Scalp eschar and neck lymphadenopathy by Rickettsia slovaca after Dermacentor marginatus tick bite case report: multidisciplinary approach to a tick-borne disease

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.

Tick-borne pathogens in questing adults Dermacentor reticulatus from the Eastern European population (north-eastern Poland)

Dermacentor reticulatus is tick species with an expanding geographical range in Europe, which creates the possibility of spreading microorganisms of significant veterinary and medical importance. The study aimed to investigate the prevalence and genetic diversity of Rickettsia spp., Babesia spp., Borrelia spp. and Anaplasma phagocytophilum in adult D. reticulatus ticks from the Eastern European population in the urban and the natural biotopes of north-eastern Poland. Microorganisms were detected by PCR and identified by DNA sequencing. The overall infection rate of at least one of the pathogens was 29.6%. The predominantly was Rickettsia spp. (27.1%) (with R. raoultii-9.1%) followed by Babesia spp. (2.4%) with B. canis (1.5%) as the most frequent. Based on 18S rRNA gene sequence, three B. canis genotypes were revealed. The prevalence of R. raoultii and B. canis was significantly higher in ticks from natural biotopes. The infection rates of B. afzelii and A. phagocytophilum were determined at 0.9% and 0.3%, respectively. Co-infections were detected in 3.8% of infected ticks. In diagnosing tick-borne diseases in humans, tick-borne lymphadenopathy should not be excluded. The prevalence of different genotypes of B. canis suggests differences in the clinical picture of canine babesiosis in the area.

Scalp eschar and neck lymph adenopathy after a tick bite (SENLAT) in Tuscany, Italy (2015-2022)

INTRODUCTION

The Scalp Eschar and Neck Lymph Adenopathy After a Tick Bite (SENLAT) syndrome is frequently caused by Rickettsia slovaca and Rickettsia raoultii. Only six microbiologically confirmed SENLAT cases have been reported in Italy between 1996 and 2021. We report ten cases of SENLAT seen between 2015 and 2022 in a tertiary care center in Tuscany, Italy.

CASES PRESENTATION

All patients were women; most common symptoms were scalp eschar on the site of tick bite (100%) and cervical lymphadenopathy (90%). No microbiological identification was obtained. Persistent alopecia, for several months to years, was observed in four patients. The known difficulty of microbiological diagnosis in SENLAT was worsened, in our cases, by factors as the absence of ticks available for identification and microbiological study, and antibiotic treatment administration previous to microbiological tests.

CONCLUSION

The report highlights the presence of SENLAT in Italy, aiming to raise the awareness toward the emergence of this clinical entity.

Rickettsia species in Dermacentor reticulatus ticks feeding on human skin and clinical manifestations of tick-borne infections after tick bite

Dermacentor reticulatus ticks are sporadically removed from human skin and therefore the medical consequences of their feeding are neglected compared to Ixodes ricinus. We investigated the prevalence of pathogens in D. reticulatus removed from human skin and possible clinical manifestations suggestive of tick-borne diseases after a tick bite. A total of 2153 ticks were studied and of these only 34 were D. reticulatus. The mean prevalence of Rickettsia in D. reticulatus was 50.0% and R. raoultii was identified in 82.4% of infected D. reticulatus ticks. We confirmed the first case of R. aeschlimannii infection in D. reticulatus ticks. Among participants bitten by D. reticulatus, 13.3% reported reddening around the tick bite site and flu-like symptoms, including lymphadenopathy and 3.3% reported eschar on the tick site bite. All of the participants with flu-like symptoms after tick removal were bitten by ticks infected with R. raoultii. The results of this study indicate that even though D. reticulatus ticks bite humans sporadically, pathogenic Rickettsia have a remarkably high prevalence in this tick species. We can expect that the incidence of tick-borne lymphadenopathy might increase with the reported expansion of the D. reticulatus into new areas and its growing abundance in Central Europe.

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.

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.

