LETTERS increased during the past 13 years (6). also owns patents on a method and ap- irrigation and prosthesis retention. J Infect. This trend is accompanied by an in- paratus for device sonication (but has re- 2007;55:1–7. http://dx.doi.org/10.1016/ j.jinf.2007.01.007 crease in the total number of peripros- linquished her rights to receive royalties), an anti-biofilm substance, and Bordetella thetic joint infections, even though the Address for correspondence: Irene G. Sia, pertussis/parapertussis PCR. overall percentage of this complica- Division of Infectious Diseases, Mayo Clinic, tion is low (7). The most commonly 200 First Street SW, Rochester, MN 55904, isolated organisms in periprosthetic Benjamin Kloesel, USA; email: [email protected] joint infections are gram-positive coc- Margaret Beliveau, Robin Patel, ci, specifically Staphylococcus aureus Robert T. Trousdale, and S. epidermidis (8). In a retrospec- and Irene G. Sia tive review, Moran et al. (9) examined Author affiliation: Mayo Clinic, Rochester, the microbiological spectrum of 112 MN, USA patients undergoing debridement and irrigation for a periprosthetic joint in- DOI: http://dx.doi.org/10.3201/eid1907.130078 Tick-borne fection (hip [52], knee [51], elbow [4], ankle [3], shoulder [2]) at a tertiary References Encephalitis Virus, care center in the United Kingdom 1. Downes J, Olsvik B, Hiom SJ, Spratt Zealand, Denmark, during 1998–2003. The most frequent- DA, Cheeseman SL, Olsen I, et al. Bul- 2011 ly isolated microorganisms were co- leidia extructa gen. nov., sp. nov., iso- agulase-negative staphylococci (47%) lated from the oral cavity. Int J Syst Evol To the Editor: In Scandinavia, Microbiol. 2000;50:979–83. http://dx.doi. followed by methicillin-sensitive S. org/10.1099/00207713-50-3-979 the incidence of tick-borne encephali- aureus (44%), methicillin-resistant S. 2. Booth V, Downes J, Van den Berg J, Wade tis (TBE) is increasing and expanding aureus (8%), aerobic gram-negative WG. Gram-positive anaerobic bacilli in its geographic range (1). TBE virus organisms (8%), and anaerobes (7%). human periodontal disease. J Periodon- (TBEV) types TBEV-Eur and TBEV- tal Res. 2004;39:213–20. http://dx.doi. Thirty-seven percent of patient speci- org/10.1111/j.1600-0765.2004.00726.x Sib occur in Estonia and Finland, along mens grew multiple microorganisms. 3. Downes J, Munson MA, Spratt DA, with 2 tick species, Ixodes persulcatus We document the ability of B. Kononen E, Tarkka E, Jousimies-Somer and I. ricinus. In Denmark, TBE has extructa to cause an infection beyond H, et al. Characterisation of Eubacterium- been reported since the 1950s only like strains isolated from oral infections. its usual habitat, the oral flora. We J Med Microbiol. 2001;50:947–51. from the isolated Bornholm Island in hypothesize that the infection in this 4. Robertson D, Smith AJ. The microbiol- the Baltic Sea with an incidence of ≈4 patient might have developed from ogy of the acute dental abscess. J Med cases per 100,000 persons (2). Statisti- hematogenous seeding in which an Microbiol. 2009;58:155–62. http://dx.doi. cal climate-matching models based on org/10.1099/jmm.0.003517-0 undiscovered and asymptomatic oral 5. Paster BJ, Russell MK, Alpagot T, Lee the known spatial distribution of TBEV infectious nidus might have served as AM, Boches SK, Galvin JL, et al. Bac- indicate that the present North Zealand the seeding focus while mild trauma to terial diversity in necrotizing ulcerative climate also would support TBEV- the hip could have facilitated access to periodontitis in HIV-positive subjects. Eur transmission cycles (3). Recently Ann Periodontol. 