Mediterranean Spotted Fever & Q Fever

ESCMID Online LectureDr. LibraryFigen KULOĞLU Trakya University Faculty of Medicine Infectious Diseases Department EDİRNE Species of Rickettsia

 Small rod-shaped bacteria

 Obligately intracellular bacteria of the α-Proteobacteria

 Gram negative cell wall structure that contains lipopolysaccharide, peptidoglycan, outer membrane protein B, a 17-kDa© lipoprotein by author and for SFG rickettsiae outer membrane protein A ESCMID Online Lecture Library  Giemsa and Gimenez stain

Species of Rickettsia

 Rickettsia spp. reside in an arthropod host for at least a part of their life cycle  tick, mite, louse, flea etc.  Transovarian transmission  Cycles involving horizontal transmission to mammalian hosts© by author

ESCMID Online Lecture Library Species of Rickettsia

 Target cells = vascular endotelium  Rickettsiae multiply in endothelial cells of small vessels, causing a vasculitis  Cell-to- cell spread  Vascular injury and subsequent host lymphohistiocytic response  A perivascular lymphohistiocytic© by author infiltrate in the skin, brain, lung, kidneys, liver, etc. ESCMID Online Lecture Library Species of Rickettsia

 Divided into two main groups

 The typhus group

 R. prowazekii, R. typhi

 The spotted fever© groupby author  R. conorii, R.rickettsii, R. akarii etc. ESCMID Online Lecture Library Etiology, epidemiology and ecology of rickettsial diseases Organism Disease Geographic ditribution Mode of transmission Natural cycle

Spotted fever group R. rickettsii Rocky Mountain spotted Western Hemisphere Tick bite Transovarian in ticks and fever rodent-tick cycles R. akari Rickettsialpox USA, Ukraine, Crotia, Korea Mite bite Transovarian in mites and mite-mouse cycles R. conorii Mediterranean spotted fever Southern Europe, Africa, Tick bite Transovarian in ticks Middle East R. africae African tick bite fever Sub-Saharan Africa, Tick bite Transovarian in ticks Caribbean R. parkeri American tick bite fever North and South America Tick bite Transovarian in ticks

R. sibirica North Asian tick typhus Asia, Europe, Africa Tick bite Transovarian in ticks R. japonica Japon spotted fever Japan Tick bite Ticks R. australis Queensland tick typhus Australia Tick bite Ticks R. honei Flinders Island spotted fever Australia, Thailand Tick bite Transovarian in ticks R. slovaca Tick-borne lymphadenopathy Eurasia Tick bite Unknown

R. felis Flea-borne spotted fever North and South America, Not known Transovarian in cat fleas Europe, Africa Typhus group R. prowazekii Primary louse-borne typhus© Worldwide by authorInfected louse feces Human-louse cycle rubbed into broken skin / mucous membranes R. prowazekii Brill-Zinsser disease Worldwide Recrudescence years after primary attack of ESCMID Online Lecturelouse-borne Library typhus R. typhi Murine typhus Worldwide Infected flea feces Rat-flea cycle rubbed into broken skin / mucous membranes Scrub typhus group O. tsutsugamushi Scrub typhus Japan, eastern Asia, Chigger bite Transovarian in mites northern Australia, west and southwest Pasific Mediterranean Spotted Fever (MSF)

 “Boutonneuse fever” because of a papular rash  Generally in spring and summer  High fever, headache, maculopapular rash ± a black eschar at the tick bite site  R. conorii is transmitted© by authorby the brown dog tick bite ESCMID R. conorii has Online a natural Lecturecycle between Library its athropod and vertebrate hosts, dogs Maculopapular Rash

© by author ESCMID Online Lecture Library Diagnosis  Serological methods  Isolation of rickettsiae: cultivation  Immunodetection  Polymerase chain reaction-based detection  16S rRNA gene  17 kDa protein encoding gene  Citrate synthase© by encoding author gene  The outer membrane proteins rOmpA ESCMIDand rOmpBOnline encoding Lecture genes Library

