Rocky Mountain Spotted Fever

23.03.2013 CHYPRE «Emerging Rickettsioses»

© by author ESCMID Online Lecture Library Didier Raoult Marseille - France [email protected] www.mediterranee-infection.com  Gram negative bacterium  Strictly intracellular  Transmitted by arthropods: ticks, fleas, lice,© mites by author

ESCMIDMosquitoes? Online Lecture Library

U R 2  Louse borne disease - typhus

 Tick borne : the big killer - RMSF

 Other: less severe

 Flea borne - Murine typhus (Maxcy 1925 and Mooser 1921 )

 Mite borne diseases - Scrub typhus (tsutsugamushi disease)

 Rickettsial pox (Huebner 1946© ) by author  OtherESCMID rickettsia: non Online pathogenic Lecture Library  Any Gram negative intracellular bacteria= Rickettsiales

U R 3 NEW RICKETTSIAL DISEASES Many new diseases comparable to Arboviruses

 New clinical features

 no rash but adenopathy (R. slovaca, R. raoultii )

 no rash, no inoculation eschar (R. helvetica )

 others?  Several species involved in a same area

 R. conorii and R. africae - Africa  R. conorii, R. mongolotimonae© by author- France  R. conorii, R. aeschlimannii - Spain, North Africa

 R. typhi and R. felis - USA ESCMID R. honei and R.Online australis - Australia Lecture Library  R. rickettsii and R. parkeri - USA

 R. conorii and R. helvetica, R. slovaca - Switzerland U R 4 SITUATION DURING THE XXTH CENTURY One tick borne rickettsiosis per geographical area

 R. rickettsii agent of RMSF in the USA – other found in ticks: non pathogenic rickettsia (such as Coxiella burnetii or Legionella pneumophila)  R. conorii alone in Europe© byand author Africa ESCMID Online Lecture Library  Diagnostic provided by unspecific

tools never contradict this! U R 5 TICK BORNE DISEASES IN THE 80 ties

R. conorii R. sibirica

R. rickettsii © by author

ESCMID Online Lecture R.Library australis Anything else : non pathogenic

U 6 R END XXTH BEGINNING XXITH CENTURY Molecular Biology

 16S rRNA: first revolution  Rickettsia specific genes: second revolution: Diagnostic PCR New Rickettsia and rickettsial disease © by author  Genotyping rickettsiae correlation: ESCMID Genotype: epidemiology,Online Lecture pathotype? Library

U R 7 R. rickettsii MOLECULAR BIOLOGY Rickettsia rickettsii R. prowazekii R. prowazekii Orientia tsutsugamushi R. tsutsugamushi R. quintana Ehrlichia chaffeensis E. ewingii C. burnetii E. canis E. ruminantium E. canis Anaplasma E. phagocytophila phagocytophilum E. sennetsu WolbachiaA. marginale pipientis C. ruminantium N. helminthoeca Neorickettsia sennetsu N.helminthoeca Bartonella quintana W. pipientis B. henselae W. persica B. talpae a B. bacilliformis R. grylli Brucella melitensis © by authorCoxiella burnetii Rickettsiales B. bacilliformis Rickettsiella grylli G. talpae Legionella pneumophila «Wolbachia persica» g Francisella tularensis ESCMIDA. marginale Online Lecture Library E. ovis Eperythrozoon ovis Hemobartonella felis H. felis Mycoplasma pneumoniae Gram + 8 Ureaplasma urealyticum a 1984 c b NOW END XXTH BEGINNING XXITH CENTURY Molecular Biology

U R 9 SKIN BIOPSY IS THE KEY OF DISCOVERY OF NEW RICKETTSIAL DISEASES

U R 10 SWABING Bechah Y, Socolovschi C, Raoult D. Identification of rickettsial infections by using cutaneous swab specimens and PCR. Emerg Infect Dis. 2011 Jan;17(1):83-6.

Mouffok N, Parola P, Raoult D. Murine typhus, Algeria. Emerg Infect Dis. 2008 Apr;14(4):676-8.

