A case of tick-transmitted lymphadenopathy in Bulgaria associated with Rickettsia slovaca

History and Current Status of Mediterranean Spotted Fever (MSF) in the Crimean Peninsula and Neighboring Regions along the Black Sea Coast

Mediterranean spotted fever (MSF) is a tick-borne rickettsiosis caused by Rickettsia conorii subspecies conorii and transmitted to humans by Rhipicephalus sanguineus ticks. The disease was first discovered in Tunisia in 1910 and was subsequently reported from other Mediterranean countries. The first cases of MSF in the former Soviet Union were detected in 1936 on the Crimean Peninsula. This review summarizes the historic information and main features of MSF in that region and contemporary surveillance and control efforts for this rickettsiosis. Current data pertinent to the epidemiology of the disease, circulation of the ticks and distribution of animal hosts are discussed and compared for each of the countries in the Black Sea basin where MSF occurs.

Emerging tick-borne spotted fever group rickettsioses in the Balkans

The impact of tick-borne pathogens (TBPs) on human health has increased in the last decades, since the incidence of emerging and re-emerging infectious and zoonotic tick-borne diseases has increased worldwide. Tick-borne rickettsiae of the Spotted Fever group (SFGR) are considered as emerging pathogens that can infect humans and cause a variety of non-specific clinical symptoms. Here, we report nine cases of atypical tick-borne diseases (9/460; 1.95%) that occurred over a period of four months (from 15 April 2021 to 16 August 2021) in Serbia, from which five cases were classified as confirmed SFGR infection, two cases as probable SFGR infection and two cases as suspected SFGR infection. Within cases of confirmed SFGR infection, R. helvetica was detected as the causative agent in two cases. The most common clinical finding was non-expanding persistent circular redness, followed by eschar and enlargement of regional lymph nodes, and pain at lesion site. Rickettsia outer membrane protein B (ompB) and citrate synthase (gltA) gene fragments were amplified from clinical samples and ticks attached to patients and IgG reacting with Rickettsia conorii antigen were detected in sera samples of patients, which are highly suggestive of exposure to SFGR. Surveillance and monitoring of rickettsial diseases in Serbia should continue and extended to new areas due to the increasing trend of clinical infections caused by SFGR in the country.

Spotted Fever Group Rickettsia spp. Diversity in Ticks and the First Report of Rickettsia hoogstraalii in Romania

Simple Summary

Ticks are important parasites that feed on the blood of various host species, representing the most important arthropods transmitting diseases in Europe. Continuous changes in both tick distribution and abundance are related to multiple factors, including climate change. These changes have strong implications for both animal and human health; therefore, continuous surveillance of tickborne diseases is required for an appropriate evaluation of the potential risks faced by animals and humans in a given area. The spotted fever group Rickettsia comprises a large number of zoonotic agents with an increasing importance recognized in the last 30 years. The aim of this study was to evaluate these bacteria in ticks in Romania. Five Rickettsia species were identified in different tick species, with new pathogen–tick associations reported. Rickettsia hoogstraalii, one member of this group, was detected for the first time in Romania and in Rhipicephalus rossicus ticks. This species was first described in 2006 in Croatia, and its pathogenicity is not well known. In addition, the detection of R. raoultii and R. monacensis in unfed larvae of Haemaphysalis punctata reinforce the hypothesis of transmission of Rickettsia from female ticks to larvae; therefore the bite of larvae could pose a health risk.

Abstract

Tickborne bacterial pathogens have been described worldwide as risk factors for both animal and human health. Spotted fevers caused by Rickettsiae may cause non-specific symptoms, which make clinical diagnosis difficult. The aim of the current study was to evaluate and review the diversity of SFG Rickettsiae in ticks collected in 41 counties in Romania. A total of 2028 questing and engorged ticks collected in Romania belonging to five species were tested by PCR amplification of Rickettsia spp. gltA and 17-D gene fragments: Ixodes ricinus (n = 1128), Dermacentor marginatus (n = 507), D. reticulatus (n = 165), Rhipicephalus rossicus (n = 128) and Haemaphysalis punctata (n = 100). Five Rickettsia species were identified following DNA sequence analysis: R. helvetica, R. monacensis, R. slovaca, R. raoultii, and R. hoogstraalii. The most common species detected was R. monacensis. Moreover, R. hoogstraalii was detected for the first time in Romania and in R. rossicus ticks. The detection of R. raoultii and R. monacensis in questing larvae of Hae. punctata suggests the possible transovarial transmission of these Rickettsia species in ticks. The detection of R. hoogstraalii for the first time in Romania increases the reported SFG Rickettsia diversity in the country.