2002;7:8–16. http:// the joint space. dx.doi.org/10.1902/annals.2002.7.1.8 (2008 and 2009), we reported TBE in 6. Singh JA. Epidemiology of knee and hip 2 persons who had histories of tick-bite Acknowledgments arthroplasty: a systematic review. Open and originated from a single location in Orthop J. 2011;5:80–5. http://dx.doi. a small forest area (Tokkekøb Hegn) in The authors thank Daniel R. Gus- org/10.2174/1874325001105010080 tafson and the outstanding staff of the 7. Kurtz SM, Lau E, Watson H, Schmier JK, North Zealand where TBE was previ- Mayo Clinic anaerobic bacteriology labo- Parvizi J. Economic burden of peripros- ously unrecognized (4). ratory for identification of this patient’s thetic joint infection in the United States. To determine whether TBE was J Arthroplasty. 2012;27(Supl):61–5. http:// established in this possibly new TBE bacterium. dx.doi.org/10.1016/j.arth.2012.02.022 focus in mainland Denmark outside Support was provided solely from in- 8. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint in- Bornholm, we collected ticks by flag- stitutional and departmental sources (De- fection: the incidence, timing, and ging (4) from 3 sites at Tokkekøb dur- partment of Internal Medicine, Division of predisposing factors. Clin Orthop Relat ing June–July 2011. The 3 sites yielded Res. 2008;466:1710–5. http://dx.doi. Infectious Diseases, Mayo Clinic, Roches- 896 ticks (854 nymphs, 22 male adults, ter, MN). org/10.1007/s11999-008-0209-4 9. Moran E, Masters S, Berendt AR, McLar- 20 female adults) in 24 pools. A fourth Dr Patel receives research support as dy-Smith P, Byren I, Atkins BL. Guiding site at Grib Forest 10 km to the north empirical antibiotic therapy in ortho- yielded 198 ticks (183 nymphs, 9 male a principal investigator from Pfizer, Prad- paedics: the microbiology of prosthetic ama, Tornier, Pocared, and Astellas. She joint infection managed by debridement, adult, 6 female adults) in 13 pools.
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Flagging was repeated in September flagging session (all nymphs) in Tok- locate to a spate clade. The missing 2011 at Tokkekøb to confirm the pres- kekøb were TBEV PCR positive, and 2 link between the isolates from Born- ence of TBEV and to obtain material yielded isolates (T2, T3) in VeroB4 cell holm and Zealand also was observed suitable for virus isolation. Here, we ob- culture. Considering that the duration of in a median joining network analysis tained 7 pools (100 nymphs each) and 1 the nymphal stage in I. ricinus is usu- (Splits Tree program, Epsilon1 [www. pool with adults (15 male, 15 female). ally only 1 or 2 years in northern Eu- splitstree.org], 2,000 iterations [data In September 2011, we also obtained 13 rope (7), the repeated identification of not shown]). pools (738 nymphs, 37 male adults, 41 TBEV in nymphs at the same location Two severe clinical cases of TBE female adults) at 3 suspected TBE loca- in 2009 and 2011 indicates establish- connected to this new focus occurred tions on Bornholm Island. In addition, ment of a new focus of endemic TBEV in 2008–2009 (4). To search for ad- 1,073 ticks in 58 pools were collected in in Denmark. ditional missed clinical TBE cases 2010 and 2011 from deer inspected by Phylogenetic analysis of TBEV- from this area, we examined serum the National Center for Wildlife Health E sequences (1,488 nt) of central Eu- and cerbrospinal fluid of 96 patients from 54 various locations (Figure, ropean (8) and Scandinavian TBEV (2007–2009) in whom encephalitis panel A). All ticks were identified as I. strains did not group the Zealand iso- developed after tick bite; these sam- ricinus on the basis of morphology. For late T2 (T3 was not sequenced) with ples were found negative for Borrelia TBEV-specific real-time PCR (5), ticks the Bornholm strain but into a sub- spp. by antibody ELISA and PCR were homogenized in 0.5 mL nucleic clade with 2 isolates from Sweden, (online Technical Appendix, wwwnc. acid extraction buffer and RNA/DNA Torö-2003 (9) (GenBank accession cdc.gov/EID/article/19/7/13-0092- extracted from 0.2 mL homogenate by no. DQ401140) and Saringe-2009 Techapp1.pdf). To assess anti-TBEV using the MagNA Pure total NA kit (GenBank accession no. KC469073); seroprevalence, we also tested serum (Roche, Indianapolis, IN, USA). Three an isolate from Norway (GenBank ac- from 78 patients experiencing “sum- of 37 pools (2 with nymphs, 1 with cession no. EF565947), and isolates mer flu” who had histories of tick bite; adult females) from Tokkekøb were from North Bohemia (Czech Repub- this serum was submitted by general TBEV RNA positive. None of 58 tick lic). The Bornholm strain located into practitioners in North Zealand dur- pools from other locations in Denmark a different subclade containing vari- ing July–November 2010 (online or Bornholm were positive for TBEV ous sequences from South and Central Technical Appendix). Except for 1 but contained other pathogens (6). Five Bohemia (Figure, panel B). TBEV se- patient infected in Bornholm and 2 pa- of the 8 pools obtained from the second quences from the Baltics and Finland tients infected in Sweden, none were
Figure. A) Tick collection areas in Denmark. Red indicates ticks sampled from animals; blue indicates flagging. B) Neighbor-joining phylogenetic analysis of a 1,488-nt set of 78 tick-borne encephalitis virus (TBEV)–Eur E gene sequences including reference strains Neudoerfl (Austria) and Hypr 71 (South Moravia) performed in ClustalW with a 1,000 bootstrap approach (LASERGENE, MEGALIGN, DENDROSCOPE) outgrouped to Louping ill virus (data not shown). Sequence designations of central European strains as in (8). Dark gray indicates Denmark Bornholm clade; white indicates Swedish-Norwegian clade. For simplicity, some subtrees were collapsed; these are designated with region and number of sequences in the collapsed subtree in brackets.
1172 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 7, July 2013 LETTERS positive by ELISA (Enzygnost Anti- References Usutu Virus in TBE/FSME Virus [IgG, IgM] Siemens, Erlangen, Germany) or PCR (online 1. Jääskeläinen AE, Tonteri E, Sironen T, Migratory Song Pakarinen L, Vaheri A, Vapalahti O. Technical Appendix). Since the 1980s, European subtype tick-borne encephalitis Thrushes, Spain Sweden has experienced a 4-fold in- virus in Ixodes persulcatus ticks. Emerg crease in human TBE incidence, with Infect Dis. 2011;17:323–5. http://dx.doi. To the Editor: Usutu virus spread southwest (10). The emergence org/10.3201/eid1702.101487 (USUV), a member of the Japanese 2. Skarphédinsson S, Jensen PM, Kristiansen of the TBEV strain T2 closely related encephalitis virus antigenic group, K. Survey of tick-borne infections in Den- was first detected in 1959 in to isolates from Sweden may be a con- mark. Emerg Infect Dis. 2005;11:1055–61. tinuation of this geographic trend. A http://dx.doi.org/10.3201/eid1107. mosquitoes in South Africa (1), and it previous antibody study found 3 deer 041265 emerged in 1996 in blackbirds (Turdus 3. Randolph SE, Rogers DJ. Fragile trans- positive for TBEV in Zealand-Falster merula) in Italy (2). Recent cases of mission cycles of tick-borne encephalitis USUV infection in asymptomatic (2); however, without convincing virus may be disrupted by predicted climate neutralization data, this finding is not change. Proc Biol Sci. 2000;267:1741–4. blood donors (3) and severe disease confirmed. The lack of TBEV viremia http://dx.doi.org/10.1098/rspb.2000.1204 in immunocompromised persons (4) 4. Fomsgaard A, Christiansen CB, Bød- and seropositivity among the patients have shown its zoonotic potential. ker R. First identification of tick-borne Epidemiology and molecular in Zealand who had histories of tick encephalitis in Denmark outside of bites supports a recent introduction to Bornholm, August 2009. Euro Surveill. phylogeny of USUV isolated in Italy, the new focus. Thus, 2 distinct intro- 2009;14:pii19326. Austria, Hungary, Switzerland, and 5. Schwaiger M, Cassinotti P. Development ductions of TBEV have occurred in Germany suggest that stable endemic of a quantitative real-time RT-PCR assay mosquito–bird cycles have been Denmark. The underlining environ- with internal control for the laboratory mental or climatic factors driving this detection of tick borne encephalitis virus established in Europe (5,6). Where geographic trend remain unknown. (TBEV) RNA. J Clin Virol. 