11 DIAGNOSTIC: PCR

Tested R. prowazekii B. quintana B. recurrentis

Ants 40 0 0 0

Lice 44 16 (36%) 5 (11%) 0

Tested gene Citrate synthase Citrate synthase 16srRNA © by authorITS Negative controls are critical ESCMIDTwo different genes Online for confirmation Lecture of atypical/unique Library case Avoid “open” nested PCR and positive controls

U R 12 RAPID ID OF A TICK FROM PATIENT BY MALDI-TOF October 2-2012

Symtoms EPIDEMIOLOGY  Travel place / date :  Date of symtoms :  Fever X Morphological identification: Ixodes ricinus  Eschar only/ localisation :  Eschar multiples / localisation : X mass spectrometry: I.ricinus score 1,5 Adenopathy / localisation :  Single bite/ localisation :

 multiple bite / localisation : Rash :  Maculo-papulus  Purpuric  Vesiculus  Animals contact:

=> Identify risk factor X Other manifestation: erythematous lesions

Date smarlab Bartonella C. burnetii Rickettsies Coxiella-like Borrelia A. phagoc 08/10/2012 1279089 neg neg neg neg neg ec 13 TICK-BORNE RICKETTSIOSES R. PA4 R. monacensis R. massiliae R. conorii caspia

R. sibirica R. sibirica R. parkerii R. helvetica sibirica mongolitimonae

R. mongolotimonae R. heilongjiangensis

R. amblyommii R. conorii indica R.slovaca R. conorii R. 364D conorii R. conorii israeli R. japonica

R. rickettsii © by author R. conorii conorii

ESCMID Online LectureR. australis Library R. aeschlimannii R. africae R. honei 14 HOW TO FIND NEW (RICKETTSIAL) DISEASE 1. Anything atypical is a candidate (seasonal variation, severity, atypical clinical symptoms, atypical host) Exemple in France

- R.conorii summer, mild to severe, fever generalized rash, 1 inoculation escar on the body.

- R.massiliae South est, adultes males no difference, co-infection with R.conorii

- R.sibirica mongolitimonae Spring, mild, several inoculation escars, rope like lymphangitis, adenitis, generalized rash and fever

- R.slovaca/R.raoultii Cold season, children and women, scalp inoculation, neck adenitis© , bypost infection author fatigue, no fever or rash

- R.africae Traveler, very mild, no or low fever, several inoculation eschars, rash in 50 % (vesicular in half case) ESCMID Online Lecture Library - R.helvetica fever, no rash, spring no escar

2. Swab escar or vesicule => PCR 15 What’s new? In Europe

P. Parola, C.D. Paddock, D. Raoult. Tick-Borne Rickettsioses around the World: Emerging diseases challenging old concepts. © by authorClin Microbiol Rev. 2005; 18(4):719-56. ESCMID Online LectureFrom Library 1 to 9: Tick borne spotted fever since 1997. U 16 R Mediterranean Spotted Fever Rickettsia conorii Known since 1909  More common  More severe (2-10% mortality rate in Portugal)  More multiple escars  Transmitted by Rhipicephalus sanguineus (world wide dog tick)

Restricted to the old world: WHY!!!! © by author ESCMID Online Lecture Library

U R 17 R.SANGUINEUS AGRESSIVITY INCREASE WITH TEMPERATURE R. sanguineus

ESCMIDWarmer weather linked Online to tick attack andLecture emergence of severeLibrary rickettsioses. Parola P, Socolovschi C, Jeanjean L, Bitam I, Fournier PE, Sotto A, Labauge P, Raoult D. PLoS Negl Trop Dis. 2008;2(11):e338. Epub 2008 Nov 18. May be true for RMSF 18  (Tibola-Debonel) Scalp Escar and Neck lymphadenopathy after tick bite - R. slovaca, R. raoultii  Lymphangitis Associated Rickettsiosis - R. sibirica mongolitimonae  Aneruptive rickettsiosis:© by author R. helvetica ESCMID Online Lecture Library

U R 19 DERMACENTOR TICKS IN EUROPE R. SLOVACA

Ambush strategy: • waits, falls • bites head • children © by author • cold season ESCMID Online Lecture Library

U R 20 DERMACENTOR SEEKING HAIR

U R 21 R. slovaca infection (compared to MSF)

 Based on 17 PCR confirmed cases  More tick bite found  Lesion in the hair  Less fever  More cervical lymph node  Sequels : residual asthenia, localised alopecia  Low death rate © by author  Young age  Females > males  LowESCMID serological titres Online Lecture Library (Raoult D, et al. Clin Infect Dis. 2002 ;34:1331-6.)

