LETTERS baumannii isolate also being resistant 3. Kolayli F, Gacar G, Karadenizli A, Sanic Human Infection to carbapenems. This resistance was A, Vahaboglu H; The Study Group. PER- 1 is still widespread in Turkish hospitals with sp. likely acquired in vivo under imipen- among and em treatment, but the susceptible Acinetobacter spp. FEMS Microbiol Lett. related to R. strain was not available for strain 2005;249:241–5. japonica, Thailand comparison. This is also the first 4. Naas T, Bogaerts P, Bauraing C, Degheldre Y, Glupczynski Y, Nordmann description of a PER-1 A. baumannii P. Emergence of PER and VEB extended- To the Editor: Although rick- isolate from Russia, a country from spectrum beta-lactamases in Acineto- ettsioses caused by scrub and which little epidemiologic data on bacter baumannii in Belgium. J typhus group rickettsiae are well rec- antimicrobial drug resistance are Antimicrob Chemother. 2006;58:178–82. ognized in Thailand, few spotted- 5. Naas T, Coignard B, Carbonne A, available, except for the emergence of Blanckaert K, Bajolet O, Bernet C, et al. fever group rickettsiae (SFGR), ESBLs of CTX-M type in VEB-1 extended-spectrum β-lactamase– including Rickettsia honei TT118 and (10). producing , R. felis, have been documented to be This study highlights the impor- France. Emerg Infect Dis. 2006;12: associated with human illnesses (1,2). 1214–22. tance of international patient transfer 6. Clinical and Laboratory Standards We report a case of human infection in the spread of antimicrobial drug Institute. Performance standards for with an SFGR species closely related resistance, thus emphasizing the need antimicrobial susceptibility testing: 15th to R. japonica in Thailand. for hospitals to isolate and screen for informational supplement. M100-S15. In January 2005, a 36-year-old Wayne (PA): Clinical and Laboratory multidrug-resistant pathogens in all Standards Institute; 2005. man with prolonged fever, pneumo- patients admitted to hospitals from 7. Fernández-Cuenca F, Martínez-Martínez nia, and septic shock was transferred foreign countries. This is particularly L, Conejo MC, Ayala JA, Perea EJ, from a private hospital to critical when the foreign country is Pascual A. Relationship between β-lacta- Phramongkutklao Army Hospital in mase production, outer membrane protein known for a high prevalence of mul- and penicillin-binding protein profiles on Bangkok. Two weeks before the onset tidrug-resistant or when no the activity of carbapenems against clini- of fever, the patient had camped at antimicrobial drug resistance data are cal isolates of Acinetobacter baumannii. J Khao Yai National Park, ≈175 km available. Antimicrob Chemother. 2003;51:565–74. northeast of Bangkok. The park is a 8. Poirel L, Cabanne L, Vahaboglu H, Nordmann P. Genetic environment and popular location for tourists and the expression of the extended-spectrum largest national park declared as a nat- This work was funded by a grant beta-lactamase blaPER-1 gene in gram-neg- ural wildlife reserve area. The patient from the Ministère de l’Education ative bacteria. Antimicrob Agents reported the presence of wild deer Nationale et de la Recherche (UPRES- Chemother. 2005;49:1708–13. around the camping area but did not 9. Tenover FC, Arbeit RD, Goering RV, EA3539), Université Paris XI, and by the recall being bitten by an arthropod. European Community (6th PCRD, Mickelsen PA, Murray BE, Persing DH, et al. Interpreting chromosomal DNA Ten days before hospitalization, he LSHMCT- 2003-503-335). restriction patterns produced by pulsed- developed flulike symptoms, fever, field gel electrophoresis: criteria for bac- and sore throat. Six days later, he terial strain typing. J Clin Microbiol. Thierry Naas,* Serge Kernbaum,† 1995;33:2233–9. noted petechiae on his lower extremi- Sophie Allali,† 10. Edelstein M, Pimkin M, Palagin I, ties, and his condition worsened. At and Patrice Nordmann* Edelstein I, Stratchounski L. Prevalence the time of hospital admission, the *Hôpital de Bicêtre, K.