Suspected and Confirmed Vector-Borne Rickettsioses of North America Associated with Human Diseases

A Case of Tick Bite Induced Babesiosis With Lyme Disease

The Ixodes tick may transmit multiple pathogens, Lyme disease being the most common. Early detection of tick bites and using prophylaxis measures is the key to prevent tick bite-associated diseases like babesiosis, anaplasmosis, and Lyme disease. It is recommended to follow preventive measures like using diethyltoluamide (DEET) on the skin, applying permethrin on clothes while visiting the tick-infested areas. Co-infection is an uncommon occurrence but still representative in endemic areas. If there is delayed initiation of therapy in these kinds of patients, there may be dire consequences that may require aggressive therapy. Clinicians should consider co-infection when suspecting tick-borne disease which can prove to be fatal if not addressed promptly. Here, we present the case of a 72-year-old female with atypical symptoms, who was found to have coinfection with Lyme disease and Babesiosis on serology testing and peripheral smear and was diagnosed and treated promptly.

Novel Rickettsia Species Infecting Dogs, United States

In 2018 and 2019, spotted fever was suspected in 3 dogs in 3 US states. The dogs had fever and hematological abnormalities; blood samples were Rickettsia seroreactive. Identical Rickettsia DNA sequences were amplified from the samples. Multilocus phylogenetic analysis showed the dogs were infected with a novel Rickettsia species related to human Rickettsia pathogens.

John HK, Richards AL, Ryan SJ. Exploring the Niche of Rickettsia montanensis (Rickettsiales: Rickettsiaceae) Infection of the American Dog Tick (Acari: Ixodidae), Using Multiple Species Distribution Model Approaches

The American dog tick, Dermacentor variabilis (Say) (Acari: Ixodidae), is a vector for several human disease-causing pathogens such as tularemia, Rocky Mountain spotted fever, and the understudied spotted fever group rickettsiae (SFGR) infection caused by Rickettsia montanensis. It is important for public health planning and intervention to understand the distribution of this tick and pathogen encounter risk. Risk is often described in terms of vector distribution, but greatest risk may be concentrated where more vectors are positive for a given pathogen. When assessing species distributions, the choice of modeling framework and spatial layers used to make predictions are important. We first updated the modeled distribution of D. variabilis and R. montanensis using maximum entropy (MaxEnt), refining bioclimatic data inputs, and including soil variables. We then compared geospatial predictions from five species distribution modeling frameworks. In contrast to previous work, we additionally assessed whether the R. montanensis positive D. variabilis distribution is nested within a larger overall D. variabilis distribution, representing a fitness cost hypothesis. We found that 1) adding soil layers improved the accuracy of the MaxEnt model; 2) the predicted 'infected niche' was smaller than the overall predicted niche across all models; and 3) each model predicted different sizes of suitable niche, at different levels of probability. Importantly, the models were not directly comparable in output style, which could create confusion in interpretation when developing planning tools. The random forest (RF) model had the best measured validity and fit, suggesting it may be most appropriate to these data.

Ticks infesting dogs and cats in North America: Biology, geographic distribution, and pathogen transmission

A diverse array of ixodid and argasid ticks infest dogs and cats in North America, resulting in skin lesions, blood loss, and disease. The ticks most commonly found on pets in this region are hard ticks of the genera Amblyomma, Dermacentor, Ixodes, and Rhipicephalus, as well as the more recently established Haemaphysalis longicornis. Soft tick genera, especially Otobius and Ornithodoros, are also reported from pets in some regions. In this review, we provide a summary of the complex and diverse life histories, distinct morphologies, and questing and feeding behaviors of the more common ticks of dogs and cats in North America with a focus on recent changes in geographic distribution. We also review pathogens of dogs and cats associated with the different tick species, some of which can cause serious, potentially fatal disease, and describe the zoonotic risk posed by ticks of pets. Understanding the natural history of ticks and the maintenance cycles responsible for providing an ongoing source of tick-borne infections is critical to effectively combatting the challenges ticks pose to the health of pets and people.