Epidemiological, Clinical, and Microbiological Characteristics in a Large Series of Patients Affected by Dermacentor-Borne-Necrosis-Erythema-Lymphadenopathy from a Unique Centre from Spain

During recent decades, a tick-borne rickettsial syndrome, characterized by eschar and painful lymphadenopathy after Dermacentor marginatus-bite, has been described as an emerging rickettsiosis in Europe. Our group named it DEBONEL (Dermacentor-borne-necrosis-erythema-lymphadenopathy), regarding the vector and the main infection signs. Other groups called it TIBOLA (tick-borne-lymphadenophathy) and, later, SENLAT (scalp-eschar-and-neck-lymphadenopathy-after-tick-bite), expanding, in the latter, the etiological spectrum to other pathogens. Objective: To investigate the etiology of DEBONEL agents in our area, and to compare their epidemiological/clinical/microbiological characteristics. During 2001-2020, 216 patients clinically diagnosed of DEBONEL (the largest series from one center) in La Rioja (northern Spain) were examined. Rickettsia spp. were amplified in 14/104 (13.46%) blood samples, 69/142 (48.59%) eschar swabs, 7/7 (100%) biopsies, and 71/71 (100%) D. marginatus from patients. For samples in which Rickettsia was undetected, no other microorganisms were found. 'Candidatus Rickettsia rioja', Rickettsia slovaca, Rickettsia raoultii, and Rickettsia DmS1 genotype were detected in 91, 66, 4, and 3 patients, respectively. DEBONEL should be considered in patients with clinical manifestations herein described in areas associated to Dermacentor. The most frequently involved agent in our environment is 'Ca. R. rioja'. The finding of Rickettsia sp. DmS1 in ticks attached to DEBONEL patients suggests the implication of other rickettsia genotypes.

Tick-Borne Pathogens and Diseases in Greece

Tick-borne diseases (TBDs) are recognized as a serious and growing public health epidemic in Europe, and are a cause of major losses in livestock production worldwide. This review is an attempt to present a summary of results from studies conducted over the last century until the end of the year 2020 regarding ticks, tick-borne pathogens, and tick-borne diseases in Greece. We provide an overview of the tick species found in Greece, as well as the most important tick-borne pathogens (viruses, bacteria, protozoa) and corresponding diseases in circulation. We also consider prevalence data, as well as geographic and climatic conditions. Knowledge of past and current situations of TBDs, as well as an awareness of (risk) factors affecting future developments will help to find approaches to integrated tick management as part of the ‘One Health Concept’; it will assist in avoiding the possibility of hotspot disease emergencies and intra- and intercontinental transmission. Increased surveillance in Greece is required to ensure clear and effective policies for TBD control.

The Unexpected Holiday Souvenir: The Public Health Risk to UK Travellers from Ticks Acquired Overseas

Overseas travel to regions where ticks are found can increase travellers' exposure to ticks and pathogens that may be unfamiliar to medical professionals in their home countries. Previous studies have detailed non-native tick species removed from recently returned travellers, occasionally leading to travel-associated human cases of exotic tick-borne disease. There are 20 species of tick endemic to the UK, yet UK travellers can be exposed to many other non-native species whilst overseas. Here, we report ticks received by Public Health England's Tick Surveillance Scheme from humans with recent travel history between January 2006 and December 2018. Altogether, 16 tick species were received from people who had recently travelled overseas. Confirmed imports (acquired outside of the UK) were received from people who recently travelled to 22 countries. Possible imports (acquired abroad or within the UK) were received from people who had recently travelled to eight European countries. Species-specific literature reviews highlighted nine of the sixteen tick species are known to vector at least one tick-borne pathogen to humans in the country of acquisition, suggesting travellers exposed to ticks may be at risk of being bitten by a species that is a known vector, with implications for novel tick-borne disease transmission to travellers.

