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First Isolation of R. slovaca was demonstrated in References the tick and the biopsy by using PCR 1. Raoult D, Berbis P, Roux V, Xu W, Maurin Rickettsia slovaca with primers derived from the citrate M. A new tick-transmitted disease due to synthase and the rOmpA genes as pre- Rickettsia slovaca. Lancet 1997;350:112–3. from a Patient, 2. La Scola B, Raoult D. Laboratory diagnosis France viously reported (2). R. slovaca was of rickettsioses: current approaches to the found in human embryonic lung cells diagnosis of old and new rickettsial dis- (2), 3 days after the cells were injected eases. J Clin Microbiol 1997;35:2715–27. To the Editor: Rickettsia slovaca with the skin-biopsied material. Sero- 3. Raoult D, Lakos A, Fenollar F, Beytout J, is a bacterium that infects Dermacen- conversion, determined by indirect Brouqui P, Fournier PE. A spotless rick- ettsiosis caused by Rickettsia slovaca and tor marginatus ticks in central and immunofluorescence, occurred with associated with Dermacentor ticks. Clin western Europe. First detected in titers to both R. slovaca and R. conorii Infect Dis 2002;34:1331–6. ticks, the bacterium was subsequently of <1/8 and 1/128 in acute- and conva- 4. Lakos A. Tick-borne lymphadenopathy—a identified with genomic amplification lescent-phase sera (sampled 2 months new rickettsial disease? Lancet by using polymerase chain reaction later), respectively. 1997;350:1006. 5. Raoult D, Fournier PE, Fenollar F, Jense- (PCR) followed by sequencing in a R. slovaca, first identified in der- nius M, Prioe T, de Pina JJ, et al. Rickettsia skin biopsy from a French patient (1). macentor ticks from Slovakia, has africae, a tick-borne in travelers We describe the first isolation of the subsequently been found in both D. to sub-Saharan Africa. N Engl J Med organism from a patient. marginatus and D. reticulatus in 2001;344:1504–10. A 79-year-old woman from St. France, Switzerland, Portugal, Spain, 6. Zavala-Velasquez JE, Sosa-Ruiz JA, Zav- ala-Castro J, Jimenez-Delgadillo B, Vado- Etienne, France, found a tick on the Armenia, and Germany (3). Since the Solis IE, Sanchez-Elias RA, et al. Rickett- parietal area of her scalp 6 days after first human with R. slovaca sia felis—the etiologic agent of three cases she returned from a trip to rural south- were reported, patients with similar of in Yucatan. Lancet ern Burgundy. The tick was removed clinical signs have been observed in 2000;356:1079–80. and subsequently identified as an adult France and Hungary (4). Some of 7. Raoult D, Brouqui P, Roux V. A new spot- ted-fever-group rickettsiosis. Lancet female D. marginatus tick. The patient these cases have been confirmed by 1996;348:412. saw a physician 1 day later for low- PCR and others by serology (3), 8. Raoult D, La Scola B, Enea M, Fournier grade fever (38°C) and myalgia. She although serologic titers are frequently PE, Roux V, Fenollar F, et al. A -associ- was given (3 g once a low and show cross-reactions with ated Rickettsia pathogenic for humans. day), but the fever worsened. She was other Rickettsiae. We have described Emerg Infect Dis 2001;7:73–81. examined at University on the isolation of R. slovaca from a September 24, 2001, 4 days later. At patient, which provides the first defin- Address for correspondence: Didier Raoult, that time, the patient had a fever; the itive evidence that R. slovaca is a Unité des Rickettsies, CNRS: UPRESA 6020, site of the tick bite showed a necrotic human pathogen. Clinical signs of Faculté de Médecine, Université de la Médi- black lesion surrounded by an consist of a skin lesion at the terranée, 27, Boulevard Jean Moulin, 13385 Marseille cedex 05, France; fax: 33-04-91-83- erythematous halo 4 cm in diameter. site of a tick bite on the scalp (often a 0390; e-mail: Didier.Raoult@medecine. Right cervical lymphadenopathy and a dermacentor tick) and regional lym- univ-mrs.fr papular rash consisting of 10 pink phadenopathy that may be painful. spots on the thorax and arms were Fever and rash develop subsequently, observed. Routine blood tests were and the acute disease can be followed within normal ranges but asparate by fatigue and residual alopecia at the Enteropathogenic aminotransferase (53 IU; normal <45), bite site. The disease may be prevalent creatine phosphokinases (140, normal