Describing fine spatiotemporal dynamics of rat fleas in an insular ecosystem enlightens abiotic drivers of murine typhus incidence in humans

Murine typhus is a flea-borne zoonotic disease that has been recently reported on Reunion Island, an oceanic volcanic island located in the Indian Ocean. Five years of survey implemented by the regional public health services have highlighted a strong temporal and spatial structure of the disease in humans, with cases mainly reported during the humid season and restricted to the dry southern and western portions of the island. We explored the environmental component of this zoonosis in an attempt to decipher the drivers of disease transmission. To do so, we used data from a previously published study (599 small mammals and 175 Xenopsylla fleas from 29 sampling sites) in order to model the spatial distribution of rat fleas throughout the island. In addition, we carried out a longitudinal sampling of rats and their ectoparasites over a 12 months period in six study sites (564 rats and 496 Xenopsylla fleas) in order to model the temporal dynamics of flea infestation of rats. Generalized Linear Models and Support Vector Machine classifiers were developed to model the Xenopsylla Genus Flea Index (GFI) from climatic and environmental variables. Results showed that the spatial distribution and the temporal dynamics of fleas, estimated through the GFI variations, are both strongly controlled by abiotic factors: rainfall, temperature and land cover. The models allowed linking flea abundance trends with murine typhus incidence rates. Flea infestation in rats peaked at the end of the dry season, corresponding to hot and dry conditions, before dropping sharply. This peak of maximal flea abundance preceded the annual peak of human murine typhus cases by a few weeks. Altogether, presented data raise novel questions regarding the ecology of rat fleas while developed models contribute to the design of control measures adapted to each micro region of the island with the aim of lowering the incidence of flea-borne diseases.

Murine typhus is a neglected zoonotic disease, as the number of human cases is likely underestimated in the absence of specific symptoms. It is caused by Rickettsia typhi, a pathogenic bacterium transmitted by rat fleas (Xenospylla spp). The distribution and dynamics of this disease result from complex interactions involving vectors, reservoirs and humans within a shared environment. In this study, we explored the environmental drivers of rat fleas’ abundance on Reunion Island, where murine typhus has recently emerged. Results showed that i) rat fleas’ abundance is highly dynamic, characterized by a peak at the end of the dry season and ii) among the factors investigated, rainfall, temperature and land cover are the main determinants of rat fleas’ abundance. We modeled a predictive map of flea distribution that strongly correlates with the spatial distribution of human cases on the island. This study highlights the importance of accounting for environmental and climatic characteristics to better understand the spatial and temporal drivers of flea-borne diseases.

Molecular Characterization of Bartonella Species Discovered in Ectoparasites Collected from Domestic Animals, Cuzco, Peru

Rickettsiae and bartonellae are Gram-negative bacteria that can cause zoonotic and human diseases and are vectored by hematophagous arthropods. In the Americas, rickettsioses and bartonelloses have reemerged as significant public health threats. Bartonella species have been identified as causing zoonotic infections responsible for a variety of clinical syndromes in humans and animals. The aim of this study was to investigate the distribution, prevalence, and molecular heterogeneity of Rickettsia spp. and Bartonella spp. among ectoparasites collected from domestic animals in 14 farming communities in the Andes Mountains of Cuzco, Peru. A total of 222 domestic animals representing 8 different species (sheep, donkeys, goats, cattle, pigs, llamas, guinea pigs, and horses) were sampled. Nine species of ectoparasites (n = 1,697) collected from 122 animals were identified resulting in 1,657 chewing lice, 39 ticks, and 1 flea. DNA was individually extracted from a random sample of 600 (35.4%) considering variability of ectoparasite species, hosts, and sample location elevation. All 600 samples were negative for rickettsial DNA by a genus-specific molecular assay. A subset of 173 (28.8%) samples were selected based on variability of arthropods species, host, and location for Bartonella testing. Ninety-one (52.6%) of these samples including Melophagus ovinus (90/110) and Bovicola bovis (1/7) were positive for Bartonella by a genus-specific molecular assay. Five Bartonella genes of seven DNA samples from M. ovinus were analyzed by the multilocus sequence typing for characterization. We identified five identical Bartonella melophagi specimens and two specimens with Bartonella species related to B. melophagi from the seven M. ovinus. The Bartonella agents detected were widely distributed and frequent in multiple studied locations.