U 22 R U R

 Cases very closely related to TIBOLA  Clinical cases identical to that caused by R. slovaca  Present in Dermacentor, ¼ of that of R. slovaca  Less pathogenic © by author  Present in all Eurasia ESCMID Online Lecture Library

23 Scalp eschar and neck lymphadenopathy caused by Bartonella henselae after Tick Bite. Angelakis E, Pulcini C, Waton J, Imbert P, Socolovschi C, Edouard S, Dellamonica P, Raoult D. Clin Infect Dis. 2010 Feb 15;50(4):549-51. Abstract Rickettsia slovaca and Rickettsia raoultii have been associated with a syndrome characterized by scalp eschar and neck lymphadenopathy following tick bites. However, in many cases, the causative© by agentauthor remains undetermined. We report 3 cases of this syndrome caused by Bartonella henselae,ESCMID and Onlinewe propose Lecture the term Library "SENLAT" to collectively describe this clinical entity.

24 OTHERS AGENTS MORE COMMON IN COLD MONTHS AND SCALP ESCAR

• Bartonella henselae

• Francisella tularensis © by author Borrelia? ESCMID• Online Lecture Library

U R 25 LYMPHANGITIS ASSOCIATED RICKETTSIOSIS (LAR) R.sibirica mongolitimonae

Lymphadenopathy  Fever, rash in spring

 Lymphangitis (5/10 cases)

 2 “taches noires” (3/10 cases)

 Lymphadenitis Lymphangitis  Clustered cases © by author Eschar

Lymphangitis-associatedESCMID rickettsiosis, Online a new Lecture rickettsiosis caused Library by Rickettsia sibirica mongolotimonae: seven new cases and review of the literature. Fournier PE, Gouriet F, Brouqui P, Lucht F, Raoult D. U Clin Infect Dis. 2005 May 15;40(10):1435-44. 26 R ‘‘RICKETTSIA SIBIRICA MONGOLITIMONAE’’ HISTORICAL ASPECTS

 1993 : First isolation from Hyalomma asiaticum ticks from Inner Mongolia Yu X, et al. J Clin Microbiol. 1993;31: 83-8.

 1996 - 2003: – 9 cases in Marseilles, from France and Algeria Raoult D, et al. Lancet. 1996 ;348:412

Fournier PE, et al. Emerg Infect Dis. 2000;6:290-2.  2000 found in Hylomma sp. in© Mali by author Parola P, et al.. Emerg Infect Dis. 2001 ;7:1014-7.

 In Greece in Hyalomma PsaroulakiESCMID A,et al. J Clin Microbiol. 2005 Jul ;43(7):3558Online-9. Lecture Library  2003: One case reported in South Africa Pretorius AM, Emerg Infect Dis. 2004;10:125-6.

• 2008-2012 found in Rhipicephalus  2006: in Portugal U  pusillus in Europe 27 2005: in Greece R

R. helvetica

 Unspotted fever  Found in ticks from Europe to Japan -  Cases in France, Switzerland, Thailand, Japan  Fever, no rash, no“tache noire”

U 28 R  A patient in Sicily in 1984 presented with fever, rash and “tache noire”  A Rickettsia was isolated in the blood  Identified in 2005: Vitale G, et al. Rickettsia massiliae human isolation. Emerg Infect Dis, 2006,12:174-5.  Found in the USA : M. Eremeeva, 2006 (Appl Environ Microbiol, 72:5569-77)  Coinfection with R.conorii

U ESCMID Online Lecture Library R

Warmer weather linked to tick attack and emergence of severe rickettsioses. Parola P, Socolovschi C, Jeanjean L, Bitam I, Fournier PE, Sotto A, Labauge P, Raoult D.

PLoS Negl Trop Dis. 2008;2(11):e338. Epub 2008 Nov 18. 29 R. monacensis  Found in I. ricinus in Germany and Spain  First case (typical MSF) found in la Rioja, Spain (Dr. Oteo)

30 What’s new? In America P. Parola, C.D. Paddock, D. Raoult. Tick-Borne Rickettsioses around the World: Emerging diseases challenging old concepts. © by authorClin Microbiol Rev. 2005; 18:719-56. ESCMID Online Lecture Library

U R 31 ROCKY MOUNTAIN SPOTTED FEVER

 Rickettsia rickettsii  Transmitted by tick bites (Dermacentor andersoni and others)  Summer disease  USA : 500 cases/year (South-eastern states) Prevalent in Brazil © by author and Central America  Fever, eruption, ESCMID Online 1Lecture - 2.5 p. 106 Library 5 - 80 % mortality 2.6 - 5 p. 106 without treatment > 5 p. 106 U R 32 What is this?