within the distribution range of D. <120), and lactate dehydrogenases marginatus and D. reticulatis in south- pneumoniae (890, normal <620) were elevated. A ern, western, and central Europe. This HIV-Infected skin biopsy from the patient’s scalp, new spotted rickettsiosis should be Adults, Africa serum, and the tick were sent to added to the list of recognized rickett- Marseille to test for possible rickett- sial diseases, mainly those caused by To the Editor: Although Kleb- sial infection. The patient was treated R. africae (5), R. felis (6) and R. mon- siella pneumoniae lives as a commen- with doxycycline (200 mg once a day, golotimonae (7,8). sal in the intestine, this bacterium can 15 d), and her condition improved. At occasionally cause in HIV- a check-up 1 month later, she com- C. Cazorla,* M. Enea,† F. Lucht,* negative persons (1–4). Some of these plained of fatigue and insomnia; 2 and D. Raoult† diarrheagenic strains encode thermo- months later, she had recovered com- *Centre Hospitalier Universitaire de Saint stable or thermolabile toxins (2). One pletely, although alopecia still Etienne, Saint Etienne, France; and †Univer- group of researchers showed that a appeared at the site of the tick bite. sité de la Méditerranée, Marseille, France

Emerging Infectious Diseases • Vol. 9, No. 1, January 2003 135 LETTERS

K. pneumoniae strain isolated from CD4+ cell count was 122 cells/mL in trols, χ=40.7, p<10-6). All HEp-2– bloody diarrhea can bind to HeLa cells the patients and 436 cells/mL in the adherent K. pneumoniae isolated from and cytoskeletal proteins, such as the controls. AIDS-related symptoms six of the patients produced toxins. actin that accumulates at the point of were observed in all of the cases (Cen- The culture supernatants of the HEp- bacterium-host contact (3). However, ters for Disease Control and Preven- 2–adherent K. pneumoniae strains iso- this isolate did not contain any of the tion [CDC] stage C2 or C3) and none lated from four of the patients with genes encoding virulence factors that of the controls (CDC stage A1). Of the bloody chronic diarrhea and have been ascribed to pathogenic 31 patients, 7 (22.6%) had bloody pseudomembranous colitis had cyto- strains and are chronic diarrhea, 9 (29%) had watery toxic effects on Vero and Y1 cells, as responsible for bloody diarrhea or chronic diarrhea, and 15 (48.4 %) had characterized by the rounding of cells dysenteric syndromes (3). mild chronic diarrhea. Pseudomem- after 24 h, followed by their detach- In Bangui, the rate of isolation of branous colitis was diagnosed in nine ment from the culture plate and death pure cultures of K. pneumoniae from patients (six with bloody diarrhea, after 72 h. These effects were not neu- the stools of immunocompromised three with watery chronic diarrhea) tralized by rabbit antisera raised HIV-infected adults with chronic diar- who had been taking several antibiot- against the Shiga toxin or the rhea is increasing. This finding was ics, including , for a long toxin. The HEp-2–adherent K. pneu- observed during the routine biological period (>1 month). Five K. pneumo- moniae strains isolated from two analyses performed in the Pasteur niae colonies were randomly picked patients with watery chronic diarrhea Institute Medical Laboratory and is up from each case sample and exam- were enterotoxigenic in ligated rabbit consistent of that made by Gassama et ined. Control colonies were chosen if ileal loops. Only the HEp-2–adherent al. in Dakar (5). The role of K. pneu- their appearance suggested K. pneu- K. pneumoniae strains isolated from moniae in HIV-infected adults is not moniae. The mean number of strains one patient with watery chronic diar- well documented. As no other known tested was 4.99 for patients and 4.64 rhea and pseudomembranous colitis (5 enteric were isolated from for controls (not significant, p=0.969). strains) and from four patients with these samples, we conducted a case- All of the enteric isolated mild chronic diarrhea (20 strains) car- control study in Bangui in 1999–2001 from the patients and grown on nonse- ried sequences related to virulence to determine the clinical significance lective bromocresol purple medium genes from pathogenic enteroaggrega- of K. pneumoniae. The study popula- were K. pneumoniae, whereas an aver- tive E. coli. These isolates were