Epidemiology, Clinical Aspects, Laboratory Diagnosis and Treatment of Rickettsial Diseases in the Mediterranean Area During COVID-19 Pandemic: A Review of the Literature

The purpose of the present review is to give an update regarding the classification, epidemiology, clinical manifestation, diagnoses, and treatment of the Rickettsial diseases present in the Mediterranean area.

We performed a comprehensive search, through electronic databases (Pubmed – MEDLINE) and search engines (Google Scholar), of peer-reviewed publications (articles, reviews, and books).

The availability of new diagnostic tools, including Polymerase Chain Reaction and nucleotide sequencing has significantly modified the classification of intracellular bacteria, including the order Rickettsiales with more and more new Rickettsia species recognized as human pathogens. Furthermore, emerging Rickettsia species have been found in several countries and are often associated with unique clinical pictures that may challenge the physician in the early detection of the diseases.

Rickettsial infections include a wide spectrum of clinical presentations ranging from a benign to a potentially life treating disease that requires prompt recognition and proper management. Recently, due to the spread of SARS-CoV-2 infection, the differential diagnosis with COVID-19 is of crucial importance. The correct understanding of the clinical features, diagnostic tools, and proper treatment can assist clinicians in the management of Rickettsioses in the Mediterranean area.

A Case of Human Infection by Rickettsia slovaca in Greece

Although tick-borne rickettsiosis is endemic in Greece, until recently, human samples arriving at the National Reference Centre under suspicion of rickettsial infection were routinely tested only for Rickettsia typhi and R. conorii. However, identification of additional rickettsia species in ticks prompted revision of the protocol in 2010. Until that year, all human samples received by the laboratory were tested for antibodies against R. conorii and R. typhi only. Now, tests for R. slovaca, R. felis, and R. mongolotimonae are all included in routine analysis. The current description of a human R. slovaca case is possible as a result of these changes in routine testing.

Syndromic classification of rickettsioses: an approach for clinical practice

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

Monitoring human tick-borne disease risk and tick bite exposure in Europe: available tools and promising future methods

Ticks are the main vector for infectious disease pathogens in both humans and animals, and tick-borne diseases are currently spreading throughout Europe. Various surveillance methods have been developed to estimate the burden and risk of tick-borne diseases and host exposure to tick bites. The ultimate aims of these approaches are to determine the risk level of a tick-borne disease in a given area, determine its health priority, identify the at-risk population and propose specific countermeasures or complementary studies as needed. The purpose of this review is to present the current methods for monitoring the circulation of tick-borne diseases and to highlight the use of salivary antigens as original and recently developed serological tools that could be useful for tick bite risk assessment and could improve the current surveillance methods.

Tick-borne lymphadenopathy, an emerging disease

Tick-borne lymphadenopathy (TIBOLA) is a spotted fever group disease characterized by an eschar and pronounced enlarged lymph nodes after a scalp tick bite. The goal of this synopsis is to review the TIBOLA literature published until May 2013: Forty-one articles (reporting 537 cases) were included. There was a predominance of cases in females and young people. Spain, France, and Hungary reported the majority of cases, and they were mainly reported in the colder seasons. The involved tick bite was frequently on the scalp. Rickettsia slovaca was the most frequent identified bacterium and Dermacentor marginatus the most frequently identified vector. The most prescribed antibiotic was doxycycline. TIBOLA has the potential to emerge outside Europe: improving knowledge of TIBOLA may promote early symptoms recognition and may allow early treatment.

Rickettsia slovaca infection in humans, Portugal

Fifteen years after the initial detection of Rickettsia slovaca in ticks in Portugal, 3 autochthonous cases of R. slovaca infection were diagnosed in humans. All patients had an eschar on the scalp and lymphadenopathy; 2 patients had facial edema. R. slovaca infection was confirmed by serologic testing, culture, and PCR.