Serological Assays

 Weil-Felix test

P. vulgaris OX2, SFG

P. vulgaris OX19, TG and Rocky Mountain Spotted Fever

P. mirabilis OXK, Orientia tsutsugamushi © by author  Weil-Felix test is positive if: ESCMIDA fourfold or Onlinegreater increase Lecture in antibody Library titer A single antibody titer  cut-off value of 1/320

Serological Assays

 Indirect immunofluorescence assay (IFA)

 The most commonly used technique for the dignosis

 IFA is positive if:

(i) A seroconversion (ii) A fourfold or greater© increase by author in antibody titers (iii) A single antibody titer ≥ cut-off values of 1:128 for IgG ESCMID Online Lecture Library and 1:64 for IgM

 Mediterranean spotted fever (MSF) caused by a tick-borne pathogen, Rickettsia© conorii by subsp.author conorii  Belongs to the spotted fever group (SFG) rickettsiae ESCMID Online Lecture Library Mediterranean spotted fever in the Trakya region of Turkey

 Aim: To evaluate the cases with confirmed diagnosis of MSF from 2003 to 2009 in the Trakya region of Turkey  Patients with high fever+ maculopapular rash (involving the palms or soles) ± a black inoculation eschar at the site of the tick bite (tache noire) were included in the study  There were 128 patients© withby confirmed author MSF diagnosis  Before doxycycline treatment, skin biopsy specimens, ESCMIDpreferably from theOnline eschar or fromLecture the maculopapular Library rash, were obtained for DNA extraction Mediterranean spotted fever in the Trakya region of Turkey

© by author ESCMID Online Lecture Library Mediterranean spotted fever in the Trakya region of Turkey  IFA was performed to detect antibodies against R. conorii in acute and convalescent sera  Seroconversion or a 4 fold or greater rise in titre in 97 (77%) patients  A single high titre in 16 (12.7%) patients  A standard PCR reaction using primers suitable for hybridisation within the conserved region of genes coding for ompA and citrate synthase (gltA)  According to PCR analysis,© by58 (73%) author of 79 biopsy specimens from the eschar and 19 (70%) of 27 specimens from the maculopapular rash showed positive results (totally 77 (72.6%) of 106 biopsy ESCMIDsamples) Online Lecture Library  No significant difference was found between the rate of positive skin biopsies taken from the eschar and the maculopapular rash (chi-square: 0,094; p: 0,759) Mediterranean spotted fever in the Trakya region of Turkey  14 (10.9%) patients presented with a severe course of disease  5 had pneumonia, 4 had meningoencephalitis, 1 had both pneumonia and meningoencephalitis, 3 had multiple organ dysfunction, and 1 had pneumonia and multiple organ dysfunction  Two (1.6%) old patients with multiple organ dysfunction died  Doxycycline was administered for 7–14 days  Quinolones were used only in 2 patients  In the MSF cases, the mean© byduration author of high fever was 2.5 ± 1.4 days after doxycycline therapy  Since 2007, we had 3 patients in whom a differentiation between ESCMIDCrimean Congo haemorrhagic Online fever Lecture and SFG rickettsiosis Library could not be made according to clinical characteristics  Later these cases were serologically diagnosed as SFG rickettsioses Mediterranean spotted fever in the Trakya region of Turkey  DNA sequence analysis was performed  R. conorii conorii (type strain: Malish, ATCC VR-613)  MSF is a potentially severe and even fatal disease resembling viral haemorrhagic fevers  While IFA allows for retrospective diagnosis in MSF  Advanced molecular© techniques by author provide the rapid detection of rickettsia in all skin samples, including eschar ESCMIDand maculopapular Online rash Lecture Library

 Patients and methods: Epidemiological, clinical characteristics and risk factors for severe MSF cases were analysed retrospectively  A patient with two or more organ dysfunctions or patient death was defined as a severe case  Results: From January 1999 to December 2009, 161 MSF cases were referred and 26 cases (16.1%)© by were authorconsidered severe  Doxycycline administration prior to deterioration of disease (in 31 patients) protected patients from development of severe MSF  ESCMIDFluoroquinolone treatment Online (in 21 patients)Lecture was significantly Library and independently associated with MSF severity  Conclusions: Fluoroquinolone treatment was associated with increased MSF disease severity