all tion included 31 adults hospitalized age of 10% to 20% of the enteric bac- positive for the astA gene, which with chronic diarrhea and 31 matched teria isolated from the controls were encodes the EAST1 toxin, and for the controls. (Because of civil unrest in K. pneumoniae. We used assays typi- genes that produce the AAF/I fim- Bangui due to military rebellions and cally used to identify the virulence briae. the difficulties involved in recruiting factors of diarrheagenic E. coli (7) to K. pneumoniae is normally resis- controls, the study was performed on a characterize the virulence properties tant to β-lactams. Multidrug-resistant small sample.) To be included in the of the K. pneumoniae isolates, their K. pneumoniae have been reported study, the patients had to be HIV posi- genotypes, and their phenotypes (their (1). All K. pneumoniae isolates in this tive, be >18 years of age, have pro- ability to bind to cultured HEp-2 cells study were resistant to several antibi- vided a stool sample containing K. and to promote cytoskeleton modifica- otics including cotrimoxazole and pneumoniae on the day of recruitment, tions [fluorescent actin staining test], ampicillin, which are largely used in and have given informed consent. to invade epithelial cells, to produce Bangui according to the recommenda- Inclusion criteria were the same for various enterotoxins and cytotoxins, tions of the World Health Organiza- controls except that they did not have and to induce fluid accumulation in tion (8). In addition to the nonspecific diarrhea on the day of recruitment or the intestines of newborn mice). The measures used to correct and prevent in the previous month. Controls were rabbit ligated ileal loops test was per- fluid, electrolyte, and nutritional family members or neighbors of the formed when the genetic or pheno- imbalances, all persons with bloody patients, matched by age (within 5 typic (on Vero or Y1 cells) tests were and watery chronic diarrhea (includ- years) and sex. Specimens from cases positive for toxins. All isolates from ing those with pseudomembranous and controls were collected over the 27 patients (7, 9, and 11 with bloody, colitis) and 5 of the 15 patients with same 1-month period. Known enteric watery, and mild chronic diarrhea, mild chronic diarrhea (10 were lost to pathogens were identified by standard respectively) and two of the isolates follow-up) were treated with methods as described (6). Endoscopic from one control displayed an aggre- (800 mg/day) or ceftriaxone (2 g/day), examinations were used to diagnose gative adherence phenotype on HEp-2 based on the results of pseudomembranous colitis in patients cells. This phenotype appeared to be susceptibility testing. The state of all with bloody chronic diarrhea or significantly associated with chronic patients with pseudomembranous coli- watery chronic diarrhea. The median diarrhea (27/31 cases vs. 1/31 con- tis and mild chronic diarrhea, and of

136 Emerging Infectious Diseases • Vol. 9, No. 1, January 2003 LETTERS five of the patients with watery had the pathogenic marker for entero- 7. Nataro JP, Kaper JP. Diarrheagenic Escher- chronic diarrhea (one patient died), aggregative E. coli. These findings ichia coli. Clin Microbiol Rev improved within 10 days of treatment. suggest that not only is K. pneumo- 1998;11:142–66. 8. World Health Organization. Guidelines for In Dakar, during the study describ- niae associated with chronic diarrhea the clinical management of HIV infection ing ordinary and opportunistic entero- in HIV-infected persons but also that in adults. pub no. WHO/GPA/IDS/HCS/ pathogens associated with diarrhea in infection with particular HEp-2- 91.6. Geneva: The Organization, Global adults (5), stool samples were col- adherent K. pneumoniae subtypes Program on AIDS; 1991. lected from five HIV-infected adults may be associated with specific clini- with watery chronic diarrhea. In all cal illness. Address for correspondence: Yves Germani, cases, heavy K. pneumoniae growth Unité des Maladies Infectieuses Opportunistes, was observed on the primary culture Financial support was provided by BP 923, Bangui, Central African Republic; fax: media, and no other known pathogens Agence Nationale de Recherche sur le 236 61 01 09; e-mail: [email protected] were recovered. These K. pneumo- SIDA (contract 1227) and