High Prevalence of Tick-Borne Zoonotic Rickettsia slovaca in Ticks from Wild Boars, Northeastern Italy

Simple Summary

Tick-borne rickettsioses are emerging diseases that have become widespread in many European countries, particularly in those facing the Mediterranean basin. Although Rickettsia conorii was traditionally thought to be the most threatening species, in recent decades, thanks to the improvements in biomolecular tools, other zoonotic species have been identified, such as Rickettsia slovaca, the etiological agent of scalp eschar and neck lymphadenopathy after tick bite (SENLAT), as well as other neglected species. These pathogens are present in Italy, but few data are available. This research aimed to improve the epidemiological knowledge of rickettsial infections in tick and wild boar populations in the Euganean Hills Regional Park, an enclosed area in northeastern Italy. Both tick and wild boar blood samples were tested using biomolecular methods to detect and identify Rickettsia species. Only ticks tested positive, and Rickettsia slovaca was the most frequently detected species, showing a high prevalence, followed by Rickettsia monacensis and Rickettsia helvetica. These data highlight a non-negligible presence of these pathogens in northern Italy and outline that rickettsial infections deserve further investigation.

Abstract

Tick-borne rickettsiae are emerging pathogens that are becoming widespread in Europe. Rickettsiae are endemic in Italy, but epidemiological data are currently scarce. This study aimed to improve our knowledge about rickettsial infections in tick and wild boar populations. Blood and ticks were collected from 102 wild boars in 2010 and 2018. Ticks were also collected from the vegetation in the area. All of the samples were examined using real-time PCR targeting the gltA gene to detect Rickettsia DNA. Positivity was confirmed by PCR amplifying the gltA and/or ompB genes. A total of 254 ticks and 89 blood samples were analyzed. Zoonotic rickettsiae were detected in the ticks but not in the blood samples. Rickettsia slovaca (R. slovaca) was the most prevalent in ticks and was found in 23.7% of Dermacentor marginatus (D. marginatus) and in 3.4% of Ixodes ricinus (I. ricinus). Other zoonotic species were identified, such as Rickettsia monacensis, which was detected in 12% of I. ricinus ticks, and Rickettsia helvetica which was found in 3.4% of questing I. ricinus ticks and in 1.1% of D. marginatus collected from wild boars. This study highlights a high prevalence of zoonotic rickettsiae, particularly that of R. slovaca, in northeastern Italy. As rickettsioses are underreported and underdiagnosed in human medicine, both clinicians and researchers should pay more attention to this topic.

Rickettsiosis with Pleural Effusion: A Systematic Review with a Focus on Rickettsiosis in Italy

Background: Motivated by a case finding of Mediterranean spotted fever (MSF) associated with atypical pneumonia and pleural effusion in which Rickettsia conorii subsp. israelensis was identified by molecular methods in the pleural fluid, we wanted to summarize the clinical presentations of rickettsiosis in Italy by systematic research and to make a systematic review of all the global cases of rickettsiosis associated with pleural effusion. Methods: For the literature search, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. We chose to select only the studies published in last 25 years and confirmed both with serological and molecular assays. Results: Human cases of rickettsiosis in Italy were reported in 48 papers describing 2831 patients with very different clinical presentations; the majority was MSF accounted to R. conorii and was reported in Sicily. Pleural effusion associated with infection with microorganisms belonging to Rickettsiales was described in 487 patients. It was rarely associated with microorganisms different from O. tsutsugamushi; also rarely, cases of scrub typhus were reported outside Southeast Asia and in the largest majority, the diagnosis was achieved with serology. Conclusions: MSF, especially when caused by R. conorii subsp. israelensis, may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis

Ticks on humans in an Atlantic rainforest preserved ecosystem in Brazil: Species, life stages, attachment sites, and temporal pattern of infestation

