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Rickettsia Conorii Indian Tick Typhus Strain and R. Slovaca in Humans

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Rickettsia Conorii Indian Tick Typhus Strain and R. Slovaca in Humans LETTERS humans. Additionally, Mycobacteria Nottingham, Sutton Bonington, UK (J. Address for correspondence: David W. Verner- spp. can occasionally cause disease in Leigh); and Oxford Radcliffe University Jeffreys, Cefas Weymouth Laboratory, The humans through contact with fi sh (M. Hospitals, Headington, UK (N. Jones) Nothe, Barrack Rd, Weymouth, Dorset DT4 8UB, UK; email: david.verner-jeffreys@cefas. marinum), and pedicure treatments DOI: http://dx.doi.org/10.3201/eid1806.111782 have previously been associated with co.uk M. fortuitum infections (10). References Recently, the risks associated with exposure to G. rufa fi sh were 1. Health Protection Agency Fish Spa reported to be low (1). To date, there Working Group. Guidance on the man- agement of the public health risks from are only a limited number of reports fi sh pedicures: draft for consultation. of patients who might have been 2011 Aug 31 [cited 2012 Mar 21]. http:// infected by this exposure route (1). www.hpa.org.uk/webc/HPAwebFile/ Rickettsia conorii However, our study raises some HPAweb_C/1317131045549 2. Jones N, Bohnsack JF, Takahashi S, Indian Tick Typhus concerns over the extent that these Oliver KA, Chan MS, Kunst F, et al. fi sh, or their transport water, might Multilocus sequence typing system for Strain and harbor potential zoonotic disease group B Streptococcus. J Clin Micro- R. slovaca in pathogens of clinical relevance. In biol. 2003;41:2530–6. http://dx.doi. org/10.1128/JCM.41.6.2530-2536.2003 Humans, Sicily particular, patients with underlying 3. Evans JJ, Bohnsack JF, Klesius PH, Whit- conditions (such as diabetes mellitus ing AA, Garcia JC, Shoemaker CA, et al. To the Editor: Rickettsiae are or immunosuppression) should Phylogenetic relationships among Strep- vector-borne pathogens that affect be discouraged from undertaking tococcus agalactiae isolated from piscine, dolphin, bovine and human sources: a dol- humans and animals worldwide such treatments, especially if they phin and piscine lineage associated with a (1). Pathogens in the Rickettsia have obvious breaks in the skin or fi sh epidemic in Kuwait is also associated conorii complex are known to cause abrasions. This risk can probably be with human neonatal infections in Japan. J Mediterranean spotted fever (MSF) (R. reduced by use of certifi ed disease- Med Microbiol. 2008;57:1369–76. http:// dx.doi.org/10.1099/jmm.0.47815-0 conorii Malish strain), Astrakhan fever free fi sh reared in controlled facilities 4. Janda JM, Abbott SL. The genus Aeromo- (R. conorii Astrakhan strain), Israeli under high standards of husbandry and nas: taxonomy, pathogenicity, and infec- spotted fever (R. conorii Israeli spotted welfare. tion. Clin Microbiol Rev. 2010;23:35–73. fever strain), and Indian tick typhus http://dx.doi.org/10.1128/CMR.00039-09 5. Jones MK. Oliver, JD. Vibrio vulnifi cus: (R. conorii Indian tick typhus strain) The UK Department for Environment disease and pathogenesis. Infect Im- in the Mediterranean basin and Africa, mun. 2009;77:1723–33. http://dx.doi. Food and Rural Affairs provided funding southern Russia, the Middle East, org/10.1128/IAI.01046-08 and India and Pakistan, respectively for this study through projects FA001 and 6. Morris JG. Non–O group-1 Vibrio chol- FB002. era—a look at the epidemiology of an (2). These rickettsioses share some occasional pathogen. Epidemiol Rev. clinical features, such as febrile illness 1990;12:179–91. and generalized cutaneous rash, David W. Verner-Jeffreys, 7. Wagner D, Young LS. Nontuberculous and are transmitted to humans by mycobacterial infections: a clinical re- Craig Baker-Austin, Rhipicephalus spp. ticks (2). Michelle J. Pond, view. Infection. 2004;32:257–70. http:// dx.doi.org/10.1007/s15010-004-4001-4 MSF is endemic to Sicily (Italy); Georgina S. E. Rimmer, 8. Skoff TH, Farley MM, Petit S, Craig AS, fatal cases occur each year, and the Rose Kerr, David Stone, Schaffner W, Gershman K, et al. Increas- prevalence of R. conorii in dogs ing burden of invasive group B strepto- Rachael Griffi n, Peter White, is high (3–6). Recently, R. conorii Nicholas Stinton, coccal disease in non-pregnant adults, 1990–2007. Clin Infect Dis. 2009;49:85– Malish strain and R. conorii Israeli Kevin Denham, James Leigh, 92. http://dx.doi.org/10.1086/599369 spotted fever strain were confi rmed Nicola Jones, 9. Verner-Jeffreys DW, Welch TJ, Schwarz in humans in Sicily in whom MSF T, Pond MJ, Woodward MJ, Haig SJ, et Matthew Longshaw, was diagnosed (4), which suggests and Stephen W. Feist al. High prevalence of multidrug-tolerant bacteria and associated antimicrobial re- that other R. conorii strains might Author affi liations: Centre for Environment, sistance genes isolated from ornamental be present and diagnosed as causing Fisheries & Aquaculture Science Weymouth fi sh and their carriage water. PLoS ONE. MSF. The rickettsiae within the R. Laboratory, Weymouth, UK (D.W. Verner- 2009;4:e8388. http://dx.doi.org/10.1371/ journal.pone.0008388 conorii complex, which are relevant Jeffreys, C. Baker-Austin, M.J. Pond, 10. De Groote MA, Huitt G. Infections due for the study of bacterial evolution G.S.E. Rimmer, R. Kerr, D. Stone, R. to rapidly growing mycobacteria. Clin In- and epidemiology, can be properly Griffi n, P. White, N. Stinton, K. Denham, fect Dis. 2006;42:1756–63. http://dx.doi. identifi ed only by appropriate genetic org/10.1086/504381 M. Longshaw, S.W. Feist); University of analyses. 