© by author ESCMID Online Lecture Library Raoult D, Parola P. Rocky Mountain spotted fever in the USA: a begnin disease or a common diagnostic error? Lancet Infect Dis, 2008: in press U 33 R A cluster of cases was recently found in Arizona R. sanguineus the dog tick (vector of R. conorii) was identified as the vector

Demma LJ, et al. Rocky Mountain Spotted Fever from an Unexpected Tick Vector in Arizona. N Engl J Med,2005;353:587-94. U 34 R  First isolation from Amblyoma maculatum in 1931  This tick is prevalent in South East USA and bite humans  One isolate of a patient who died of “RMSF” in Ohio was similar to R. parkeri but considered R. rickettsii (Ralph et© al. byAnn Nauthor Y Acad Sci - 1990)  Found in A. maculatum, A. cajennense, A. triste ESCMID Online Lecture Library

U R 35 © by author ESCMID Online Lecture Library Emerging Infectious Diseases, 2007;13:334-336

U R 36 Now in Argentina and Brazil Rickettsia parkeri rickettsiosis and its clinical distinction from Rocky Mountain spotted fever. Paddock CD, Finley RW, Wright CS, Robinson HN, Schrodt BJ, Lane CC, Ekenna O, Blass MA, Tamminga CL, Ohl CA, McLellan SL, Goddard J, Holman RC, Openshaw JJ, Sumner JW, Zaki SR, Eremeeva ME. Clin Infect Dis. 2008 Nov 1;47(9):1188-96. BACKGROUND: Rickettsia parkeri rickettsiosis, a recently identified spotted fever transmitted by the Gulf Coast tick (Amblyomma maculatum), was first described in 2004. We summarize the clinical and epidemiological features of 12 patients in the United States with confirmed or probable disease attributable to R. parkeri and comment on distinctions between R. parkeri rickettsiosis and other United States rickettsioses.

METHODS: Clinical specimens from patients in the United States who reside within the range of A. maculatum for whom an veschar or esicular rash was described were evaluated by > or =1 laboratory assays at the Centers for Disease Control and Prevention (Atlanta, GA) to identify probable or confirmed infection with R. parkeri.

RESULTS: During 1998-2007, clinical samples from 12 patients with illnesses epidemiologically and clinically compatible with R. parkeri rickettsiosis were submitted for diagnostic evaluation. Using indirect immunofluorescence antibody assays, immunohistochemistry, polymerase chain reaction assays, and cell culture isolation, we© identified by 6 confirmedauthor and 6 probable cases of infection with R. parkeri. The aggregate clinical characteristics of these patients revealed a disease similar to but less severe than classically described Rocky Mountain spotted fever.

CONCLUSIONS: Closer attention to the distinct clinical features of the various spotted fever syndromes that existESCMID in the United States Online and other countries Lecture of the Western hemisphere,Library coupled with more frequent use of specific confirmatory assays, may unveil several unique diseases that have been identified collectively as Rocky Mountain spotted fever during the past century. Accurate assessments of these distinct infections will ultimately provide a more valid description of the currently recognized distribution, incidence, and case-fatality rate of Rocky Mountain spotted fever. 37 Detection of Rickettsia amblyommii in association with a tick bite rash. Billeter SA, Blanton HL, Little SE, Levy MG, Breitschwerdt EB. Vector Borne Zoonotic Dis. 2007 Winter;7(4):607-10.

In the summer of 2006, an Amblyomma americanum tick was removed from a woman in central North Carolina, who subsequently developed a rash at the site of tick attachment. When examined by polymerase chain reaction (PCR) for Borrelia, Anaplasma, Ehrlichia, Babesia, Rickettsia, and Bartonella DNA, only the Rickettsia primers generated an amplicon, which was identified as "R. amblyommii" by sequencing. To our knowledge, this is the first case in which R. amblyommii was temporally associated with a rash.

Tick-borne diseases in North Carolina: is "Rickettsia amblyommii" a possible cause of rickettsiosis reported as Rocky Mountain spotted fever? Apperson CS, Engber B, Nicholson WL, Mead DG, Engel J, Yabsley MJ, Dail K, Johnson© by J, Watsonauthor DW. Vector Borne Zoonotic Dis. 2008 Oct;8(5):597-606. Given the low relative abundance of American dog ticks, the high relative abundance of loneESCMID star ticks around residencesOnline and, theLecture prevalence of “LibraryR. amblyommii” in lone star tick pools, we reasoned that the probable RMSF case patients were being exposed to and possibly infected with another SFGR, most likely “R.amblyommii.”

