Molecular diagnosis of autochthonous human anaplasmosis in Austria - an infectious diseases case report

[Equine granulocytic anaplasmosis (EGA): Case description and overview of the epidemiological situation with focus on Germany]

Equine granulocytic anaplasmosis (EGA) is a tick-borne disease caused by Anaplasma (A.) phagocytophilum. In Central, Northern, Western, and Eastern Europe, ticks of the Ixodes (I.) ricinus/I. persulcatus complex, in Germany mainly I. ricinus, are considered as vectors. Ixodes ricinus ticks show peaks of activity during the spring and summer months, particularly April to July. Changing climatic conditions, however, have meanwhile led to a year-round risk of tick exposure and thus infections with A. phagocytophilum. The presented case report underlines the seasonal peak phase of the infection risk in that the presentation of the horse to the veterinarian occurred in June. Additionally, clinical signs - including fever - are mostly unspecific and thrombocytopenia represents the most significant hematological abnormality. Direct and indirect detection methods are available for the diagnosis of an infection or contact with the pathogen. A positive PCR confirms an acute infection, as in the presented case, while positive antibody levels indicate contact with the pathogen in the (recent) past. Additionally, inclusion bodies, so called morulae, may be detected rapidly and inexpensively in smears derived from the peripheral blood and are predominantly found in neutrophilic granulocytes, less frequently in eosinophilic granulocytes. However, microscopy has a lower sensitivity compared to PCR-testing. In the presented case, morulae could not be detected in EDTA blood despite positive PCR. Antibiotics with intracellular activity, such as oxytetracycline and/or doxycycline are the treatment of choice and, as in the described case, often result in rapid clinical improvement in horses suffering from EGA. The elimination of the pathogen should be confirmed by PCR-testing 5-8 days after the completion of the antibiotic therapy. Whether and how long antibodies against A. phagocytophilum could possibly be protective against reinfection remains unknown. In humans, A. phagocytophilum is classified as an emerging pathogen of increasing clinical importance in the northern hemisphere.

Anaplasma phagocytophilum Ecotype Analysis in Cattle from Great Britain

Anaplasma phagocytophilum (A. phagocytophilum) is the aetiological agent of tick-borne fever in cattle and sheep, and granulocytic anaplasmosis in human and dogs. Livestock, companion animal and human infections with A. phagocytophilum have been reported globally. Across England and Wales, two isolates (called ecotypes) have been reported in ticks. This study examined A. phagocytophilum isolates present in livestock and wildlife in Great Britain (GB), with a particular focus on cattle. Clinical submissions (EDTA blood) from cattle (n = 21) and sheep (n = 3) were received by APHA for tick-borne disease testing and the animals were confirmed to be infected with A. phagocytophilum using a PCR targeting the Msp2 gene. Further submissions from roe deer (n = 2), red deer (n = 2) and Ixodes ricinus ticks (n = 22) were also shown to be infected with A. phagocytophilum. Subsequent analysis using a nested PCR targeting the groEL gene and sequencing confirmed the presence of ecotype I in cattle, sheep, red deer and Ixodes ricinus, and ecotype II in roe deer and I. ricinus removed from deer carcasses. Despite the presence of two ecotypes, widely distributed in ticks from England and Wales, only ecotype I was detected in cattle in this study.

Human Granulocytic Anaplasmosis-A Systematic Review of Published Cases

Anaplasma phagocytophilum is an emerging, Gram-negative, obligate intracellular pathogen that is transmitted by a tick vector. Human infection ranges from asymptomatic to severe disease that can present with pancytopenia, multiorgan failure, and death. The aim of this systematic review is to analyze case reports and case series reported over the last two decades in peer-reviewed journals indexed in the Medline/PubMed database according to the PRISMA guidelines. We found 110 unique patients from 88 case reports and series. The most common mode of transmission was tick bite (60.9%), followed by blood transfusion (8.2%). Infection was acquired by blood transfusion in nearly half (42%) of the immunocompromised patients. Most patients reported fever (90%), followed by constitutional (59%) and gastrointestinal symptoms (56%). Rash was present in 17% of patients, much higher than in previous studies. Thrombocytopenia was the most common laboratory abnormality (76%) followed by elevated aspartate aminotransferase (AST) (46%). The diagnosis was most commonly established using whole-blood polymerase chain reaction (PCR) in 76% of patients. Coinfection rate was 9.1% and Borrelia burgdorferi was most commonly isolated in seven patients (6.4%). Doxycycline was used to treat 70% of patients but was only used as an empiric treatment in one-third of patients (33.6%). The overall mortality rate was 5.7%, and one patient died from trauma unrelated to HGA. The mortality rates among immunocompetent and immunocompromised patients were 4.2% (n = 4/95) and 18.2% (n = 2/11), respectively. Four of the six patients who died (66.6%) received appropriate antibiotic therapy. Among these, doxycycline was delayed by more than 48 h in two patients.

Infections with Tickborne Pathogens after Tick Bite, Austria, 2015-2018

Knowledge about outcomes of tick bites is crucial because infections with emerging pathogens might be underestimated.

