European Review for Medical and Pharmacological Sciences 2016; 20: 2630-2633 Human Rickettsia aeschlimannii infection: first case with acute hepatitis and review of the literature

A. TOSONI1, A. MIRIJELLO2, A. CIERVO3, F. MANCINI3, G. REZZA3, F. DAMIANO4, R. CAUDA4, A. GASBARRINI1, G. ADDOLORATO1, ON BEHALF OF THE INTERNAL MEDICINE SEPSIS STUDY GROUP*

1Department of Medical Sciences, Internal Medicine and Gastroenterology Unit, Catholic University of the Sacred Heart, Gemelli Hospital, School of Medicine, Rome, Italy 2Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy 3Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanità, Rome, Italy 4Institute of Clinical Infectious Disease, Catholic University of the Sacred Heart, Gemelli Hospital, School of Medicine, Rome, Italy *Internal Medicine Sepsis Study Group: Michele Impagnatiello, Giovanna Passaro, Carla Vallone, Giulio Ventura, Vincenzo Zaccone

Abstract. – OBJECTIVE: Rickettsia conorii is decade, other rickettsial species (i.e. R. monacensis, responsible for the Mediterranean Spotted Fever. R. massiliae, R. slovaca, R. helvetica, R. sibirica Recently, new rickettsial species have been rec- and R. aeschlimannii) have been recognized in ognized in Europe and implicated in human dis- Europe and implicated as human pathogens1. eases. Clinical features often differ greatly from 2 each other, but non-severe liver involvement is fre- MSF is endemic in Southern Italy ; moreover, two quently observed during any rickettsial infection. cases of human rickettsioses due to R. monacensis CASE REPORT: We describe the unique case and R. massiliae have been recently described3,4. of a patient presented with significant high ami- Tick-borne spotted fever rickettsioses are notransferase levels due to the first human R. characterized by headache, high-grade fever, aeschlimannii infection ever detected in Italy. The hypothesis of rickettsiosis was made on the ba- cutaneous rash and the presence of the typical tache sis of a comprehensive medical history and was noire. However, in the early stages, symptoms are confirmed by serological tests. Molecular analy- nonspecific: characteristic signs may be absent ses made on a sample of hepatic tissue revealed or unobserved, with an increased probability of the presence of a rickettsial species never found misdiagnosis. Moreover, clinical signs may differ before in human liver. depending on the rickettsial species implicated. CONCLUSIONS: A brief review of the litera- ture is reported to highlight how relevant this Liver involvement is frequently observed during 5 case is and to remind that rickettsioses should any rickettsial infection . However, only a slight be in the differential diagnoses of acute hepati- increase in aminotransferases is usually observed, tis, considering mostly the recent spread of new with a rapid return to their normal blood levels. rickettsial species. Here, we report the first human case of Key Words rickettsiosis due to R. aeschlimannii in Italy, Rickettsia aeschlimannii, Acute hepatitis, High trans- characterized by liver dysfunction and significant aminases, Rickettsiosis, Italy. hyperaminotransferasemia.

Case Report Introduction A 43-year-old man, with unremarkable medical history, developed low-grade fever, sore throat and Mediterranean Spotted Fever (MSF) due to asthenia while coming back home from a two- Rickettsia conorii represents the most common weeks summer holiday in Southern Italy. During tick-borne rickettsiosis in Europe. In the last this trip, he was in contact with wild animals (dogs).