Tick-borne rickettsioses in Europe

Rickettsioses are caused by obligate intracellular bacteria within the genus Rickettsia, mainly transmitted by arthropods. Until recently, Mediterranean spotted fever (MSF) caused by Rickettsia conorii was considered the only tick-borne rickettsiosis in Europe. However, 'new' TBR have been described in Europe during last years. For instance, other subspecies such as R. conorii caspia and R. conorii israelensis have been involved in MSF. Dermacentor-borne necrosis erythema and lymphadenopathy/tick-borne lymphadenopathy (DEBONEL/TIBOLA) cases caused by Rickettsia slovaca, Rickettsia raoultii, and Rickettsia rioja been described in several countries where Dermacentor marginatus ticks (the mainly implicated vector) are present. Rickettsia helvetica has also been involved as a human pathogen in cases of fever with and without rash and in patients with meningitis and carditis. Other TBR such as lymphangitis-associated rickettsioses (LAR), caused by Rickettsia sibirica mongolitimonae, have been diagnosed in different European countries (France, Spain, Portugal and Greece). Rickettsia massiliae is considered an etiological agent of MSF-like illness in the Mediterranean basin. Furthermore, Rickettsia monacensis that is distributed all along Europe has been isolated from patients with MSF-like illness in Spain. Although Rickettsia aeschlimannii has been associated with MSF-like in Africa and is distributed in the Mediterranean area, no autochthonous human cases have been reported for Europe. Other Rickettsia species detected in ticks and unrelated to human disease (Candidatus Rickettsia kotlanii, Candidatus Rickettsia barbariae, Candidatus Rickettsia vini) could be potentially involved in the next years. Climate changes, among other factors, may contribute to the emergence of other rickettsioses or change their distribution. Lastly, African tick-bite fever (ATBF), caused by Rickettsia africae, is frequently diagnosed in Europe in patients returning from endemic areas.

Contact with horses is a risk factor for tick-borne lymphadenopathy (TIBOLA): a case control study

Tick-borne lymphadenopathy (TIBOLA) is an emerging infection caused by Rickettsia slovaca. We describe here the seasonal, age and gender characteristics as well as the association with horse contact as risk factors for acquiring TIBOLA in comparison with another, more frequent tick-borne disease, Lyme borreliosis.We analysed a dataset of 855 patients diagnosed with either Lyme (n = 805) or TIBOLA (n = 50) disease using Fisher's exact tests and generalized linear models. Then we performed a matched case-control study in which all TIBOLA patients were paired with one Lyme patient matching in age and gender. We identified the species of ticks collected from the TIBOLA patients (n = 16).We found that horse contact was significantly more frequent among TIBOLA (34/50; 68 %) than among Lyme patients (110/805; 13.7 %) (OR = 13.35, p < 0.001). The younger age and female gender associated with higher risk of acquiring TIBOLA (OR = 3.99, p < 0.001). Ten of the 16 ticks were D. marginatus, six were D. reticulatus suggesting that both species are responsible for transmitting R. slovaca. Two patients acquired the infection from male ticks. TIBOLA is a tick-borne zoonosis, which might have a specific association with horse contact.

First detection of Rickettsia slovaca in Greece

Seven hundred and three ticks collected in November and June of 2004-2006 from domestic animals in four localities of Halkidiki prefecture, Northern Greece, were tested for the presence of ricketsial DNA. Rickettsia slovaca was detected in one pool of Rhipicephalus bursa ticks, representing the first report of detection of R. slovaca in Greece.

Rickettsial diseases: from Rickettsia-arthropod relationships to pathophysiology and animal models