The aim of this prospective study was to assess the risk for tickborne infections after a tick bite. A total of 489 persons bitten by 1,295 ticks were assessed for occurrence of infections with Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Rickettsia spp., Babesia spp., Candidatus Neoehrlichia mikurensis, and relapsing fever borreliae. B. burgdorferi s.l. infection was found in 25 (5.1%) participants, of whom 15 had erythema migrans. Eleven (2.3%) participants were positive by PCR for Candidatus N. mikurensis. One asymptomatic participant infected with B. miyamotoi was identified. Full engorgement of the tick (odds ratio 9.52) and confirmation of B. burgdorferi s.l. in the tick by PCR (odds ratio 4.39) increased the risk for infection. Rickettsia helvetica was highly abundant in ticks but not pathogenic to humans. Knowledge about the outcome of tick bites is crucial because infections with emerging pathogens might be underestimated because of limited laboratory facilities.

Novel Protozoans in Austria Revealed through the Use of Dogs as Sentinels for Ticks and Tick-Borne Pathogens

We previously isolated and cultivated the novel Rickettsia raoultii strain Jongejan. This prompted us to ask whether this strain is unique or more widely present in Austria. To assess this issue, we retrospectively screened ticks collected from dogs in 2008. Of these collected ticks, we randomly selected 75 (47 females and 28 males) Dermacentor reticulatus, 44 (21 females, 7 males, and 16 nymphs) Haemaphysalis concinna, and 55 (52 females and 3 males) ticks of the Ixodes ricinus complex. Subsequently, these ticks were individually screened for the presence of tick-borne pathogens using the reverse line blot hybridization assay. In our current study, we detected DNA from the following microbes in D. reticulatus: Anaplasma phagocytophilum, Borrelia lusitaniae, Borrelia spielmanii, Borrelia valaisiana, and R. raoultii, all of which were R. raoultii strain Jongejan. In H. concinna, we found DNA of a Babesia sp., Rickettsia helvetica, and an organism closely related to Theileria capreoli. Lastly, I. ricinus was positive for Anaplasma phagocytophilum, Borrelia afzelii, Borrelia burgdorferi sensu stricto, Borrelia garinii/Borrelia bavariensis, B. lusitaniae, B. spielmanii, B. valaisiana, Candidatus Neoehrlichia mikurensis, Rickettsia helvetica, Rickettsia monacensis, and Theileria (Babesia) microti DNA. The detection of DNA of the Babesia sp. and an organism closely related to Theileria capreoli, both found in H. concinna ticks, is novel for Austria.

Ecotyping of Anaplasma phagocytophilum from Wild Ungulates and Ticks Shows Circulation of Zoonotic Strains in Northeastern Italy

Simple Summary

Tick-borne infectious diseases represent a rising threat both for human and animal health, since they are emerging worldwide. Among the bacterial infections, Anaplasma phagocytophilum has been largely neglected in Europe. Despite its diffusion in ticks and animals, the ecoepidemiology of its genetic variants is not well understood. The latest studies identify four ecotypes of Anaplasma phagocytophilum in Europe, and only ecotype I has shown zoonotic potential. The aim of the present study was to investigate the genetic variants of Anaplasma phagocytophilum in wild ungulates, the leading reservoir species, and in feeding ticks, the main vector of infection. The analyzed samples were collected in northeastern Italy, the same area where the first Italian human cases of anaplasmosis in the country were reported. Using biomolecular tools and phylogenetic analysis, ecotypes I and II were detected in both ticks (Ixodes ricinus species) and wild ungulates. Specifically, ecotype II was mainly detected in roe deer and related ticks; and ecotype I, the potentially zoonotic variant, was detected in Ixodes ricinus ticks and also in roe deer, red deer, chamois, mouflon, and wild boar. These findings reveal not only the wide diffusion of Anaplasma phagocytophilum, but also the presence of zoonotic variants.

Abstract

Anaplasma phagocytophilum (A. phagocytophilum) is a tick-borne pathogen causing disease in both humans and animals. Human granulocytic anaplasmosis (HGA) is an emerging disease, but despite the remarkable prevalence in European ticks and wild animals, human infection appears underdiagnosed. Several genetic variants are circulating in Europe, including the zoonotic ecotype I. This study investigated A. phagocytophilum occurrence in wild ungulates and their ectoparasites in an area where HGA has been reported. Blood samples from wild ungulates and ectoparasites were screened by biomolecular methods targeting the mps2 gene. The groEL gene was amplified and sequenced to perform genetic characterization and phylogenetic analysis. A total of 188 blood samples were collected from different wild ungulates species showing an overall prevalence of 63.8% (88.7% in wild ruminants and 3.6% in wild boars). The prevalence of A. phagocytophilum DNA in ticks (manly Ixodes ricinus), and keds collected from wild ruminants was high, reflecting the high infection rates obtained in their hosts. Among ticks collected from wild boars (Hyalomma marginatum and Dermacentor marginatus) no DNA was detected. Phylogenetic analysis demonstrated the presence of ecotype I and II. To date, this is the first Italian report of ecotype I in alpine chamois, mouflon, and wild boar species. These findings suggest their role in HGA epidemiology, and the high prevalence detected in this study highlights that this human tick-borne disease deserves further attention.