2630 Corresponding Author: Giovanni Addolorato, MD; e-mail: [email protected] Acute hepatitis due to R. aeschlimannii

A three-day antibiotic treatment with amoxicillin- CMV, EBV, HSV, HIV, adenovirus, echovirus, clavulanate was prescribed without remission of coxsackievirus, Dengue virus, or malaria and symptoms. The patient soon developed a high-grade tuberculosis were excluded. Laboratory tests for fever (peak 40°C) with left knee monoarthritis: autoimmune disease (anti-nuclear, anti-smooth an arthrocentesis was performed together with muscle, anti-liver kidney microsomal, anti-neutrophil ceftriaxone treatment. A second arthrocentesis cytoplasmic and anti-mitochondrial antibodies) were was performed 10 days later. Both specimens negative, and so were blood, urine and throat cultures. were sent for routine cultures and were reported No abnormal findings were detected by negative. Because of high aminotransferase levels abdominal ultrasound, and an echocardiogram on laboratory evaluation, the patient was admitted was unremarkable. to our Internal Medicine Inpatient Unit. The indirect fluorescent antibody (IFA) assay At admission, blood pressure was 140/80 showed the presence of antibodies against R. mmHg, pulse rate was 85 beats/minute, oxygen conorii. However, only IgM (at a titer of 1/32) saturation (SatO2) was 97% in room air, was present, while specific IgG antibodies were temperature was 37.5°C. Mild, indolent, edema of undetectable. Five days later, titers of IgM the left knee was present; a very small ulcerated antibodies increased (1/64) and IgG antibodies crust was found posteriorly on the left leg. No became detectable (titer of 1/32). IgM and IgG other symptoms (i.e. itch, headache or abdominal antibodies were both at titers of 1/64 after 10 days. pain) were reported, nor other abnormal signs The patient did not receive any antibiotic were present at the physical examination. therapy, due to the well-known hepatic toxicity of Laboratory findings showed markedly elevated anti-Rickettsia antibiotics; moreover, laboratory aminotransferases (ALT 1388 u/L [normal value studies revealed a decrease in aminotransferase 7-45 u/L], AST 526 u/L [n.v. 7-45 u/L]), with mild levels that was synchronous to the increase in cholestasis (alkaline phosphatase 217 u/L [n.v. antibodies titers (Table I). 40-129 u/L], gamma-glutamyl transferase 183 A liver biopsy was performed: inflammatory u/L [n.v. 8-61 u/L], total bilirubin 0.6 mg/dL [n.v. and Kupffer cells hyperactivity was found, with 0.3-1.2 mg/dl]), prolongation of prothrombin time no granulomatous lesions. A sample of hepatic (INR 1.52 [n.v. 0.8-1.2]), mild thrombocytosis tissue was sent to the Istituto Superiore di Sanità, (platelet count 460 x 10^9/L), and increase in Department of Infectious, Parasitic and Immuno- acute-phase proteins (CRP 28 mg/L [n.v. <3 mediated Diseases, Rome, Italy, for molecular mg/L], ESR 108 mm [n.v. 0-9 mm]). Ten days analyses. Rickettsial detection was determined by after admission, aminotransferase levels reached real-time PCR and classical PCR, using primers their peak (ALT 2050 u/L, AST 798 u/L), with no for ompB (outer membrane protein B) and ompA significant increase in cholestasis. (outer membrane protein A) genes6,7. R. conorii No alcohol abuse history was detected. The and R. typhii were used as positive controls. The patient was not on any regular medications and pathogen identification was done by sequencing of denied using over-the-counter drugs, weight loss PCR amplicons. The nucleotide sequences analyzed or body building supplements, herbal medications by the BLAST search tool (www.ncbi.n/m.nib.gov/ or teas. A total amount of 5000 mg of oral blast), showed 100% identity with the ompB R. paracetamol in 5 days has been needed to lower aeschlimannii strain MC16 (GenBank accession no. fever before admission, no more needed thereafter. AF123705), and with the ompA R. aeschlimannii Serological assays for hepatitis A, B, C and E strain MC16 (GenBank accession no. U43800). viruses were negative. Several diseases with a R. aeschlimannii was then identified as the possible liver involvement such as bacterial infection cause of the illness in the patient reported here. with Leptospira, Brucella, Salmonella, Borrelia, At 1-month follow-up, the patient recovered Treponema, Toxoplasma, or viral infections with completely.