Rickettsiae cause spotted fevers and typhus-related diseases in humans. Some of these diseases occur worldwide and are life-threatening, for example, epidemic typhus is still a major health problem despite the apparent efficiency of antibiotic treatment. In addition, Rickettsia prowazekii, the agent of epidemic typhus, and R. rickettsii, the agent of Rocky Mountain spotted fever, are microorganisms that could potentially be used as bioweapons to induce panic in the population. Rickettsiae are obligate intracellular bacteria in both vertebrate and invertebrate hosts, but rickettsial species differ in terms of association with arthropods, behavior of the vector to infection, pathophysiology and outcome of the disease. Understanding the pathogenic steps of rickettsioses is essential to develop protective strategies against these bacteriological threats. Unfortunately, the mechanisms involved in the pathogenesis of many rickettsioses are poorly characterized, and protective immunity is incompletely understood, in part because accurate animal models that mimic human diseases are lacking. In the past, murine models have been of limited value because infection of mice was without effect or resulted in erratic mortality. Recent studies have reported that rickettsial infection can be established in mice, depending on the genetic background of mice, the type of rickettsial species and the route of inoculation. These models may be useful for analyzing the pathogenesis of rickettsioses, especially epidemic typhus, evaluating new therapeutic molecules and vaccine candidates, and preventing future outbreaks.

Spotted fever rickettsioses in southern and eastern Europe

Mediterranean spotted fever due to Rickettsia conorii conorii was thought, for many years, to be the only tick-borne rickettsial disease prevalent in southern and eastern Europe. However, in recent years, six more species or subspecies within the spotted fever group of the genus Rickettsia have been described as emerging pathogens in this part of the world. Tick-borne agents include Rickettsia conorii israelensis, Rickettsia conorii caspia, Rickettsia aeschlimannii, Rickettsia slovaca, Rickettsia sibirica mongolitimonae and Rickettsia massiliae. Many Rickettsia of unknown pathogenicity have also been detected from ticks and could represent potential emerging pathogens to be discovered in the future. Furthermore, a new spotted fever rickettsia, Rickettsia felis, was found to be associated with cat fleas and is an emerging human pathogen. Finally, the mite-transmitted Rickettsia akari, the agent of rickettsialpox, is also known to be prevalent in Europe. We present here an overview of these rickettsioses, focusing on emerging diseases.

Rickettsiosis in Europe

In Europe, rickettsioses are long-known infectious diseases. Until recently, it was thought that Mediterranean spotted fever due to Rickettsia conorii was the only tick-borne rickettsiosis in Europe. In the last decade new Rickettsia spp. have been implicated in human pathology (R. slovaca, R. sibirica mongolotimonae, R. helvetica). Furthermore, cases of infection due to flea-borne rickettsioses (R. typhi, R. felis) have been described. Finally, although no outbreak of epidemic typhus has been reported yet in central and southern Europe, we should be aware of the possibility of reemergence of this disease in Europe. Other rickettsioses exist that have not yet been implicated in human pathology. We should consider that climate changes and other factors could contribute to the emergence and reemergence of other new diseases.

Tick-borne rickettsioses around the world: emerging diseases challenging old concepts

During most of the 20th century, the epidemiology of tick-borne rickettsioses could be summarized as the occurrence of a single pathogenic rickettsia on each continent. An element of this paradigm suggested that the many other characterized and noncharacterized rickettsiae isolated from ticks were not pathogenic to humans. In this context, it was considered that relatively few tick-borne rickettsiae caused human disease. This concept was modified extensively from 1984 through 2005 by the identification of at least 11 additional rickettsial species or subspecies that cause tick-borne rickettsioses around the world. Of these agents, seven were initially isolated from ticks, often years or decades before a definitive association with human disease was established. We present here the tick-borne rickettsioses described through 2005 and focus on the epidemiological circumstances that have played a role in the emergence of the newly recognized diseases.

Tick-borne rickettsial diseases: emerging risks in Europe

Ticks are currently considered the main vectors of human infectious diseases in Europe, particularly since their role in the transmission of the agent of Lyme borreliosis was demonstrated in the 1980s. In the recent years, ticks have also been shown to be the vectors of numerous emerging rickettsial diseases. Although Mediterranean spotted fever (MSF) due to Rickettsia conorii was thought for a long time to be the only tick-borne rickettsial disease prevalent in Europe, five more spotted fever rickettsiae have been described as emerging pathogens in the last decade. Further, cases of infection due to Anaplasma phagocytophilum, the agent of human anaplasmosis (previously known as human granulocytic ehrlichiosis), have been reported throughout Europe. We present here these emerging diseases and discuss other potential threat for the future.