2003;27:136– active vector surveillance programs 45. http://dx.doi.org/10.1016/S1386-6532 exist, USUV is detected in mosquitoes (02)00168-3 before bird deaths and human Acknowledgment 6. Fertner ME, Mølbak L, Boye Pihl TP, infections. USUV strains similar We thank Anne Lyhning Jensen for Fomsgaard A, Bødker R. First detection to African strains were detected in expert technical assistance. of tick borne “Candidatus Neoehrlichia mikurensis” in Denmark 2011. Euro Sur- mosquitoes in Spain in 2006 and Baxter Denmark provided financial veill. 2012;17:pii20096. 2009 (7,8). 7. Sonenshine DE. Biology of ticks. Vol. 2. support for this study. New York: Oxford University Press; 1993. In November 2012, two live song 8. Weidmann M, Ruzek D, Krivanec K, thrushes (Turdus philomelos) with Anders Fomsgaard, Zöller G, Essbauer S, Pfeffer M, et central nervous system signs were Mette E. Fertner, al. Relation of genetic phylogeny and recovered from a die-off of ≈10 birds geographical distance of tick-borne en- Sandra Essbauer, cephalitis virus in central Europe. J Gen at a hunting estate in southern Spain. Alex Y. Nielsen, Stefan Frey, Virol. 2011;92:1906–16. http://dx.doi.org/ A full necropsy was conducted on the Pontus Lindblom, 10.1099/vir.0.032417-0 2 thrushes (which died shortly after Per-Eric Lindgren, 9. Melik W, Nilsson AS, Johansson M. capture), and samples were collected Detection strategies of tick-borne Rene Bødker, encephalitis in Swedish Ixodes ricinus for virus detection and histopathologic Manfred Weidmann, reveal evolutionary characteristics of examination. Total RNA was extracted and Gerhard Dobler emerging tick-borne flavivirus. Arch Vi- from oral and cloacal swab specimens, Author affiliations: University of Southern rol. 2007;152:1027–34. http://dx.doi. from serum from a cardiac blood org/10.1007/s00705-006-0922-9 Denmark, Odense, Denmark (A. Foms- 10. Jaenson TGT, Hjertqvist M, Bergström clot, and from heart, kidney, spleen, gaard); Statens Serum Institut, Copenha- T, Lundkvist A. Why is tick-borne and brain tissues by using High Pure gen, Denmark (A. Fomsgaard, M.E. Fertner, encephalitis increasing? A review of RNA Tissue Kit (Roche Diagnostics, A.Y. Nielsen); Institut für Mikrobiologie der the key factors causing the increasing Barcelona, Spain) and analyzed incidence of human TBE in Sweden. Bundeswehr, Munich, Germany (S. Essbau- Parasit Vectors. 2012;5:184. http://dx.doi. by generic flavivirus SYBR Green er, S. Frey, G. Dobler); Linköping University, org/10.1186/1756-3305-5-184 (QIAGEN, Madrid, Spain) real-time Linköping, Sweden (P. Lindblom, P.-E. Lind- reverse transcription PCR (RT-PCR) gren); Technical University of Denmark, Address for correspondence: Anders Fomsgaard, and by a generic conventional nested Copenhagen (R. Bødker); and Abteilung Department of Microbiology Diagnostic and flavivirus RT-PCR (9). The product Virologie, Universitätsmedizin Göttingen, Virology, Statens Serum institute, 5 Artillerivej, of the first PCR (1,048 bp) was Göttingen, Germany (M. Weidmann) DK-2300 Copenhagen, Denmark; email: resin purified, cloned into pGEM-T [email protected] DOI: http://dx.doi.org/10.3201/eid1907.130092 (Promega, WI, USA), and sequenced.
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