1008 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 6, June 2012 LETTERS We analyzed 15 blood and 19 patient who had confi rmed R. slovaca gltA (U59730), respectively. The inoculation eschar samples collected infection. R. conorii Malish strains R. slovaca strain showed 99.4%, during 2005–2009 from 31 patients showed 99.9%–100%, 100%, 100%, 97.8%, 100%, 93.7%, 99.7%, and in Palermo Province and 2 in Catania 98.7%–100%, 100%, and 97.8%– 99.4% pairwise nt sequence identity Province, none of whom had recently 100% pairwise nt sequence identity to to R. slovaca atpA (AY124734), traveled. None were severely ill, but reference strain Malish 7 (AE006914) dnaK (DQ821824), ompA all 33 had clinical manifestations atpA, dnaK, ompA, ompB, gltA, and (HM149286), ompB (HQ232242), and laboratory results compatible 17-kDa protein, respectively. gltA (AY129301), and R. conorii with MSF: 1-week incubation after The R. conorii Indian tick typhus strain Malish 7 (AE006914) 17-kDa tick bite, fever, headache, myalgia, strain showed 100%, 100%, 99.4%, protein, respectively. The sequences papulonodular rash that started 100%, 100%, and 99.9% pairwise nt were deposited in GeneBank under on the upper limbs and spread sequence identity to R. conorii strain accession nos. JN182782–JN182804. centripetally with or without tache Malish 7 (AE006914) atpA, dnaK, Multilocus sequence analysis noire, and detection of antibody 17-kDa protein, and R. conorii Indian (Figure, panel A) and in silico PstI- titers >180 to R. conorii by indirect tick typhus reference strain ompA RsaI restriction analysis of ompA immunofl uorescence antibody test (U43794), ompB (AF123726), and sequences also confi rmed the identity (bioMérieux, Marcy L’Etoile, France). Total DNA was extracted by using the GeneElute Mammalian Genomic DNA Miniprep Kit (Sigma- Aldrich, Milan, Italy) and used to analyze Rickettsia spp. sequences by PCR, cloning, and sequence analysis of the amplicons. At least 3 clones were sequenced for each amplicon. Genes targeted by PCR included ATP synthase α subunit (atpA) (7), heat- shock protein 70 (dnaK) (7), outer membrane protein A (ompA) (primers Rr190.70p and 190–701 [8]), outer membrane protein B (ompB) (primers rompBSFGIF and rompBSFG/TGIR [9]), citrate synthase (gltA) (2), and 17-kDa protein (primers TZ15–19 and TZ16–20 [6]). Nucleotide sequence identity to reference strains (2), multilocus analysis by atpA– dnaK–ompA–ompB–gltA–17-kDa and ompA–ompB sequences and in silico PstI-RsaI restriction analysis of ompA sequences (8) were used to Figure. Multilocus sequence analysis of Rickettsia spp. Evolutionary history was inferred characterize Rickettsia spp. and R. by using the neighbor-joining method for ATP synthase α subunit (atpA)–heat shock conorii strains. protein 70 (dnaK)–outer membrane protein A (ompA)–ompB–citrate synthase (gltA)– Results for 15 (45%) patients were 17-kDa (A) and ompA–ompB sequences (B). The optimal tree with the sum of branch positive for Rickettsia spp. Thirteen length = 0.06205323 (A) and 0.11097561 (B) is shown. The percentage of replicate trees in which the associated taxa clustered together in the bootstrap test (1,000 replicates) are isolates were confi rmed as R. conorii shown next to the branches. The tree is drawn to scale, with branch lengths in the same Malish strain (identifi cation [ID] nos. units as those of the evolutionary distances used to infer the phylogenetic relationship. 44, 45, 47, 49, 54, 55, 57, 59, 61, 66, Evolutionary distances were computed by using the Kimura 2-parameter method and are 68, 92, 112) and 1 each as R. conorii in the units of the number of base substitutions per site. All ambiguous positions were Indian tick typhus strain (ID no. 58) removed for each sequence pair. Evolutionary analyses were conducted in MEGA5 (www. megasoftware.net). Identifi cation numbers of strains detected are shown with the species/ and R. slovaca (ID no. 50). R. slovaca strain name next to them. Rc, R. conorii strain Malish 7; Ra, R. africae strain ESF-5; Rr, DNA was also found in a Dermacentor R. rickettsii strain Iowa; Rs, R. slovaca; Rm, R. massiliae strain MTU5; Rcind, R. conorii marginatus tick removed from the Indian tick typhus strain. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 6, June 2012 1009 LETTERS of the Rickettsia spp.
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