38 Rickettsia 364D: a newly recognized cause of eschar- associated illness in California. Shapiro MR, Fritz CL, Tait K, Paddock CD, Nicholson WL, Abramowicz KF, Karpathy SE, Dasch GA, Sumner JW, Adem PV, Scott JJ, Padgett KA, Zaki SR, Eremeeva ME.

Clin Infect Dis. 2010 Feb 15;50(4):541-8.

Conclusions. This is the first confirmation of human disease associated with the SFGR 364D, which was likely transmitted by D. occidentalis. Although the patients described here presented with a single cutaneous eschar as the principal manifestation, the full spectrum of illness associated with 364D has yet to be determined. Possible infection with 364D or other SFGR should be confirmed through molecular techniques in patients who present with “spotless”© by Rocky author Mountain spotted fever or have serum antibodies to R. rickettsii with group-specific assays. ESCMID Online Lecture Library

39 R. AFRICAE INVASION OF THE NEW WORLD

Parola P, et al. N Engl J Med. 1998 ;338:1391 U R 40 THEN NOW IN THE US

NAME WHERE RMSF - R.rickettsii – severe/rare – rash no eschar SE,W

? - R.parkeri – mild – vesicular rash – inoculation eschar SE

? - R.amblyommii, mild, rarely rash, no fever SE

- R.massiliae – mild – rash – eschar (dog tickles) ?

- Rickettsia 364D – mild© –by no rash author – inoculation eschar California

ATBF - R.africae Travellers ESCMID Online Lecture Library

41 WHAT’S NEW? In Asia

R.sibirica sibirica (Russia, Mongolia, China) R.sibirica mongolitimonae R.heilongjiangensis R.japonica R.helvetica R.kellyi © by author ESCMID Online Lecture Library

U R 42 LYMPHANGITIS ASSOCIATED RICKETTSIOSIS (LAR) R.sibirica mongolitimonae

Lymphadenopathy  Fever, rash in spring

 Lymphangitis (5/10 cases)

 2 “taches noires” (3/10 cases)

 Lymphadenitis Lymphangitis  Clustered cases © by author Eschar

44 JAPANESE OR ORIENTAL SPOTTED FEVER Emerging infectious disease (1984)

 Rickettsia japonica  Transmitted by tick bite (Dermacentor taïwanensis, Haemaphysalis flava)  Described by Dr. Mahara, associated with a positive Weil Felix Test © by author  Prevalent in Japan ESCMIDFever, eruption, Online eschar Lecture Library  Mild

45 R. heilongjangensis

 Described in 2004 by O. Mediannikov  Close to R. japonica  13 cases for Russian Far East diagnosed by PCR and serology  Tick bite: 6  Fever (13), rash (12), eschar (12), local adenopathy (10), lymphangitis© by(2) author

MediannikovESCMID OY, Sidelnikov Online Y, Ivanov L, Mokretsova Lecture E, Fournier Library PE, Tarasevich I, Raoult D. Acute tick-borne rickettsiosis caused by Rickettsia heilongjiangensis in Russian Far East. Emerg Infect Dis. 2004;10:810-7.

U 46 R CHINEESE SF RICKETTSIA

R. sibirica - R. sibirica - HA-90 (cluster) - R. mongolotimonae (Hyalomma asiaticum) (HA-91)

R. - «R. heilongjiangii» (D. silvaticus) Japonica 054 (a case with fever rash, «tache noire» and regional lymphadenopathy) (cluster) - «R. hulinii» (Haemaphysalis concinna) (HL-93)

R. heilongjiangensis R. sibirica mongolitimonae © by author ESCMID Online Lecture Library R. sibirica

47 "Candidatus Rickettsia kellyi," India. Rolain JM, Mathai E, Lepidi H, Somashekar HR, Mathew LG, Prakash JA, Raoult D. Emerg Infect Dis. 2006 Mar;12(3):483-5.

Abstract We report the first laboratory-confirmed human infection due to a new rickettsial genotype in India, "Candidatus Rickettsia kellyi," in a 1-year-old boy with fever and maculopapular rash. The diagnosis was made by serologic testing, polymerase chain reaction detection, and immunohistochemical© by author testing of the organism from a skin biopsy specimen. ESCMID Online Lecture Library

U R 48 IN AUSTRALIA

- R.australis - R.honei - R.gravesi

49 QUEENSLAND TICK TYPHUS

 Rickettsia australis  Transmitted by tick bite (Ixodes holocyclus)  Fever, eruption (vesicular), eschar, enlarged lymph nodes  Mild to severe © by author ESCMID Online Lecture Library

