LETTERS

Rickettsia and goats and sheep grazed at close phase blood samples were drawn for proximity to his residence. serum and whole blood analysis. Ti- aeschlimannii Serum and whole blood samples ters against R. conorii were detected Infection in a Man, were drawn, and a local skin biopsy in both the initial samples (IgM 1/100, Greece was performed from the center of the IgG 1/60) and the convalescent-phase skin lesion. Laboratory tests revealed samples (IgM 1/100, IgG 1/120). To the Editor: In Greece, 6 spotted a high level of C-reactive protein, mi- DNA was extracted from the blood fever group (SFG) Rickettsia species croscopic hematuria, and a leukocyte samples, the skin biopsy, and the tick have been detected in ticks: Rickettsia count of 6.01 × 109 cells/L. Hepatic by using a QIAamp Tissue Kit (QIA- conorii, R. massiliae, R. aeschlimannii, enzymes alanine transaminase and as- GEN, Courtaboeuf, France ) and used R. sibirica mongolitimonae, R. slovaca, partate aminotransferase were within as a template in previously described and R. rhipicephali (1). SFG species normal ranges. The patient was treated PCR assays by using primers RpCS present characteristic clinical signs, with doxycycline, 100 mg twice daily 877p-RpCS 1258n and Rr19070p- including high fever, headache, and for 7 days; he did not develop further Rr190602n, targeting a 381-bp portion maculopapular rash; an inoculation es- symptoms, and the skin lesion healed of the gltA and a 532-bp portion of the char at the tick bite site is characteristic without ulceration. ompA genes of Rickettsia spp. (5). of some, but not all, SFG rickettsioses. All samples were sent to the Lab- The whole blood drawn in the hospi- Symptoms during the early stages of oratory of Clinical Bacteriology, Para- tal, the skin biopsy, and the tick were illness are nonspecific, and diagnosis is sitology, Zoonoses and Geographic positive for both genes. However, a challenge for physicians who are not Medicine at the University of Crete the convalescent-phase blood sample familiar with rickettsial diseases. So for further testing. The tick was identi- was negative. far, 2 SFG Rickettsia species have been fied asRhipicephalus turanicus by us- PCR products were purified by implicated in human disease in Greece: ing standard taxonomic keys (4). IgG using the QIAquick Spin PCR Purifi- Mediterranean spotted fever caused and IgM titers reactive to SFG rickett- cation Kit (QIAGEN) and sequenced by R. conorii (2), and lymphagitis- siae antigens were determined by an (Bioanalytica–Genotype, Athens, associated rickettsiosis (LAR) caused immunofluorescence antibody assay Greece) according to the manufactur- by R. sibirica mongolitimonae (3). We as described by the manufacturer (bio- er’s instructions. Sequences obtained report a rickettsiosis case in a man on Mérieux, Marcy l’Etoile, France). shared 100% similarity to the cor- the island of Crete, Greece caused by Twenty days after initial assess- responding fragment of the genome a third Rickettsia species belonging to ment and treatment, convalescent- of R. eschlimannii (gltA: JF803904; the SFG, R. aeschlimannii. During June 2010, a 70-year-old man residing in an agricultural area of eastern Crete was admitted to the emergency unit of General Hospital of Agios Nikolaos for evaluation of a reddish, painless papule on the ante- rior surface of his left arm. The pap- ule was 2 cm in diameter, and was surrounded by a less reddened infil- trated area 8 cm in diameter (Figure). The area was without tenderness or pruritus. At the center of the papule, which was cyanotic, the presence of a tick was recorded, and the tick was removed carefully in its entirety. The patient was afebrile and reported no other symptoms. The papule had de- veloped within few hours, although 5 days previously, the patient had noticed a dark colored nodule on his Figure. Papule on the anterior surface of the left arm of a 70-year-old man, Crete, Greece. left arm but paid no attention to it. The The papule was surrounded by an infiltrated area without tenderness or pruritus. A tick was patient reported that rabbits were bred found in the center of the papule and carefully removed in its entirety.