-Bicêtre, France; and and molecular epidemiology of CTX-M patient had fever of 38.6°C, tachycar- extended-spectrum beta-lactamase-pro- †American Hospital of Paris, Neuilly-sur- dia, dyspnea, hypotension, nausea, Seine, France ducing and in Russian hospitals. vomiting, generalized maculopapular Antimicrob Agents Chemother. rash, and subconjunctival hemor- References 2003;47:3724–32. rhage. Laboratory investigation 1. Allen DM, Hartman BJ. Acinetobacter showed thrombocytopenia (platelets Address for correspondence: Thierry Naas, species. In: Mandell GL, Bennett JE, 64,000/mm3), leukocytosis (14,000/ Service de Bactériologie-Virologie, Hôpital de Dolin R, editors. Principles and practice mm3), and elevated levels of serum of infectious diseases. 5th ed. Bicêtre, 78 rue du Général Leclerc, 94275 K.- hepatic enzymes (aspartate amino- Philadelphia: Churchill Livingstone; Bicêtre CEDEX, France; email: thierry.naas@ 2000. p. 2339–44. transferase 287 IU/L [reference 5–50 bct.ap-hop-paris.fr 2. Nordmann P, Poirel L. Emerging car- IU/L]; alanine aminotransferase 186 bapenemases in gram-negative aerobes. IU/L [reference 5–40 IU/L]). Chest Clin Microbiol Infect. 2002;8:321–31. radiograph showed interstitial pneu- monitis. Serum antibody test results were negative for leptospira and

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 4, April 2007 671 LETTERS dengue virus; blood smear was nega- cific 17-kDa antigen gene (3) and a this patient is closely related and clus- tive for malaria. 690 bp-portion of the Orientia 56- tered within the same clade of R. Samples of the patient’s whole kDa antigen gene (4). An appropriate japonica (Figure). Isolation of this blood were collected in EDTA on control panel included DNA from a rickettsial agent from the patient’s days 10, 18, 20, and 25 after illness reference sample of human blood, blood by animal inoculation and by onset, and each sample was sent at the Coxiella sp., and Leptospira interro- cell culture methods is ongoing. time of collection to the Armed Forces gans. Platinum Taq DNA Polymerase Persons visiting Khao Yai Research Institute of Medical High Fidelity (Invitrogen, Carlsbad, National Park are at risk for rick- Sciences, Bangkok, to be investigated CA, USA) enzyme mixture was used ettsioses, particularly SFGR. Vectors for rickettsial infection. Plasma was in PCR. By resolution on agarose gel, for SFGR have been found in this area separated and tested for , a PCR fragment of the expected size (5). The clinical and molecular find- typhus group, and SFGR-specific for the 17-kDa antigen gene was ings in this case add to the accumulat- immunoglobulin M (IgM) and IgG by observed from the day-10 sample but ing data on the emerging rickettsial immunofluorescence assay by using not from the control samples. AluI agents and their geographic distribu- Karp-Kato- restriction pattern of amplified 17- tion in Thailand. Gilliam strains and R. typhi kDa fragment was similar to that of Wilmington and R. honei TT118 SFGR. Additional rickettsial gene Acknowledgments whole cell antigens. No antibodies to fragments, 630 nt-ompA (nt 70–701) We thank Naovarat Khajeejit for lab- rickettsiae were detected in the initial and 945 nt-gltA (RpCS.193F-5′- oratory assistance with immunofluores- sample. On day 18, only antibodies GTAGGGTATCTGCGGAAGCC-3′, cence assay and Pimmada against R. honei TT118 antigen were RpCS.1143R-5′ -GAGCGAGA Jeamwattanalert for data analysis and detected at a low titer, 50 for IgM and GCTTCAAGTTCTATTGC-3′), were manuscript preparation. 