New Jersey-Wide Survey of Spotted Fever Group Rickettsia (Proteobacteria: Rickettsiaceae) in Dermacentor variabilis and Amblyomma americanum (Acari: Ixodida: Ixodidae)

For the last decade, the New Jersey (NJ) Department of Health has reported between 42 and 144 new cases each year of "spotted fever group rickettsiosis" (SFGR), a statistic that reflects uncertainty regarding which rickettsial agents (Proteobacteria: Rickettsiaceae: Rickettsia) are infecting NJ residents. To identify the Rickettsia circulating in NJ ticks, we used a combination of conventional and real time PCR approaches to screen 560 Dermacentor variabilis Say and 245 Amblyomma americanum L. obtained from a 1-day state-wide surveillance in May 2018 and an additional 394 D. variabilis collected across NJ in 2013-2018. We found zero D. variabilis infected with Rickettsia rickettsii, the agent of Rocky Mountain spotted fever and, on average, 1.3% infected with presumed nonpathogenic Rickettsia montanensis. We also found zero A. americanum infected with R. rickettsii, and 20% infected with Rickettsia amblyommatis, a prevalence somewhat lower than in more southern states. Overall, we conclude that it is unlikely that R. rickettsii vectored by D. variabilis is a primary cause of SFGR cases in NJ and discuss our findings in the context of known facts and current limitations. We conclude that understanding the causes of SFGR east of the Mississippi will require collaboration among medical doctors, public health authorities, and medical entomologists to follow up presumptive human cases of SFGR with detailed histories of exposure, species-specific molecular assays, and active surveillance of putative vectors and the pathogens they may carry.

A Brief History of the Major Rickettsioses in the Asia-Australia-Pacific Region: A Capstone Review for the Special Issue of TMID

The rickettsioses of the "Far East" or Asia-Australia-Pacific region include but are not limited to endemic typhus, scrub typhus, and more recently, tick typhus or spotted fever. These diseases embody the diversity of rickettsial disease worldwide and allow us to interconnect the various contributions to this special issue of Tropical Medicine and Infectious Disease. The impact of rickettsial diseases-particularly of scrub typhus-was substantial during the wars and "police actions" of the last 80 years. However, the post-World War II arrival of effective antibiotics reduced their impact, when recognized and adequately treated (chloramphenicol and tetracyclines). Presently, however, scrub typhus appears to be emerging and spreading into regions not previously reported. Better diagnostics, or higher population mobility, change in antimicrobial policies, even global warming, have been proposed as possible culprits of this phenomenon. Further, sporadic reports of possible antibiotic resistance have received the attention of clinicians and epidemiologists, raising interest in developing and testing novel diagnostics to facilitate medical diagnosis. We present a brief history of rickettsial diseases, their relative importance within the region, focusing on the so-called "tsutsugamushi triangle", the past and present impact of these diseases within the region, and indicate how historically, these often-confused diseases were ingeniously distinguished from each another. Moreover, we will discuss the importance of DNA-sequencing efforts for Orientia tsutsugamushi, obtained from patient blood, vector chiggers, and rodent reservoirs, particularly for the dominant 56-kD type-specific antigen gene (tsa56), and whole-genome sequences, which are increasing our knowledge of the diversity of this unique agent. We explore and discuss the potential of sequencing and other effective tools to geographically trace rickettsial disease agents, and develop control strategies to better mitigate the rickettsioses.

Assessing human exposure to spotted fever and typhus group rickettsiae in Ontario, Canada (2013-2018): a retrospective, cross-sectional study

BACKGROUND

Assessing the burden of rickettsial infections in Ontario, Canada, is challenging since rickettsial infections are not reportable to public health. In the absence of reportable disease data, we assessed the burden of rickettsial infections by examining patient serological data and clinical information.

