LETTERS sequences clustered within the Europe/ mission emphasizes the need for rapid 5. Papa A, Drosten C, Bino S, Papadimitriou Turkey clade. The genetic distance be- diagnosis of CCHF, especially in cases E, Panning M, Velo E, et al. Viral load in Crimean-Congo hemorrhagic fever. tween the 2 strains was 1.15%, but the with atypical clinical manifestations. Emerg Infect Dis. 2007;13:805–6. 2 sequences were identical at the amino 6. Rodriguez LL, Maupin GO, Ksiazek TG, acid level. Sequences from the present Acknowledgments Rollin PE, Khan AS, Schwarz TF, et al. Molecular investigation of a multisource study showed 96.4%–98.8% similar- We thank Licia Bordi, Eleonora Lalle, outbreak of Crimean-Congo hemorrhagic ity with respective CCHFV sequences Silvia Meschi, and Roberta Chiappini for fever in the United Arab Emirates. Am J from Bulgaria from a former study valuable help in tick investigations. Trop Med Hyg. 1997;57:512–8. (BUL10/02 and BUL1/03) (3) but 7. Kunchev A, Kojouharova M. Probable differed from the Kosovo 9553/2001 This work was partially funded by cases of Crimean-Congo-haemorrhagic fever in Bulgaria: a preliminary report. strain by 0.8%–2.0% and from the RiViGene (contract no. SSPE-CT-2005- 022639). Euro Surveill. 2008;13. pii: 18845. Greek 66/08 strain by 1.2%–2.4%. 8. Papa A, Maltezou HC, Tsiodras S, Dalla Two additional suspected CCHF VG, Papadimitriou T, Pierroutsakos I, et cases occurred in the same area, on Iva Christova, Antonino Di Caro, al. A case of Crimean-Congo haemor- rhagic fever in Greece, June 2008. Euro March 30 and April 9 (7). Both per- Anna Papa, Concetta Castilletti, Surveill. 2008;13. pii: 18952. sons were negative for CCHFV infec- Lubena Andonova, tion. All 119 ticks of various species Nikolay Kalvatchev, Address for correspondence: Iva Christova, (Hyalomma marginatum, Dermacen- Evangelia Papadimitriou, National Center of Infectious and Parasitic tor marginatus, Rhipicephalus bursa, Fabrizio Carletti, Diseases, Blvd Yanko Sakazov 26, Sofia 1504, Ixodes ricinus) collected from the Emad Mohareb, Bulgaria; email: [email protected] area and tested by reverse transcrip- Maria R. Capobianchi, tion–nested PCR were negative for Giuseppe Ippolito, CCHFV. and Giovanni Rezza This cluster of CCHF cases has Author affiliations: National Centre of In- several important highlights. First, it fectious and Parasitic Diseases, Sofia, occurred in a region that was consid- Bulgaria (I. Christova, N. Kalvachev); Na- ered to have low CCHF endemicity; tional Institute for Infectious Diseases “L. however, the area is only a few kilo- Spallanzani,” Rome, Italy (A. Di Caro, C. Wohlfahrtiimonas meters from Greece, where a human Castilletti, F. Carletti, M.R. Capobianchi, chitiniclastica fatal case was observed in June 2008 G. Ippolito); Aristotelian University of Thes- Bacteremia in (8). The index case was observed ear- saloniki, Thessaloniki, Greece (A. Papa, lier in the year than in previous years, E. Papadimitriou); Infectious Diseases Homeless Woman and clinical manifestations of the Hospital, Sofia (L. Andonova); US Naval To the Editor: In May 2006, a cases were unusual (absence of cran- Medical Research Unit 3, Cairo, Egypt (E. 60-year-old homeless woman with a iopharyngeal syndrome and bleeding Mohareb); and Istituto Superiore di Sanità, history of alcoholism was admitted to from gastrointestinal tract that are Rome (G. Rezza). the emergency department of the Con- typical for CCHF patients from Bul- DOI: 10.3201/eid1506.081567 ception Hospital, Marseille, France. garia); in the fatal case, autopsy of the Firefighters had just found her in an patient showed hemorrhages only in References abandoned container in the outskirts the lungs. Two cases were attributable of the city, beside the body of her com- to tick exposure, whereas the other 2 1. Ergonul O, Whitehouse CA. Crimean- panion, who had died several days ear- were most likely secondary cases at- Congo hemorrhagic fever, a global per- lier. She described no symptoms other tributable to contact with the index spective. New York: Springer; 2007. 