50 FLINDER'S ISLANDS SPOTTED FEVER Emerging infectious disease (1991)

 Rickettsia honei  Identical to Tick Thai Typhus Rickettsia ?  Transmitted by ?  Located to the Flinder's Islands  Fever, eruption, eschar, enlarged lymph nodes © by author  Described by Dr. Stewart ESCMID Online Lecture Library

51 What’s new? In Africa

P. Parola, C.D. Paddock, D. Raoult. Tick-Borne Rickettsioses around the World: Emerging diseases challenging old concepts. Clin Microbiol Rev. © by author 2005; 18:719-56. ESCMID Online Lecture Library

U 52 R AFRICAN TICK BITE FEVER Emerging infectious disease (1992)

 Rickettsia africae  Transmitted by tick bite (Amblyomma haebraeum)  High incidence in Southern Africa  Fever, "tache noire" (multiple) rare eruption (vesicular)  Mild  Discovered twice © by author  Considered identical to MSF ESCMIDuntil 1992 Online Lecture Library  Extremely common in travellers (second only to U Malaria) R 53 AMBLYOMMA TICKS R. AFRICAE

U R 54 Clinical specificity : – Less febrile – Local lesion * more inoculation eschars * multiple inoculation eschars * more locations on legs of eschars * more regional lymphadenopathies – Rash * less rash © by author * no purpuric rash * ESCMIDvesicular rash Online LectureRaoult D,et al.N EnglLibrary J Med. 2001;344:1504-10. – Clustered cases – Low death rate U – Late seroconversion 55 R

LYMPHANGITIS ASSOCIATED RICKETTSIOSIS (LAR)

 Fever, rash in spring Lymphadenopathy  Lymphangitis (5/10 cases)

 2 “taches noires” (3/10 cases)

 Lymphadenitis © by author Lymphangitis  Clustered cases Lymphangitis-associated rickettsiosis, a new rickettsiosis causedESCMID by Rickettsia sibirica mongolotimonae: Online seven Lecture new LibraryEschar cases and review of the literature. Fournier PE, Gouriet F, Brouqui P, Lucht F, Raoult D. U Clin Infect Dis. 2005 May 15;40(10):1435-44. 56 R R. aeschlimanii

 Found in Hyalomma sp. Camel tick in Northern Africa and other species in Southern Europe 2 cases described: one in France from Morocco, one in South Africa • Case in Algeria

57 IN TICKS IN AFRICA Tick-borne rickettsioses, neglected emerging diseases in rural Senegal Mediannikov O, Diatta G, Fenollar F, Sokhna C, Trape JF, Raoult D. PLoS Negl Trop Dis. 2010 Sep 14;4(9). BACKGROUND: Rickettsioses are one of the most important causes of systemic febrile illness among travelers from developed countries, but little is known about their incidence in indigenous populations, especially in West Africa. METHODOLOGY/PRINCIPAL FINDINGS: Overall seroprevalence evaluated by immunofluorescence using six rickettsial antigens (spotted fever and typhus group) in rural populations of two villages of the Sine-Saloum region of Senegal was found to be 21.4% and 51% for spotted fever group rickettsiae for Dielmo and Ndiop villages, respectively. We investigated the role of tick-borne rickettsiae as the cause of acute non-malarial febrile diseases in the same villages. The incidence of rickettsial DNA in 204 blood samples from 134 (62M and 72F) febrile patients negative for malaria was studied. DNA extracted from whole blood was tested by two qPCR systems. Rickettsial DNA was found in nine patients, eight with Rickettsia felis (separately reported). For the first time in West Africa, Rickettsia conorii was diagnosed in one patient. We also tested 2,767 Ixodid ticks collected in two regions of Senegal (Niakhar and Sine-Saloum) from domestic animals (cows, sheep, goats, donkeys and horses) by qPCR and identified five different pathogenic rickettsiae. We found the following: Rickettsia aeschlimannii in Hyalomma marginatum rufipes (51.3% and 44.8% in Niakhar and Sine-Saloum region, respectively), in Hyalomma truncatum (6% and 6.8%) and in Rhipicephalus evertsi evertsi (0.5%, only in Niakhar); R. c. conorii in Rh. e. evertsi (0.4%,© only by in Sine-Saloum); author Rickettsia massiliae in Rhipicephalus guilhoni (22.4%, only in Niakhar); Rickettsia sibirica mongolitimonae in Hyalomma truncatum (13.5%, only in Sine-Saloum); and Rickettsia africae in Rhipicephalus evertsi evertsi (0.7% and 0.4% in Niakhar and Sine-Saloum region, respectively) as well as in Rhipicephalus annulatus (20%, only in Sine-Saloum). We isolated two rickettsial strains from H.ESCMID truncatum: R. s. mongolitimonae Online and R. aeschlimannii. Lecture Library CONCLUSIONS/SIGNIFICANCE: We believe that together with our previous data on the high prevalence of R. africae in Amblyomma ticks and R. felis infection in patients, the presented results on the distribution of pathogenic rickettsiae in ticks and the first R. conorii case in West Africa show that the rural population of Senegal is at risk for other tick-borne rickettsioses, which are significant causes of febrile disease in this area. 58  Geographic repartition of scrub typhus