METHODS

Our retrospective, cross-sectional study included patients who had Rickettsia serological testing ordered by their physician, in Ontario, from 2013 to 2018. We tested sera from 2755 non-travel patients for antibodies against spotted fever group rickettsiae (SFGR) and typhus group rickettsiae (TGR) using an indirect immunofluorescence assay (IFA) (positive IgG titers ≥1:64). We classified cases using a sensitive surveillance case definition: confirmed (4-fold increase in IgG titers between acute and convalescent sera with clinical evidence of infection), possible (single positive sera with clinical evidence) and previous rickettsial infection (single positive sera without clinical evidence). We classified cases seropositive for both SFGR and TGR as unspecified Rickettsia infections (URIs).

RESULTS

Less than 5% of all patients had paired acute and convalescent sera tested, and of these, we found a single, laboratory-confirmed SFGR case, with a 4-fold increase in IgG titers and evidence of fever, maculopapular rash and headache. There were 45 possible (19 SFGR, 7 TGR, 19 URI) and 580 previous rickettsial infection (183 SFGR, 89 TGR, 308 URI) cases. The rate of positive tests for SFGR, TGR and URI combined (all case classifications) were 4.4 per 100,000 population. For confirmed and possible cases, the most common signs and symptoms were fever, headache, gastrointestinal complaints and maculopapular rash. The odds of having seropositive patients increased annually by 30% (odds ratio = 1.3, 95% confidence interval: 1.23-1.39).

CONCLUSIONS

The rates of rickettsial infections in Ontario are difficult to determine. Based on confirmed and possible cases, rates are low, but inclusion of previous rickettsial infection cases would indicate higher rates. We highlight the need for education regarding the importance of testing acute and convalescent sera and consistent completion of the laboratory requisition in confirming rickettsial disease. We suggest further research in Ontario to investigate rickettsial agents in potential vectors and clinical studies employing PCR testing of clinical samples.

An apparent, locally acquired case of rickettsialpox (Rickettsia akari) in Ontario, Canada

Rickettsialpox, caused by Rickettsia akari, is a spotted fever group rickettsiae transmitted to humans through the bite of the house mouse mite (Liponyssoides sanguineus). Worldwide, rickettsialpox is most commonly associated with exposure to rodents in urban environments. Here, we present the case of a 47-year-old woman from Brantford, Ontario, with fever, eschar on the right leg, expanding erythema, and right groin lymphadenopathy. Early in infection, R. akari serology was negative (IgG <1:64), but convalescent titre increased to 1:1,024. The patient did not travel outside of Ontario in the previous year. She denied any rodent or arthropod exposures in her home, but recently visited a friend's home infested with bats and mice. The patient was afebrile after treatment with doxycycline, with resolution of most clinical and laboratory findings in 5 days. This is the first rickettsialpox case reported in Canada and highlights the importance of obtaining convalescent serology to assist in the diagnosis of rickettsial infection.

Spotted fever group rickettsiae canine serosurveillance near the US-Mexico border in California

BACKGROUND

Dogs are vulnerable to pathogens transmitted by brown dog ticks. An epidemic of Rocky Mountain spotted fever (RMSF) is underway in Mexicali, a Mexican city bordering California affecting people and dogs; several human cases have been reported in California residents who travelled to Mexico. To evaluate risks of RMSF, we conducted seroprevalence surveys in Imperial County in 2016 and 2017 using dogs as sentinels.

METHODS

Blood was collected from 752 dogs and was tested for antibodies against R. rickettsii, E. canis and A. phagocytophilum (as a proxy for A. platys). Samples were considered seropositive to spotted fever group rickettsia (SFGR) if the R. rickettsia titre was ≥1:64 and seropositive to E. canis and A. phagocytophilum if the titre was ≥1:32. Owners provided information on dog age, exposure risks, health status and tick prevention. We assessed associations between SFGR seropositivity and driving distance to the nearest US-Mexico border crossing station, whether proximity to a border crossing increased likelihood of taking dogs across the border, and whether distance to the border was associated with seropositivity. Logistic regression was performed to assess relationships between the titre classes and other predictor variables.

RESULTS

12.2% of dogs were seropositive against SFGR. Dogs close to the border were significantly more likely to be taken across the border and to be seropositive. Risk factors that increased seropositivity included owners seeing ticks on the dog (OR = 1.9), being an adult dog, travel to Mexico (OR = 3.0) and living in a rural area (OR = 4.0). There was statistically significant co-exposure to SFGR and Anaplasma spp.