2. Ergonul O. Crimean-Congo haemorrhagic than fatigue. On examination, she was case-patient (in this regard, CCHFV fever. Lancet Infect Dis. 2006;6:203–14. found to be dirty and covered with sequences of the secondary cases were DOI: 10.1016/S1473-3099(06)70435-2 thousands of body and hair lice; doz- almost identical). Finally, the longer 3. Papa A, Christova I, Papadimitriou E, ens of larvae were in her hair. incubation period of the wife of the Antoniadis A. Crimean-Congo hemor- rhagic fever in Bulgaria. Emerg Infect Dis. She was mildly febrile (38°C) and had index case-patient might be associated 2004;10:1465–7. widespread excoriations but no sign with administration of hyperimmune 4. Monev V, Dikov I, Kamarinchev B. of localized bacterial infection. Head gamma globulin against CCHFV. Crimean-Congo-haemorrhagic fever. In: shaving exposed superficial ulcers In conclusion, CCHF emerged in Serbezov V and Kalvatchev Z, editors. Arbovirus infections viral haemorrhagic on her scalp but no maggots. Blood southwestern Bulgaria near the border fevers and biol-terrorism [in Bulgarian]. analysis showed marked neutropenia with Greece. Person-to-person trans- Sofia; 2005. p. 130–42.

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(0.44 ×109/L), thrombocytopenia (28 with W. magnifica larvae (4), which are of particular interest because they × 109/L), a marked but well-tolerated cause severe wound myiasis in cattle transmit 3 bacterial bloodstream in- iron deficiency anemia (hemoglobin (5). Because of its strong chitinase fections: trench fever (B. quintana), 6.8g/dL), and a C-reactive protein activity, I. larvae may play a role in epidemic typhus (R. prowazekii), and level of 182 mg/L. Louse infestation the metamorphosis of its host , as louse-borne relapsing fever (Borre- was treated with a single dose of iver- has been observed for other fly sym- lia recurrentis) (1). Myiasis should mectin (12 mg), and the woman was bionts, and thus may be a symbiont of also be considered as a relevant type hospitalized. On day 3, she was still W. magnifica (6). The bacterium of ectoparasitism in homeless and febrile. Louse-borne borreliosis had was later discovered in swine waste hygiene-deficient persons. In addition, been ruled out by a negative blood in Quebec (7). In 2007, three publica- like body lice, ticks, and fleas, fly lar- smear, and results of serologic testing tions renewed researchers’ interest in vae should also be regarded as another and molecular screening of lice for I. larvae. First it was reclassified as potential source of specific - the other 2 louse-transmitted bacteria, the only species within the genus Ig- borne bacterial systemic infections. Rickettsia prowazekii and Bartonella natzschineria (4). Then 2 case reports quintana (1), were negative. demonstrated that it plays a role as a Stanislas Rebaudet, In contrast, 2 cultures of blood human pathogen (8,9). Both described Séverine Genot, taken at the time of admission grew an I. larvae bacteremia in adults with Aurélie Renvoise, gram-negative rods susceptible to myiasis in southeastern France. The Pierre-Edouard Fournier, amoxicillin, ceftriaxone, imipen- first patient was an elderly farmer with and Andreas Stein em, ciprofloxacin, amikacin, and diabetes and myiasis of the leg, scro- Author affiliations: Hôpital Universitaire de trimethoprim/sulfamethoxazole. How- tum, and anus (8). The second patient la Conception, Marseille, France (S. Re- ever, phenotypic tests failed to identify was a middle-aged homeless man with baudet, S. Genot, A. Stein); and Unité des this bacterium with accuracy. Intrave- a history of alcoholism who also had Rickettsies, Marseille (A. Renvoise, P.-E. nous therapy with ceftriaxone at 2 g/d foot wound myiasis (9). Fournier, A. Stein) was initiated, and the patient’s fever, We report W. chitiniclastica bac- DOI: 10.3201/eid1506.080232 neutropenia, and thrombocytopenia teremia also in a homeless woman improved. Scalp wounds healed with from southeastern France. Although References local care. Using 16S rRNA gene am- we did not test body lice for W. chitini- plification and sequencing as previ- clastica, we believe that the bactere- 1. Brouqui P, Stein A, Dupont HT, Gallian ously described (2), we identified the mia originated from the patient’s scalp P, Badiaga S, Rolain JM, et al. Ectopara- sitism and vector-borne diseases in 930 bacilli as Wohlfahrtiimonas chitini- maggots. Unfortunately, as previously homeless people from Marseilles. Medi- clastica and determined its similarity reported for cases of I. larvae bacte- cine (Baltimore). 