200 for IgG, while antibodies to scrub also amplified from the day-10 speci- This work was supported by grant ID typhus and typhus group rickettsiae men. All amplicons were excised 02-2-RIC-28-059 from Thailand-Tropical remained negative (titers <50). from agarose gels, purified by QIAEX Diseases Research Programme (T-2), Antibody level was unchanged on II Gel Extraction Kit (QIAGEN), and Thailand to J.G. days 20 and 25. then sequenced. BLAST analysis of At the time of admission, the 17-kDa antigen gene (GenBank patient began receiving 2 g of intra- accession no. DQ909071), gltA Jariyanart Gaywee,* venous ceftriaxone and 200 mg of oral (DQ909073), and ompA (DQ909072) Piyanate Sunyakumthorn,* doxycycline daily. Three days later, segments obtained from this patient Wuttikon Rodkvamtook,* treatment with doxycycline was showed 99% identity to correspon- Toon Ruang-areerate,* stopped because the initial serologic ding genes of R. japonica. Carl Jeffries Mason,* results for rickettsia were negative. Phylogenetic analysis of these 3 genes and Narongrid Sirisopana* However, doxycycline was resumed indicates that the Rickettsia sp. from on day 21, after antibodies to Thai tick typhus agent were detected in a sec- ond specimen. Within 3 days, the patient was afebrile and asympto- matic. He was discharged from the hospital and continued oral doxycy- cline for an additional 7 days. At 2- week follow up, he had completely recovered. To identify which SFGR was responsible for the patient’s illness, we used molecular approaches. We extracted DNA from the patient’s blood specimens by using QIAamp Mini blood kit (QIAGEN, Valencia, Figure. Phylogenetic relationships between Rickettsia sp. and rickettsial genes amplified CA, USA) and subjected it to duplex from the patient (PMK 94) inferred from comparison with the rickettsial 17-kDa antigen nested–PCR assays targeting a 343-bp gene, gltA, and ompA sequences by the neighbor-joining method. Bootstrap values of fragment of the rickettsial genus–spe- 1,000 replicates are indicated.

672 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 4, April 2007 LETTERS

*Armed Forces Research Institute of 3. Higgins JA, Azad AF. Use of polymerase Address for correspondence: Jariyanart Medical Sciences, Bangkok, Thailand chain reaction to detect bacteria in arthro- Gaywee, Department of Epidemiology, pods: a review. J Med Entomol. Research Division, Armed Forces Research 1995;32:213–22. References 4. Enatsu T, Urakami H, Tamura A. Institute of Medical Sciences (AFRIMS) 315/6 1. Parola P, Miller RS, McDaniel P, Telford Phylogenetic analysis of Orientia tsutsug- Rajvithi Rd, Rajthawee, Bangkok 10400, SR, Rolain J-M, Wongsrichanalai C, et al. amushi strains based on the sequence Thailand; email: [email protected] Emerging rickettsioses of the Thai- homologies of 56-kDa type-specific anti- Myanmar border. Emerg Infect Dis. gen genes. FEMS Microbiol Lett. The opinions expressed by authors con- 2003;9:592–5. 1999;180:163–9. tributing to this journal do not necessari- 2. Jiang J, Sangkasuwan V, Lerdthusnee K, 5. Hirunkanokpun S, Kittayapong P, Cornet ly reflect the opinions of the Centers for Sukwit S, Chuenchitra T, Rozmajzl PJ, et J-P, Gonzalez J-P. Molecular evidence for Disease Control and Prevention or the al. Human infection with Rickettsia honei, novel tick-associated group institutions with which the authors are Thailand. Emerg Infect Dis. rickettsiae from Thailand. J Med affiliated. 2005;11:1473–5. Entomol. 2003;40:230–7.

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