Table I. Time course of aminotransferase levels and antibodies titers. Days after admission 0 5 10 15 30 ALT (u/L) 1388 1629 2050 1024 146 IgM - 1/32 1/64 1/64 - IgG - 0 1/32 1/64 -

2631 A. Tosoni, A. Mirijello, A. Ciervo, et al

Discussion It would be interesting to determine whether the differences in the clinical features of rickettsial R. aeschlimannii may have spread across infections could be a consequence of genetic Europe through infected ticks on migrating birds differences in the rickettsial strains as well as from Africa. These rickettsial organisms have the result of differences in the genetics and been detected in ticks collected from several bird environmental conditions of the host population or species in France, Germany and Italy1,8. in rickettsial adaptation to diverse hosts and vectors. The presence of this bacterium was also recently In the case we presented, serological tests studied in central Italy during an entomological showed typical antibody trends following infection investigation conducted in the Insugherata Natural but with antibody titers lower than expected. Reserve, localized in the urban area of Rome9. This could be explained by the differences In that survey, R. aeschlimannii was found in between antigen used in the IFA assay (R. conorii questing ticks such as Rhipicephalus turanicus and antigen) and R. aeschlimannii antigens; the lack Ixodes ricinus, demonstrating the maintenance of of specificity between patient antibodies and IFA this pathogen in an area with favorable climatic test antigen can determine low affinity in antigen- conditions and susceptible hosts. antibody interaction and consequently lower The first human rickettsial disease caused by antibody titers detected by immunoassay. R. aeschlimannii was documented in a French Given these results, serological assays have been patient after a trip to Morocco10. Recently, the first initially thought to be inconclusive, and liver biopsy autochthonous case of this infection in Europe became necessary in order to perform the histological was reported in a male patient from Greece with assessment and molecular analyses of the tissue. MSF-like symptoms11. In the meantime, we decided not to administer To date, the case here reported is the second antibiotics but to “wait and see” the clinical course European case of R. aeschlimannii infection and the even considering the mild liver damage found on first rickettsiosis in Europe without MSF-like signs histology and the spontaneous recovery of the patient. but with acute hepatitis, in which Rickettsia was The diagnosis of R. aeschlimannii infection was detected by PCR performed on the hepatic tissue. obtained retrospectively, when the patient had already Liver involvement during rickettsial infection shown a complete recovery and had been discharged. was not often matter of analysis, and a few This case supports the statement that liver biopsy manuscripts found in the literature are outdated. is mandatory when medical history, laboratory tests Studies do show a high frequency of liver and imaging are not sufficient to prove a diagnosis dysfunction, which is usually mild or moderate, of acute hepatitis; moreover, liver biopsy currently particularly during MSF12. Few liver biopsies has two more roles: for assessment of prognosis were performed, with the majority showing a through staging disease, and to assist in making granulomatous hepatitis histological pattern; therapeutic management decisions16. no intact Rickettsia conorii was identified in the tissues by immunofluorescence13. A more recent Italian study14 found elevated Conclusions aminotransferase levels in about half of patients with MSF, that stabilized at the end of The infections caused by rickettsial species are anti-rickettsial therapy and a Spanish study15 emerging diseases, characterized by the possibility showed that anti-rickettsial antibodies are more of liver involvement. Therefore, it is necessary to commonly detected in patients with unexplained consider rickettsioses in the differential diagnoses hyperaminotransferasemia than in healthy people. of acute hepatitis. Furthermore, the list of newly discovered Rickettsia species has grown rapidly in recent years and the clinical manifestations of these infections may Supportive foundations be atypical and rarely severe, with liver involvement This study was partially supported by a research grant from that should be recognized as soon as possible. the Italian Ministry of Health (CCM 2013-2014: “Sorvegli- Understanding the pathogenic mechanism anza di laboratorio di infezioni batteriche sottoposte a sor- underlying the disease is made difficult by the veglianza europea e da agenti di bioterrorismo”). small number of cases reported to date, although in this case it is reasonable to assume a direct Conflicts of interest injury to the liver caused by the microbe itself. The authors declare that they have no conflict of interests.

2632 Acute hepatitis due to R. aeschlimannii

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