2005;84:61–8. DOI: to be 99.5% with strain E43 (Gen- remia, the maggots had been rapidly 10.1097/01.md.0000152373.07500.6e Bank accession no. AJ517825). The discarded, permitting neither bacterial 2. Drancourt M, Raoult D. Sequence-based identification of new bacteria: a proposition 16S rRNA sequence obtained from analysis nor entomologic identifica- for creation of an orphan bacterium repos- the patient’s strain was deposited in tion. However, these larvae may have itory. J Clin Microbiol. 2005;43:4311–5. GenBank under no. EU484335. The been from W. magnifica flies. These DOI: 10.1128/JCM.43.9.4311-4315.2005 strain was deposited in the Collec- flies are present in southern France, 3. Toth EM, Schumann P, Borsodi AK, Keki Z, Kovacs AL, Marialigeti K. Wohlfahrtii- tion de Souches de l’Unité des Rick- and although they are not typically monas chitiniclastica gen. nov., sp. nov., ettsies (CSUR; World Data Center found at low altitude and in a semiur- a new gammaproteobacterium isolated for Microorganisms 875, http://ifr48. ban environment, their distribution is from Wohlfahrtia magnifica (Diptera: timone.univ-mrs.fr/portail2/index. known to be progressively expanding, Sarcophagidae). Int J Syst Evol Micro- biol. 2008;58:976–81. DOI: 10.1099/ php?option = com_content&task = vi in part because of their broad adapta- ijs.0.65324-0 ew&id = 96&Itemid = 52) under refer- tion capacities. hosts for W. 4. Tóth EM, Borsodi AK, Euzéby JP, Tindall ence CSUR P16. magnifica flies are numerous, but hu- BJ, Márialigeti K. Proposal to replace the W. chitiniclastica is a recently mans can also be infected; >10 cases illegitimate genus name Schineria Toth et al. 2001 with the genus name Ignatz- described γ-proteobacterium isolated of this myiasis in humans have been schineria gen. nov. and to replace the il- from larvae of the parasitic fly Wohl- reported in Europe, Asia, Morocco, legitimate combination Schineria larvae fahrtia magnifica (3). Although the and Egypt. The scalp was affected in Toth et al. 2001 with Ignatzschineria pathogenicity of this new species for 2 of these patients (10). larvae comb. nov. Int J Syst Evol Mi- crobiol. 2007;57:179–80. DOI: 10.1099/ humans is as yet undescribed, it is phy- Among homeless persons, ec- ijs.0.64686-0 logenetically close to Ignatzschineria toparasitism is very common; body larvae, another bacterium associated lice (Pediculus humanus humanus)

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5. Tóth EM, Farkas R, Marialigeti K, Mokhtar investigated the seroprevalence of N. of 1:80. Within the group of immuno- IS. Bacteriological investigations on caninum in humans in France, where compromised persons, 3 were positive wound myiasis of sheep caused by Wohl- fahrtia magnifica (Diptera: Sarcophagi- Toxoplasma spp. seroprevalence is for Neospora antibodies at a titer of dae). Acta Vet Hung. 1998;46:219–29. high. 80, and 1 was positive at a titer of 160. 6. Tóth EM, Kovacs G, Schumann P, Kovacs Our study comprised 500 serum Three of these 4 HIV-infected patients AL, Steiner U, Halbritter A, et al. Schine- samples from healthy women, fol- had high titers of anti-Toxoplasma IgG ria larvae gen. nov., sp. nov., isolated from the 1st and 2nd larval stages of Wohlfahrtia lowed at the Cochin–Port Royal Uni- (>2,000 IU/mL), suggesting Toxoplas- magnifica (Diptera: Sarcophagidae). Int J versity Hospital in 1997 within the ma serologic reactivation. We found Syst Evol Microbiol. 