1176 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 7, July 2013 LETTERS ompA: JF803906). All samples were Author affiliations: General Hospital of Ag- 9. Fernández-Soto P, Encinas-Grandes A, cultured in human embryonic lung ios Nikolaos, Crete, Greece (A. Germana- Perez-Sanchez R. Rickettsia aeschliman- nii in Spain: molecular evidence in Hya- kis); Regional Laboratory of Public Health, fibroblasts as described (6). After 4 lomma marginatum and five other tick weeks, no bacteria were isolated. Heraklion-Crete, Greece (D. Chochlakis, species that feed on humans. Emerg Infect We report a human case of R. es- Y. Tselentis); University of Crete Medical Dis. 2003;9:889–90. chlimannii infection in Crete, Greece. School, Heraklion, Greece (Emmanouil 10. Raoult D, Fournier PE, Abboud P, Caron F. First documented human Rickettsia ae- Angelakis, Anna Psaroulaki); and Aix-Mar- Our finding was confirmed by molec- schlimannii infection. Emerg Infect Dis. ular methods. However, we were not seille University School of Medicine, Mar- 2002;8:748–9. http://dx.doi.org/10.3201/ able to cultivate R. aeschlimannii from seille, France (E. Angelakis) eid0807.010480 samples collected. This result suggests DOI: http://dx.doi.org/10.3201/eid1907.130232 that living microorganisms may have Address for correspondence: Anna Psaroulaki, Laboratory of Clinical Bacteriology, Parasitology, died before testing or that only DNA, References but no living organism, was present in Zoonoses and Geographical Medicine, Faculty the samples. R. aeschlimannii was first 1 Psaroulaki A, Ragiadakou D, Kouris G, of Medicine, University of Crete, PO Box isolated from Hyalomma marginatum Papadopoulos B, Chaniotis B, Tselentis Y. 1393, Heraklion, Crete 71110, Greece; email: Ticks, tick-borne rickettsiae, and Coxiella [email protected] ticks from Morocco (7). In Europe, burnetii in the Greek Island of Cephalonia. R. aeschlimannii has also been found Ann N Y Acad Sci. 2006;1078:389–99. in ticks from Germany, Russia, Italy, http://dx.doi.org/10.1196/annals.1374.077 France, Croatia, Portugal, and Spain 2. Psaroulaki A, Germanakis A, Gikas A, Scoulica E, Tselentis Y. First isolation (8). In Greece, R. aeschlimannii has and genotypic identification of Rickett- been detected in H. anatolicum exca- sia conorii Malish 7 from a patient in Antibodies against vatum ticks collected from sheep (1). Greece. Eur J Clin Microbiol Infect Dis. The tick removed from this patient 2005;24:297–8. http://dx.doi.org/10.1007/ Rift Valley Fever s10096-005-1304-z was Rh. turanicus, a species that has 3. Psaroulaki A, Germanakis A, Gikas A, Virus in Cattle, been reported in Spain to be infected Scoulica E, Tselentis Y. Simultaneous Mozambique with R. aeschlimannii (9). detection of “Rickettsia mongolotimonae” The first human case of R. ae- in a patient and in a tick in Greece. J Clin Microbiol. 2005;43:3558–9. http://dx.doi. To the Editor: During the past schlimannii infection was identified org/10.1128/JCM.43.7.3558-3559.2005 2 decades, several countries in Africa in a patient who had fever, rash, and 4. Ioannou I, Sandalakis V, Kassinis N, Cho- and the Arabian Peninsula, to which an eschar after travel in Morocco chlakis D, Papadopoulos B, Loukaides F, Rift Valley fever virus (RVFV) is en- (10). R. aeschlimannii infections in et al. Tick-borne bacteria in mouflons and their ectoparasites in Cyprus. J Wildl Dis. demic, have reported outbreaks of Rift humans have been previously con- 2011;47:300–6. Valley fever in humans and livestock. firmed in South Africa, in Algeria, 5. Chochlakis D, Ioannou I, Sandalakis The first evidence of RVFV in Mo- and in Tunisia (8). To our knowledge, V, Dimitriou T, Kassinis N, Papado- zambique was documented as early as human cases of R. aeschlimannii in- poulos B, et al. Spotted fever group Rickettsiae in ticks in Cyprus. Microb the 1960s (1). Endemicity was subse- fection have not been reported in Ecol. 2012;63:314–23. http://dx.doi. quently confirmed in the 1980s by a Europe. Our results emphasize that org/10.1007/s00248-011-9926-4 prevalence study that identified virus- ticks should be considered as poten- 6 Angelakis E, Richet H, Rolain JM, specific antibodies in 2% of pregnant tial vectors for rickettsial infections La Scola B, Raoult D. Comparison of real-time quantitative PCR and culture for women (2) and in the 1990s by sero- in humans. We recommend that when the diagnosis of emerging Rickettsioses. surveillance in Zambezia Province, one species or serotype of tick-trans- PLoS Negl Trop Dis. 2012[cited 2012 Jul which showed that cattle had been mitted Rickettsia is identified in an 12];6:e1540. http://www.plosntds.org/arti- infected with RVFV (3). area, physicians be informed through cle/info%3Adoi%2F10.1371%2Fjournal. pntd.0001540 Apart from those observations, established clinical or public health 7. Beati L, Meskini M, Thiers B, Raoult D. the RVFV situation in Mozambique channels of the potential pathogen, Rickettsia aeschlimannii sp. nov., a new is still poorly understood. We recently its manifestations, and recommended spotted fever group rickettsia associated found an unexpectedly high level of treatments for humans. with Hyalomma marginatum ticks. Int J Syst Bacteriol. 1997;47:548–54. http:// RVFV activity in cattle in Namaacha dx.doi.org/10.1099/00207713-47-2-548 District in Maputo Province (4), a re- Antonis Germanakis, 8. Demoncheaux JP, Socolovschi C, Davoust gion where there had been no recorded Dimosthenis Chochlakis, B, Haddad S, Raoult D, Parola P. First de- evidence of the virus since 1969 (1). tection of Rickettsia aeschlimannii in Hya- Emmanouil Angelakis, We conducted a cross-sectional study Yannis Tselentis, lomma dromedarii ticks from Tunisia. Ticks Tick Borne Dis. 2012;3:398–402. http:// in which serum samples were col- and Anna Psaroulaki dx.doi.org/10.1016/j.ttbdis.2012.10.003 lected throughout Maputo Province

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