 Among the 3 first causes of infection in rural areas in far east (with murine© typhus by authorand Leptospirosis)  Currently re-emerging in India – very common in South Asia : Thailand, Vietnam  1ESCMID Billion people exposedOnline Lecture Library  1 Million cases per year (?) U R 59 SCRUB TYPHUS

 Fever  Headaches (95%)  Generalized lymphadenopathies (50%)  Eschar (50%)  Rash (25%) © by author  Severe form (27%) ESCMIDAbortion Online Lecture Library (Lao Study by P. Newton et al.)

60 TRANSMITTED DISEASES BY BODY LICE

• Rickettsia prowazekii

• Borrelia recurrentis

U R 61 TYPHUS EPIDEMIOLOGY

Infection Stress WAR Typhus Apparent Cold weather cure Relapse Bad hygiene (Years) Brill Zinsser Disease

U R TYPHUS

62 OUTBREAK Typhus Outbreak Burundi GIANT OUTBREAK New disease : "SUTAMA" (Crouching)  Fever, severe myalgias of the legs, headache, resistance to antimalarial drugs, presence of body lice  103 patients were sampled© by author (serum and body louse) 70ESCMID % of them had Online biological Lecture Library confirmation of epidemic typhus Estimated cases: 100,000 in 1997 U R (D. Raoult, et al. Lancet, 1998, 352: 353-358) 63 TYPHUS SPORADIC CASES

 Russia: 1997: 23 cases in a psychiatric institution (Tarasevich I, et al. 1998, Lancet, 352: 1151)

 Peru: outbreak near Cusco (Raoult D., et al. 1999, Clin Infect Dis, 29: 434-436)

 Algeria: cases near Batna (1998-2003) (Niang M, et al. 1999, Emerg Infect Dis.© 5:716-718 by author Mokrani K, et al. 2004, J Clin Microbiol, 42:3898-3900)

 France:ESCMID a case in a homelessOnline Lecture Library (Brouqui P, et al. Medicine (Baltimore). 2005; 84:61-8)

U R 64 Back in the XIXth century

Napoleon retreat of Russia 65 VILNIUS-CEMETERY 2002

U R 66 © by author We identified 5 lice, confirmed their identification by PCR andESCMID sequencing. OnlineWe identified Lecture B. quintana Library by PCR in 3 lice. Raoult D, et al. Evidence for louse transmitted diseases in soldiers of Napoleon’s Grand Army in Vilnius. JID, Jan 2006.

67 © by author ESCMID Online Lecture Library We extracted DNA from dental pulp of 35 soldiers and found B. quintana in 7 and R. prowazekii in 3.

69 FLEA TRANSMITTED DISEASES

U 70 R Typhus murin

• Rickettsia typhi (R. mooseri) • Vector: Rat flea • Widespread in the South of the USA, Central America and South, Africa, Asia (Indonesia, Thailand) and Mediterranean (Greece, Cyprus, Spain, North Africa) • Fever, rash(40 – 50%)© by author • Discret rash

• FirstESCMID or second cause Online of Lecture Library fever of rural origin in Southeast Asia 71  In 1970, changes in the distribution of murine typhus a disease caused by R.typhi transmitted by the rat fleas (Xenopsylla cheopis)  Cases are more prevalent in a wealthy county Orange (CA) than in poor counties  Opossums are identified© as bymajor author actors  They are infested by cat fleas (CenocephalidesESCMID felis) Online Lecture Library

72 Rickettsia felis-associated uneruptive fever, Senegal Socolovschi C, Mediannikov O, Sokhna C, Tall A, Diatta G, Bassene H, Trape JF, Raoult D. Emerg Infect Dis. 2010 Jul;16(7):1140-2.