2001;51:401–7. framework of toxoplasmosis surveil- no evidence of Neospora infection or 7. Juteau P, Tremblay D, Ould-Moulaye CB, lance during pregnancy, and 400 serum exposure in immunocompetent per- Bisaillon JG, Beaudet R. Swine waste treat- ment by self-heating aerobic thermophilic samples from HIV-infected patients. sons but could not exclude possible bioreactors. Water Res. 2004;38:539–46. All serum samples were submitted to Neospora infection associated with DOI: 10.1016/j.watres.2003.11.001 anti-Toxoplasma antibody testing by Toxoplasma infection or reactivation 8. Maurin M, Delbano JN, Mackaya L, Co- using indirect immunofluorescence in immunocompromised persons. lomb H, Guier C, Mandjee A, et al. Human infection with Schineria larvae. Emerg In- (IIF; Toxo-spot IFI; bioMérieux, Taken together, our data agree fect Dis. 2007;13:657–9. Marcy l’Etoile, France) and ELISA with data from other studies conduct- 9. Roudiere L, Jean-Pierre H, Comte C, (Platelia Toxo IgG and IgM; BioRad, ed in European countries (1,5), which Zorgniotti I, Marchandin H, Jumas-Bilak Hercules, CA, USA). An in-house mi- suggest that neosporosis in healthy E. Isolation of Schineria sp. from a man. Emerg Infect Dis. 2007;13:659–61. croplate IIF test previously validated humans is unlikely. However, the 10. Kokcam I, Saki CE. A case of cutaneous in cattle was used for simultaneous Neospora spp. seropositivity of some myiasis caused by Wohlfahrtia magnifica. detection of anti-Neospora and anti- HIV-infected patients, although weak J Dermatol. 2005;32:459–63. Toxoplasma immunoglobulin (Ig) G compared with the level of seroposi- on the same microplate. All samples tivity in cattle or dogs, could suggest Address for correspondence: Andreas Stein, were screened at dilutions of 1:20 and circulation of the parasite within im- Unité des Rickettsies, CNRS-IRD UMR6236, 1:80, as is usually done in anti-Toxo- munocompromised hosts, a hypoth- Université de la Méditerranee, Faculte de plasma IIF assays in humans. Corre- esis supported by Lobato et al. (3). Medecine, 27 blvd Jean Moulin, 13385 lation between the anti-Toxoplasma However, our observation of a strong Marseille CEDEX 5, France; email: andreas. IIF commercial test and in-house IIF serologic reactivation against T. gondii [email protected] was excellent (kappa coefficient = in 3 of 4 patients with anti-Neospora 0.98) and allowed us to compare the titers >80 mostly favors cross-reac- antibody titers against both parasites. tivity involving homologous antigens Forty (8%) samples from immuno- of both parasites and nonspecific an- competent persons and 21 (4%) from tibody binding from polyclonal stimu- immunocompromised persons yielded lation of the immune system. Finally, a weak fluorescence when diluted one should keep in mind that the posi- Serologic 1:20. All but 4 had significant titers of tive predictive value of a serologic test Screening for anti-Toxoplasma IgG (>200 IU/mL in used in screening in low-prevalence 77% of cases), which suggests low- populations is low. Large-scale stud- Neospora caninum, level cross-reactions. Whereas titers ies are needed to more precisely deter- France of >200 and >320 are considered suf- mine the potential role of this parasite ficient to diagnose neosporosis in dogs in immunodeficient humans and to To the Editor: In the June 2008 and cattle, respectively (2), positivity isolate the parasite or detect Neospora issue of Emerging Infectious Diseas- threshold was difficult to resolve in the DNA in such patients. es, McCann et al. (1) reported on sero- absence of a positive human control. logic screening for Neospora caninum We decided on a positivity threshold Florence Robert-Gangneux antibodies and reported a lack of sero- of 1:80, which is similar to the thresh- and Frédéric Klein logic evidence for Neospora infection old defined by others in further studies Author affiliations: Université Rennes 1, in humans in England, where preva- using an indirect fluorescence anti- Rennes, France (F. Robert-Gangneux); lence of infection with the closely re- body test in humans (3,4). None of the and Laboratoire Départemental de l’Orne, lated parasite Toxoplasma gondii also 500 samples from immunocompetent Alençon, France (F. Klein) is low. Only limited data are available persons were positive for Neospora DOI: 10.3201/eid1506.081414 on human exposure to Neospora. We antibodies when assessed at a dilution

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