Groupe d'Etude niae strains were subjected to the des Infections Diarrhéiques (ACIP, Réseau same phenotypic and genotypic tests International des Instituts Pasteur et Insti- as the strains isolated in Bangui. HEp- tuts Associés). Granulomatous 2–adherent K. pneumoniae was identi- Lymphadenitis as fied in four of these five samples. The a Manifestation condition of all the patients rapidly Phuong L. Nguyen Thi,* improved after treatment with ofloxa- Simon Yassibanda,† Awa Aidara,‡ of cin. In Bangui and Dakar, repeated Chantal Le Bouguénec,§ stool cultures were negative for K. and Yves Germani* To the Editor: Q fever is a world- pneumoniae by the end of treatment, wide zoonosis caused by the obligate providing further evidence that these *Institut Pasteur de Bangui, Bangui, Central intracellular pathogen Coxiella bur- K. pneumoniae were of etiologic African Republic; †Hôpital de l'Amitié, Ban- gui, Bangui, Central African Republic; netii (1). Human infection is usually importance, especially the HEp-2– ‡Institut Pasteur de Dakar, Dakar, Sénégal; the result of exposure to infected cat- adherent K. pneumoniae strains. and §Institut Pasteur, Paris, France tle, sheep or goats. Acute Q fever may Only seven patients (four with be asymptomatic or manifest as a self- mild, two with watery, and one with References limiting febrile illness, , bloody chronic diarrhea) had not 1. Ananthan S, Raju S, Alavandi S. Entero- , or meningoencephalitis. taken during the 2 weeks toxigenicity of Most cases of acute Q fever will before stool collection. The stool associated with childhood gastroenteritis in Madras, . Jpn J Infect Dis resolve without sequelae, but specimens from these seven patients 1999;52:16–7. endocarditis, granulomatous hepatitis, yielded pure primary cultures of HEp- 2. Arora DR, Chugh TD, Vadhera DY. Entero- , and endovascular infec- 2–adherent K. pneumoniae and no toxigenicity of Klebsiella pneumoniae. Ind tions are well-documented manifesta- other bacterial enteric pathogens. J Pathol Microbiol 1983;26:65–70. tions of chronic C. burnetii infection None of these seven participants was 3. Guerin F, Le Bouguenec C, Gilquin J, Had- dad F, Goldstein FW. Bloody diarrhea (1). Recently, various atypical mani- diagnosed with pseudomembranous caused by Klebsiella pneumoniae: a new festations of acute (2), and chronic (3) colitis. The HEp-2–adherent K. pneu- mechanism of bacterial virulence? Clin Q fever have been reported as well as moniae strains isolated from the two Infect Dis 1998;27:648–9. changing clinical presentation of Q participants with watery chronic diar- 4. Guerrant RL, Moore RA, Kerschfeld PM, fever endocarditis (4) and changing rhea induced the accumulation of Sande MA. Role of toxigenic and invasive bacteria in acute diarrhea of childhood. N epidemiology of Q fever (5). fluid in ligated rabbit ileal loops, and Engl J Med 1975;293:567–71. Researchers have suggested that the HEp-2–adherent strains isolated 5. Gassama A, Sow PS, Fall F, Camara P, heightened awareness of Q fever from three of the participants with Philippe H, Guèye-N’Diay A. Ordinary and among doctors, coupled with mild chronic diarrhea carried the astA opportunistic enteropathogens associated improved diagnostic methods, could gene, which is associated with patho- with diarrhea in Senegalese adults in rela- tion to human immunodeficiency virus increase the medical knowledge about genic EAEC. Among the five patients serostatus. Int J Infect Dis 2001;5:192–8. this difficult-to-diagnose and difficult- with pseudomembranous colitis, all of 6. Germani Y, Minssart P, Vohito M, Yassi- to-treat infection (4). We report two whom had received antibiotics before banda S, Glaziou P, Hocquet D, et al. Etiol- cases of granulomatous lymphadeni- the onset of illness, we found that the ogies of acute, persistent, and dysenteric tis associated with C. burnetii infec- four isolates from the patients with diarrheas in adults in Bangui, Central Afri- can Republic, in relation to human immun- tion. bloody chronic diarrhea were cyto- odeficiency virus serostatus. Am J Trop A 70-year-old man was admitted pathogenic; the one isolate from the Med Hyg 1998;59:1008–14. to the hospital because of weight loss, patient with watery chronic diarrhea night sweats, and a continuous high-

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