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 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 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

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 7, July 2013 1177 LETTERS during 2010–2011 to ascertain wheth- including irrigation ditches on sugar Province warrant further research, and er any RVFV circulation had remained cane farms, extensive flood plains, implementation of surveillance and undetected among bovids. wetlands, and ponds (5). livestock vaccination programs in the The study was approved by the South Africa keeps continuous studied area should be discussed. Mozambican Board of Agriculture. records of RVFV outbreaks, and sev- Animals investigated were of mixed eral outbreaks in cattle were reported Acknowledgment breed, had been present in their re- in KwaZulu-Natal and Mpumalanga We thank Z. Massicame and A. Malu- spective localities since birth, were >6 Provinces during 2008–2010 (6). Ma- mana for providing bovine serum samples. months of age, and had not been vac- tutuine, the southernmost district in cinated against RVFV. Samples were Maputo Province, shares a border with This study was supported by the analyzed by using a plaque-reduction KwaZulu-Natal Province, whereas Swedish International Development Co- neutralization test (4), and RVFV se- Magude and Moamba Districts border operation Agency. ropositivity was defined as 80% re- Mpumalanga Province. Accordingly, duction of virus infectivity at a serum the high seropositivity rates of 19.8% Nina Lagerqvist, dilution of 1:40. (95% CI 13.0%–26.7%), 26.5% (95% Belisário Moiane, A total of 404 serum samples were CI 11.6%–41.3%), and 29.7.% (95% Lourenço Mapaco, analyzed, and 149 were positive for CI 18.5%–40.9%) in Matutuine, Ma- José Fafetine, Sirkka Vene, RVFV-neutralizing antibodies. This gude, and Moamba Districts, respec- and Kerstin I. Falk finding represents an overall serop- tively, are not remarkable. In com- Author affiliations: Karolinska Institutet, revalence of 36.9% (95% CI 32.2%– parison, a seroprevalence of 14.3% Stockholm, Sweden (N. Lagerqvist, B. 41.6%) in Maputo Province, which is (95% CI 1.3%–27.2%) was noted in Moiane, K.I. Falk); Swedish Institute for a high level for an area in which no , which has a smaller Communicable Disease Control, Solna, RVFV disease activity has been re- livestock population. Sweden (N. Lagerqvist, S. Vene, K.I. Falk); ported during the past 4 decades. Because of long-term persistence Universidade Eduardo Mondlane, Maputo, Although the study was designed of IgG against RVFV, the actual time of Mozambique (B. Moiane, J. Fafetine); and to determine the overall prevalence infection could not be determined from Direcção de Ciências Animais, Maputo (L. in the province, our data also pro- the data obtained in our study. Howev- Mapaco) vided an indication of the distribution er, information was available regard- of RVFV at a district level. Maputo ing the age of the cattle in Moamba DOI: http://dx.doi.org/eid1907.130332 Province is subdivided into 7 districts, District. From this information, we and samples from 6 of these districts deduced that the most recent RVFV References were available for analysis: Boane (n infections in this district occurred at 1. Valadão FG. Notes about the occurrence = 28), Magude (n = 34), Manhiça (n some point during 2009–2010. of a new disease in Mozambique: Rift = 65), (n = 82), Matu- Our results strongly suggest that Valley fever [in Portuguese]. Veterinaria tuine (n = 131), and Moamba (n = 64). RVFV is widely distributed among Mocambicana. 1969;2:13–20. 2. Niklasson B, Liljestrand J, Berg- The livestock populations in Magude, bovids in Maputo Province, although ström S, Peters CJ. Rift Valley fever: a Manhiça, Matutuine, and Moamba the modality of this circulation is un- sero-epidemiological survey among preg- Districts range in size from 20,000 to known. RVFV infection can remain nant women in Mozambique. Epidemiol 70,000 animals, and Boane and Mar- undetected in adult livestock but can Infect. 1987;99:517–22. http://dx.doi. org/10.1017/S0950268800068011 racuene Districts have smaller popula- cause abortions in pregnant animals 3. Annual report 2001 [in Portuguese]. tions of 6,000 and 9,000, respectively. and neonatal death in small ruminants Maputo (Mozambique): National Direc- We found the highest serop- (7), which has major economic con- torate of Livestock; 2002. p. 32–3. revalence to be 61.5% (95% CI sequences. Transmission to humans 4. Lagerqvist N, Moiane B, Bucht G, Fafetine J, Paweska JT, Lundkvist A, 49.7%–73.4%) in Manhiça District is common during epizootics, and the et al. Stability of a formalin-inactivated and 62.2% (95% CI 51.7%–72.7%) proximity to and density of cattle in Rift Valley fever vaccine: evaluation of a in Marracuene District. Some of the an area have been shown to be major vaccination campaign for cattle in Mozam- animals affected by RVFV during out- factors for RVFV seroconversion in bique. Vaccine. 2012;30:6534–40. http:// dx.doi.org/10.1016/j.vaccine.2012.08.052 breaks in 1969 were raised on farms human populations (8). Human infec- 5. Asante K, Brito R, Brundrit G, Epstein near or in these 2 regions (1). Our tions are often manifested as a febrile P, Fernandes A, Marques MR, et al., edi- data indicate that the RVFV activity illness and can easily be mistaken for tors. Climate change report: study on the is still high in those districts, possibly other diseases. Consequently, uniden- impact of climate change on disaster risk in Mozambique. Maputo (Mozambique); because breeding of mosquito vectors tified or underdiagnosed RVFV in- National Institue for Disaster Manage- is promoted by environmental factors, fections among livestock in Maputo ment (INGC); 2009.