 They retrospectively studied 339 patients, diagnosed with MSF between 2000 and 2011  All patients presented with fever (99.4%), rash (98.2%), and 57.9% had evidence of a tick bite  There were no recorded deaths  Serologic diagnosis was© made by by author IFA  MSF is endemic in southeastern Romania  Travel-associated MSF should be suspected in patients with ESCMIDcharacteristic symptoms Online returning Lecture from this endemic Library area

 Hindawi Publishing Corporation, BioMed Research International, Volume 2013, Article ID 395806, http://dx.doi.org/10.1155/2013/395806

 The first cases of MSF were described in Tunisia in 1909  As characteristic skin eruptions were papular rather than macular, the disease was referred to as ‘boutonneuse’ fever  The eschar at the site of the tick bite, the hallmark of rickettsial diseases, was described in Marseille in 1925 by Boinet and Pieri © by author  In the 1930s, the agent Rickettsia conorii and the vector Rhipicephalus sanguineus, the brown dog tick were described  ESCMIDSince that time, MSFOnline is known Lecture by clinicians Libraryto be endemic in Tunisia

First molecular detection of R. conorii subsp. conorii in Tunisia  Clinical features suggestive of diagnosis are fever, rash and eschar  The second rickettsiosis known in Tunisia is murine typhus, a flea-borne disease caused by R. typhi  IFA is used as a reference technique for the diagnosis of human rickettsioses  Molecular methods based on PCR amplification and sequencing of rickettsial© by target author genes  Among the four cutaneous biopsies, one was PCR- ESCMIDpositive and sequences Online of partialLecture gltA and Library OmpA were 100% identical to that of R. conorii subsp. conorii

 45 patients (65% men) included in the study  68% of patients were diagnosed between August and September  The average age of the 42 adult patients was 47.3 years  75% had inoculation eschars (25% of them had several inoculation eschars)  70% of the patients were treated with doxycycline, 16% with fluoroquinolones, 10% with© thiamphenicolby author, and 2% with josamycine  3 patients were hospitalized in intensive-care units, 1 of them died  12 (41%) of 29 obtained skin biopsy specimens tested positive by PCR  ESCMIDAll sequences obtained Online from positive Lecture PCR products Library shared homology with the corresponding sequences for R. conorii conorii strain Malish

 Between January 2000 and December 2007, 119 patients  The most common clinical findings: fever, skin rash and headache  Skin rash appeared 5 days after onset of fever, involved the palms and soles in 42 cases (41%), and face in 5 cases (5%)  Eschar was solitary in 33 cases and multiple in 5 cases  MSF was the most frequent© by rickettsiosis author, followed by endemic (murine) typhus and other undetermined SFG/typhus group ESCMIDrickettsioses Online Lecture Library  Six patients (5%) had co-infection with R. conorii and Coxiella burnetii Rickettsial infection in hospitalised patients in central Tunisia  PCR was positive in 4 of 14 skin biopsies (all from eschar)  DNA sequencing of the positive PCR products gave 100% homology with R. conorii Malish  101 patients (85%) received antibiotic treatment:  doxycycline in 86 cases (85%)  ciprofloxacin in 15 cases (15%)  Severe forms were noted© in 6by cases author (5%):  lymphocytic meningitis (3 cases), ESCMID meningoencephalitis Online (1 case), Lecture Library  chorioretinitis and deafness (one case each)  No patient died

 The aim of the study was to ascertain the frequency of retinitis and the role of fundus examination in the clinical diagnosis of MSF  This prospective study was undertaken at Fattouma Bourguiba University Hospital of Monastir,Tunisia  It included 47 consecutive immunocompetent patients who were hospitalised for high fever© ±by skin rashauthor  Of 47 patients, 32 (68%) had unilateral / bilateral ocular involvement  Fundus examination revealed retinitis with typical appearance of ESCMIDretinal lesions in 20 Online patients (42.5%) Lecture unilaterally Library(n = 10) or bilaterally (n = 10)

 Retinitis presented in the form of white retinal lesions associated with mild vitreous inflammatory reaction  This study shows that a retinitis with typical fundus appearance of retinal lesions is a hallmark of MSF  A systematic fundus examination should be part of the routine evaluation of a patient who presents with fever ± skin rash living in or© returning by author from a specific endemic area  ESCMIDRetinitis should Onlinebe added to Lecture the clinical diagnostic Library criteria for MSF