Abstract During November 2008-July 2009, we investigated the origin of unknown fever in Senegalese patients with a negative malaria test result, focusing on potential rickettsial infection. Using molecular tools, we found evidence for Rickettsia felis- associated illness in © the by initial author days of infection in febrile Senegalese patients without malaria. ESCMID Online Lecture Library

73 Human Infection with Rickettsia felis, Kenya. Richards AL, Jiang J, Omulo S, Dare R, Abdirahman K, Ali A, Sharif SK, Feikin DR, Breiman RF, Njenga MK. Emerg Infect Dis. 2010 Jul;16(7):1081-6. Abstract To determine the cause of acute febrile illnesses other than malaria in the North Eastern Province, Kenya, we investigated rickettsial infection among patients from Garissa Provincial Hospital for 23 months during 2006-2008. Nucleic acid preparations of serum from 6 (3.7%) of 163 patients were positive for rickettsial DNA as determined by a genus- specific quantitative real-time© by author PCR and were subsequently confirmed by molecular sequencing to be positive for RickettsiaESCMID felis. The Online 6 febrile Lecture patients' symptoms Library included headache; nausea; and muscle, back, and joint pain. None of the patients had a skin rash.

74 Sampling: 87 pos R. felis

2008-2009 2010 2011 November- June: June-December: 384 January-March: 205 E/134 P E/323 P 409E Site Sine Saloum Site Sine Saloum •Dielmo: 2 R. felis /86E • Dielmo: 18 R. felis/210 • Dielmo: 8 R. •Ndiop: 3 R. felis/ 31E E/144 P felis/172 E/103 P • Ndiop: 8 R. felis/104 Site Niakhar : 2 R. felis/ 9E • Ndiop: 1 R. E/78 P Site Casamance: 12 R. Felis/33 E/ 31 P felis/ 122E • Site Niakhar© by : 13author R. Site Kedougou: 17 R. felis/ Total: 9 samples felis/ 70 E/P 80E Site Keur Momar Sarr: 3 R. Total: 39 samples 2010 felis/ 81E ESCMID Online Lecture Library

Total: 39 samples en 2011

75 Description of "yaaf", the vesicular fever caused by acute Rickettsia felis infection in Senegal. Mediannikov O, Fenollar F, Bassene H, Tall A, Sokhna C, Trape JF, Raoult D. J Infect. 2012 Oct 13. Rickettsiosis caused by Rickettsia felis is an emerging infection in Africa and may account for 3-4% of ambulatory febrile fevers. We report herein a case of R. felis infection, for which we propose the name "yaaf", meaning vesicle, in an 8-month-old girl who was diagnosed in the field by real-time PCR analysis of a skin lesion; these PCR analysis was performed at a local experimental point-of-care laboratory. The clinical presentation was polymorphous skin lesions, including papules, vesicles, erosions and ulcers. The patient did not produce antibodies against Rickettsia. We suggest that this disease may be a primary infection caused by R. felis.

© by author Skin lesions of the patient with a primary ESCMID Online Lecture Libraryinfection with R. felis. a – general appearance; 76 b – ulcerative lesions; c – vesicles. Now look for Rickettsia felis in mosquitos

Rickettsia felis in Aedes© albopictus by author Mosquitoes, Libreville, Gabon. Socolovschi C, Pagés F, Raoult D. Emerg Infect Dis. 2012 Oct;18(10):1687-9.

ESCMIDRickettsia Online species in African Lecture Anopheles mosquitoes Library Cristina Socolovschi,Frederic Pages,Mamadou Ousmane Ndiath, Pavel Ratmanov, Didier Raoult PLOS ONE. In press

77 Molecular evidence for the presence of Rickettsia felis in the feces of wild-living African apes. AK.Keita,C.Ahuka-Mundeke,P.Ratmanov,C.Butel,A.Ayouba,B-I Inogwabini,JJ.MuyembeTamfum,E.MpoudiNgole,E.Delaporte,M.Peeters,F.Fenollar,D.Raoult. Submitted PlosOne.

Figure 4. A map of the prevalence of Plasmodium falciparum [17] and R. felis in gorillas and chimpanzees found in our study at different collection sites in Cameroon (Table 4). The map shown is from Google © 2012. CONCLUSION

• Fastidious organisms such as Rickettsia need specific molecular tools

• That cause many of unexplained fevers (leptospiroses, Murine typhus, scrub typhus in S.E Asia, Borrelioses and Rickettsioses in Africa) © by author ESCMID Online Lecture Library • Are easy to teat with Doxycycline