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6. World Organization of Animal Health to a district pediatric outpatient clinic a low dose of methylprednisolone (OIE). World animal health information on April 1. At admission, the child for 1 week and the other was not database 2008, 2009 and 2010 [cited 2013 Apr 26]. http://www.oie.int/wahis_2/ was given oseltamivir for 5 days, given methylprednisolone. Although public/wahid.php/Wahidhome/Home even though signs and symptoms it is difficult to assess the role of 7. Ikegami T, Makino S. The pathogenesis had resolved. Nasopharyngeal swab glucocorticoids in treatment because of Rift Valley fever. Viruses. 2011;3:493– samples were positive by real-time PCR of limited number of cases, caution 519. http://dx.doi.org/10.3390/v3050493 8. Heinrich N, Saathoff E, Weller N, Clowes for avian influenza A(H7N9) virus. All is advised because of possible serious P, Kroidl I, Ntinginya E, et al. High sero- symptoms resolved uneventfully by adverse events, including death, as prevalence of Rift Valley fever and evi- April 3, and CDC was notified that reported for human infection with dence for endemic circulation in Mbeya avian influenza A(H7N9) virus was influenza A(H1N1) virus (4). region, Tanzania, in a cross-sectional study. PLoS Negl Trop Dis. 2012;6:e1557. identified in his respiratory sample. One of the adult patients reported The patient was discharged on day 11 exposure to poultry. The family of Address for correspondence: Nina Lagerqvist, after illness onset. the child patient raised chickens Swedish Institute for Communicable Disease The 4 adult patients were given and ducks, but these animals had no Control, Nobelsväg 18, SE-171 82 Solna, diagnoses of severe pneumonia with apparent disease, and cloacal swab Sweden; email: [email protected] shortness of breath, dyspnea, and specimens were negative for avian marked hypoxia (Table). Duration from influenza A(H7N9) virus. One patient disease onset to severe illness was 5–7 who died (patient 2) had frequent days. At admission, the 4 patients with occupational exposure to poultry. severe cases had decreased peripheral Sixteen contacts of the child and 45 blood leukocyte counts and increased contacts of the 4 adult patients were levels of aspartate aminotransferase; monitored, and routine virologic Avian Influenza 3 had increased levels of lactate sampling was performed. One contact A(H7N9) Virus dehydrogenase (Table). (husband of patient 1) of a patient who All 4 adult patients had died (Table) became febrile and was Infections, radiologically confirmed pneumonia positive for avian influenza A(H7N9) Shanghai, China and bilateral patchy alveolar opacities virus on April 12 (day 24 after disease or diffused lobar consolidation with onset for patient 1); as of the date of To the Editor: On March 31, or without pleural effusion (Figure, this report, he was receiving treatment 2013, the National Health and Family Appendix, wwwnc.cdc.gov/EID/article in an intensive care unit. However, Planning Commission of China /19/7/13-0523-F1.htm). Findings on it is difficult to tell if this is a case notified the World Health Organization chest radiographs for severe cases of human-to-human transmission of 3 cases of human infections with requiring mechanical ventilation or if both persons were exposed to avian influenza A(H7N9) virus. were consistent with those for acute infectious poultry. All remaining These cases were caused by a novel respiratory distress syndrome. contacts had no symptoms and were virus that was identified by laboratory Among the 4 severe cases in negative for virus by PCR. testing at the China Centers for adults, a 52-year-old woman (patient Several features of this avian Disease Control and Prevention 1) and a 49-year-old man (patient 2) influenza A(H7N9) outbreak are (CDC) on March 29 (1). died from acute respiratory distress distinct from those of previous avian As of April 19, 2013, a total syndrome and multiple organ failure influenza outbreaks. Human infection of 91 laboratory-confirmed human on days 14 and 10, respectively, with this virus showed a case-fatality cases (17 deaths) of infection with after disease onset and 1–2 days rate of 18.7% (17/91), but this rate avian influenza A(H7N9) virus were after progression to respiratory is not as high as that for avian reported in 4 provinces in China failure. Two other patients showed influenza A(H5N1) virus (case-fatality (2). We report clinical features of 2 improvement and were virus negative rate 59%) (5). infected adults who died, 2 critically 6 and 4 days after antiviral treatment. Avian influenza A(H7N9) virus ill infected adults who recovered, After 23–24 days of treatment in an infection seems to cause more severe and 1 infected child who had a intensive care unit, the 2 patients human illness than do other subgroups mild case during this outbreak in with severe cases recovered and were of H7 influenza A viruses (subtypes Shanghai, China. discharged (Table). H7N2, H7N3, and H7N7), which A 3.5-year-old boy had fever The 2 patients who died were are usually associated with poultry (39.5°C) for 3 days and mild rhinorrhea given methylprednisolone. Of the 2 outbreaks but cause mild disease in starting on March 31. He was admitted patients who recovered, 1 was given humans. However, infection with avian

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