© by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Q fever  Q fever is a worldwide zoonosis caused by Coxiella burnetii  C. burnetii is a small, obligate intracellular bacterium  It is a small pleomorphic rod with a membrane similar to that of a Gram-negative bacterium  Domestic ruminants (cattle, goats, sheep) are the main reservoirs  Transmission is mainly accomplished through inhalation of contaminated aerosols© by author  Acute Q fever is defined as primary infection with C. burnetii ESCMIDIn humans, infection Online with C. burnetiiLecture remains Library asymptomatic in ~%60 of infected persons

E. Angelakis, D. Raoult / Veterinary Microbiology 140 (2010) 297–309 Q fever  Acute Q fever may presents as  A flu-like, self-limiting disease, atypical pneumonia or hepatitis  2% of patients with acute disease are hospitalized  Chronic Q fever  Endocarditis, especially in patients with previous valvulopathy, in immunocompromised hosts and in pregnant women  Osteomyelitis,vascular infections, and chronic hepatitis have also been described  Its estimated prevalence among cases of Q fever is 2%–5%  The definite diagnosis of© Q byfever isauthor made based on a significant increase in serum antibody titers  In the acute form, IgM against phase I and phase II (avirulent bacteria) ESCMID In the chronic phase, Online high levels Lecture of IgG against both Library phases are observed  Tetracyclines are the mainstay of antibiotic therapy

E. Angelakis, D. Raoult / Veterinary Microbiology 140 (2010) 297–309 Q fever

 Acute Q fever is defined as primary infection with C. burnetii  <60% of infected patients may be asymptomatic  Acute Q fever can manifest as an influenza-like syndrome, pneumonia, or hepatitis,  Chronic Q fever is defined as an infection that lasts 6 months  The most common form of chronic Q fever is endocarditis (73%)  Chronic Q fever has a phase I (virulent bacteria) immunoglobulin (Ig) G titer ≥800 © by author  C. burnetii isolated from acutely infected animals or humans, express a wild virulent form named phase I  ESCMIDAfter several passages Online in cell culture Lecture, the bacterium Library shifts from phase I to an avirulent phase named phase II

Q Fever in France, 1985–2009

 During January 1985–December 2009, a total of 179,794 serum samples were analyzed  Serologic criterion used to define Q fever:  Serum with a phase II IgG titer ≥200 and a phase II IgM titer ≥ 50 was predictive for acute Q fever  If a phase I IgG titer was ≥ 800, chronic Q fever was suspected  3,723 patients had acute Q fever (phase II IgG titer ≥ 200 and phase II IgM titer ≥ 50)© by author  1,675 had chronic Q fever (phase I IgG titer ≥ 800)  ESCMIDThe number of serum Online samples Lecture analyzed increased Library each year  The number of positive serum samples also increased

Q Fever in France, 1985–2009

 Its increased frequency in recent years is a combination of an increase in the disease (reemergence), growing interest among physicians and better diagnosis in laboratories  Monthly analysis of the past decade demonstrates peaks during April–September  A change in the phase I IgG cut off titer for detection of Q fever endocarditis to ≥ 600 was poposed  Finally, the number of© identified by author epidemics in France and Europe is increasing  ESCMIDIncreased surveillance Online of the diseaseLecture is the only Library way to determine the effects of Q fever The Q fever epidemic in The Netherlands  Since 2007, a Q fever outbreak has been ongoing in The Netherlands  This is referred to as the largest outbreak of Q fever ever reported in the literature  Q fever abortions (abortion storms) were registered on 30 dairy goat and dairy sheep farms between 2005 and 2009  A total of 3523 human© cases by were author notified between 2007 and 2009  Proximity to aborting small ruminants and high numbers of susceptibleESCMID humans Online are probably Lecture the main causes Library of the human Q fever outbreak in The Netherlands

The Q fever epidemic in The Netherlands

 The main clinical symptom of Q fever in goats and sheep is abortion and in cattle reduced fertility  With abortion, 1 000 000 000 C. burnetii per gram of placenta can be excreted  In milk, C. burnetii can be excreted for 8 days in ewes and up to 13 months in cattle  In faeces, C. burnetii ©can bybe excreted author up to 8 days after lambing in ewes and up to 20 days in goats  Goats may shed C. burnetii in two successive kidding periods  ESCMIDMost animal species Online carrying C.Lecture burnetii show Library no symptoms The Q fever epidemic in The Netherlands