We herein describe exposure and tick attachment to researchers and field staff within the greatest preserved inland Atlantic rainforest, located in Brazil, over a non-consecutive period of five years. Overall, 433 ticks from five species were collected, Amblyomma coelebs (n = 281), Amblyomma brasiliense (n = 79), Amblyomma incisum (n = 43), Amblyomma ovale (n = 4), Haemaphysalis juxtakochi (n = 4). Clusters of larvae belonged to the genus Amblyomma (n = 21) and Haemaphysalis (n = 1). Both Haemaphysalis and Amblyomma species were observed crawling on humans but only ticks from the latter genus were found attached. Most recovered ticks (59%) were found attached and, whereas A. brasiliense was the main host-seeking tick species in the forest, A. coelebs nymphs were the ones that overwhelmingly attached to humans (70% of all attachments). At the same time only 0.4% of human bites were of A. ovale, the Rickettsia parkeri strain Atlantic rainforest vector tick in Brazil. Tick attachment sites were recorded for 132 ticks and lower/upper limbs and the trunk were more parasitized than the head/neck. Tick bites were recorded throughout the year; while larvae did not show an evident seasonal pattern, nymphs attached to humans mainly in autumn and winter and the few adult bites were recorded in spring. Our results highlighted A. coelebs nymphs as major human-biters and evidenced the necessity of studies that discern human tick bites that occur after exposure to host-seeking ticks from those that occur after tick displacement from hosts that carry ticks to human dwellings.

Ectoparasites of hedgehogs: From flea mite phoresy to their role as vectors of pathogens

Hedgehogs are synanthropic mammals, reservoirs of several vector-borne pathogens and hosts of ectoparasites. Arthropod-borne pathogens (i.e., Rickettsia spp., Borrelia spp., and Anaplasmataceae) were molecularly investigated in ectoparasites collected on hedgehogs (n = 213) from Iran (161 Hemiechinus auritus, 5 Erinaceus concolor) and Italy (47 Erinaceus europaeus). In Iran, most animals examined (n = 153; 92.2%) were infested by ticks (Rhipicephalus turanicus, Hyalomma dromedarii), and 7 (4.2%) by fleas (Archeopsylla erinacei, Ctenocephalides felis). Of the hedgehogs infested by arthropods in Italy (i.e., 44.7%), 18 (38.3%) were infested by fleas (Ar. erinacei), 7 (14.9%) by ticks (Haemaphysalis erinacei, Rh. turanicus, Rhipicephalus sanguineus sensu lato), and 6 (12.8%) by mites (Caparinia tripilis, Acarus nidicolous, Ornithonyssus spp.). Phoretic behavior of C. tripilis on Ar. erinacei was detected in two flea specimens from Italy. At the molecular analysis Rickettsia spp. was detected in 93.3% of the fleas of Italy. In Iran, Rickettsia spp. was detected in 8.0% out of 212 Rh. turanicus ticks, and in 85.7% of the Ar. erinacei fleas examined. The 16S rRNA gene for Ehrlichia/Anaplasma spp. was amplified in 4.2% of the 212 Rh. turanicus ticks. All sequences of Rickettsia spp. from fleas presented 100% nucleotide identity with Rickettsia asembonensis, whereas Rickettsia spp. from Rh. turanicus presented 99.84%–100% nucleotide identity with Rickettsia slovaca, except for one sequence, identical to Rickettsia massiliae. The sequences of the 16S rRNA gene revealed 99.57%–100% nucleotide identity with Anaplasma spp., except for one, identical to Ehrlichia spp. A new phoretic association between C. tripilis mites and Ar. erinacei fleas has been herein reported, which could be an important route for the spreading of this mite through hedgehog populations. Additionally, spotted fever group rickettsiae were herein detected in ticks and fleas, and Anaplasma/Ehrlichia spp. in ticks, suggesting that hedgehogs play a role as reservoirs for these vector-borne pathogens.

•

New phoretic association of Caparinia tripilis mites on Archaeopsylla erinacei fleas.

•

Occurrence of spotted fever group rickettsiae in Rhipicephalus turanicus from hedgehogs.

•

Occurrence of Anaplasmataceae in Rhipicephalus turanicus from hedgehogs.

•

High Prevalence of Rickettsia asembonensis in Archaeopsylla erinacei fleas from hedgehogs.

•

Hedgehogs are suggested as reservoirs of vector-borne pathogens.