indirect Fluorescence Antibody Test (IFAT). Overall, 85 out of 300 animals (28.3%) were seropositive to SFGR. Relatively higher seroprevalence was recorded in sheep than goats (28.8% vs 28.0%) but the difference was not statistically significant (p > 0.05). Furthermore, seropositivity was not affected by age, sex or location of the animals screened in this study. This is the first serological study to report the prevalence of SFGR in sheep and goats using IFAT in this study area. The presence of SFGR antibodies in domestic ruminants is of public health concern considering the close association between farmers and their animals occasioned by the management system practiced in the study area. This finding calls for further studies to evaluate the level of human exposure to this group of pathogen.