 In humans infection with C. burnetii remains asymptomatic in 60% of infected persons  In symptomatic patients, acute Q fever usually presents as a flu-like, self-limiting disease, atypical pneumonia or hepatitis  Infection in pregnancy may lead to adverse pregnancy outcomes, such as spontaneous abortion or premature delivery  About 1–5% of all Q ©fever by cases author may progress into a chronic infection, often leading to life-threatening endocarditis ESCMID Online Lecture Library The Q fever epidemic in The Netherlands

 In the epidemic in a Swiss Alpine valley in 1983, the hospitalization of 7 patients with atypical pneumonia was diagnosed as due to Q fever  This detection was followed by a very large retrospective study in which infection was identified in nearly 15% of the inhabitants of the valley, probably correlated with migration of sheep  This showed that the proportion of patients presenting sufficiently severe symptoms to be hospitalized accounted for only 2%, and that 56% were completely asymptomatic  This means that for each patient© by being author diagnosed, an additional 50 patients probably remain undiagnosed  Under these conditions, it is very difficult to evaluate the true incidence of ESCMIDQ fever, and it is highl Onliney likely that someLecture epidemics have Library gone completely unnoticed Q Fever in the Greek Island of Crete: Epidemiologic, Clinical, and Therapeutic Data from 98 Cases Yannis Tselentis , Achilleas Gikas, Diamantis Kofteridis et al.

 A retrospective study was undertaken in Crete, Greece  Over a period of 5 years (1989-1993), 98 cases of Q fever  Contact with animals was found to be a major risk factor for Q fever  The predominant clinical manifestations: fever (91.7% ), respiratory disease (88.5%), hepatitis (7.1%)  Chest radiographs frequently© by revealed author pulmonary interstitial changes (36.4% of patients) and alveolar changes (34.4%)  There was no difference in the duration of fever whether the patient ESCMIDreceived therapy with Online tetracycline Lecture or erythromycin Library

Clinical Infectious Diseases 1995;20:1311-6

Q fever endocarditis in Greece: report of five cases S. Kokkini1, D. Kofteridis2, A. Psaroulaki1, N. Sipsas4, S. Tsiodras3, E. Giannitsiotiand and A. Gikas

 This is the first description of five cases of Q fever endocarditis in Greece  Over a 7-year period (2001–2007) the medical records of five adult patients with Q fever endocarditis, hospitalised in three different  healthcare settings in Greece, were retrospectively reviewed  Diagnosis of Q fever endocarditis was based on serological (phase I IgG antibody titres to C. burnetii >1:800) and compatible clinical criteria  All patients were male with© aby median author age of 53 (35 –58) years old  Risk factors such as structural valve disease were present in four ESCMIDpatients (80%) Online Lecture Library  Aortic stenosis in 3 patients and mitral valve prolapse in 1 patient

European Society of Clinical Microbiology and Infectious Diseases, CMI, 15 (Suppl. 2), 136–137 Q fever endocarditis in Greece: report of five cases S. Kokkini1, D. Kofteridis2, A. Psaroulaki1, N. Sipsas4, S. Tsiodras3, E. Giannitsiotiand and A. Gikas

 The median duration of illness prior to diagnosis was 90 (20–240) days  On admission, fever, night sweating, weight loss and fatigue were observed  Echocardiography showed vegetation in 2 of them, and a paravalvular abscess in another patient  In all patients specific antibodies against C. burnetii had a typical profile for C. burnetii endocarditis  The median anti-phase I IgG titre was 1 ⁄ 1600  All patients received tetracycline and all infections had a favourable outcome © by author  In 4 of the 5 patients hydroxychloroquine was not included in the ESCMIDtherapeutic combination Online Lecture Library  After a follow-up period of at least 24 months, no relapses or complications were observed

European Society of Clinical Microbiology and Infectious Diseases, CMI, 15 (Suppl. 2), 136–137 Trakya University Edirne