CONCLUSION

Surveillance for brown dog tick-vectored pathogens can help identify dogs and people at risk for RMSF. Tick prevention, particularly in dogs, and surveillance of tick-borne pathogens can help prevent the spread of rickettsioses and other diseases in this dynamic border region.

Isolation and characterization of a Rickettsia from the ovary of a Western black-legged tick, Ixodes pacificus

A rickettsial isolate was obtained from a partially engorged Ixodes pacificus female, which was collected from Humboldt County, California. The isolate was provisionally named Rickettsia endosymbiont Ixodes pacificus (REIP). The REIP isolate displayed the highest nucleotide sequence identity to Rickettsia species phylotype G021 in I. pacificus (99%, 99%, and 100% for ompA, 16S rRNA, and gltA, respectively), a bacterium that was previously identified in I. pacifiucs by PCR. Analysis of sequences from complete opening frames of five genes, 16S rRNA, gltA, ompA, ompB, and sca4, provided inference to the bacteria's classification among other Rickettsia species. The REIP isolate displayed 99.8%, 99.4%, 99.2%, 99.5%, and 99.6% nucleotide sequence identity for 16S rRNA, gltA, ompA, ompB, and sca4 gene, respectively, with genes of 'R. monacensis' str. IrR/Munich, indicating the REIP isolate is closely related to 'R. monacensis'. Our suggestion was further supported by phylogenetic analysis using concatenated sequences of 16S rRNA, gltA, ompA, ompB, and sca4 genes, concatenated sequences of dksA-xerC, mppA-purC, and rpmE-tRNA^fMet intergenic spacer regions. Both phylogenetic trees implied that the REIP isolate is most closely related to 'R. monacensis' str. IrR/Munich. We propose the bacterium be considered as 'Rickettsia monacensis' str. Humboldt for its closest phylogenetic relative (=DSM 103975 T = ATCC TSD-94 T).

Emerging and re-emerging rickettsial infections

Rickettsial organisms are a diverse group of obligate intracellular bacteria; all species known to cause human disease are dependent on an arthropod vector and many are considered zoonotic diseases. Typical vectors of rickettsia are fleas, ticks, mites or lice. Humans become infected either when bitten or upon contact of broken skin or mucous membranes by infected secretions from an arthropod vector. The emergence and re-emergence of rickettsial diseases is a serious public health concern in the United States and abroad. Herein, the clinical and pathologic features of rickettsial diseases are described in tandem with the current scientific underpinnings. The histopathology of emerging and re-emerging rickettsiosis with species-specific discussion relating to vector issues and control are explored. Concepts of endemicity are addressed in the context of climate change and its impact on vector and sylvatic reservoirs, underscoring the need for clinical vigilance and broad consideration for encounters with these potentially life threating human pathogens.

Features of the Epidemiological Situation on Siberian Tick Typhus and other Tick-Borne Ricketsioses in the Russian Federation, Prognosis for 2019

The review presents an analysis of the epidemic situation on infections of rickettsial etiology, the causative agents of which are transmitted by Ixodidae ticks in the territory of the Russian Federation. The data obtained through molecular-biological verification allow to unite under the name of “tick-borne ricketsioses” a group of infections caused by R. sibirica subsp. sibirica, R. conorii, R. heilongjiangensis and other species of rickettsiae circulating in natural foci of various regions of Russia. Cases of tick-borne rickettsioses in Siberia and the Far East, caused by various species of rickettsiae, are registered under the name of “Siberian tick-borne typhus” due to the lack of available methods of differential laboratory diagnostics. The paper presents the assessment of the incidence of Siberian tick-borne typhus, indicating not only the varying degrees of epidemic hazard of endemic regions, but also changes in the distribution of risk areas, including the identification of new, epidemically significant foci. In accordance with the risk-oriented approach to prophylaxis, forecasting of epidemic situation on tick-borne rickettsioses was given and differentiation of the endemic territories of the Russian Federation as regards Siberian tick-borne typhus was carried out with distinguishing of epidemiological zones of low, medium, above average, high and very high risk of population infection.