LETTERS

Scalp Eschar and Neck Lymphadenopathy Caused by massiliae

To the Editor: Scalp eschar and neck lymphadenopathy is a common clinical entity that most frequently af- fects women and children during spring and fall. It is usually caused by Rick- ettsia slovaca and R. raoultii. Typical clinical signs are a scalp lesion at the bite site and regional, often painful, lymphadenopathy. Acute disease can be followed by residual alopecia at the bite site (1,2). Two designations have been proposed for this syndrome: tick-borne Figure. Residual alopecia 10 weeks after tick bite in 13-year-old boy with scalp eschar and lymphadenopathy and Dermacentor- neck lymphadenopathy caused by Rickettsia massiliae. Printed with permission from N.C. borne necrosis-erythema-lymphade- (photographer and author) and from parents of the patient. nopathy (both have been associated with R. slovaca); however, the most Physical examination revealed The patient was given doxycy- generic and all-inclusive term is scalp temperature 39.5°C, pulse rate 70 cline at 100 mg 2 times per day. Signs eschar and neck lymphadenopathy. beats/min, and respiratory rate 20 and symptoms began to improve 48– R. massiliae belongs to the spot- breaths/min. The boy appeared to be 72 h later and gradually disappeared. ted fever group rickettsiae, is distrib- in good condition. An ≈1-cm black Fever was gone after 3 days, and the uted worldwide, and is transmitted by eschar was noted at the site of the other symptoms had regressed after of the genus Rhipicephalus (3). tick bite. Palpation of the neck re- 7 days. To our knowledge, only 3 cases of R. vealed painful bilateral adenopathies. Serologic testing for R. conorii massiliae infection in humans have Other lymph nodes in the occipital was performed by microimmunofluo- been documented and confirmed by region were enlarged. No exanthema rescence with the R. conorii/R. typhi molecular methods. The first case was was noted, the liver was palpable 1 IgG MIF Kit (Fuller Laboratories, detected in a blood sample from a pa- cm under the costal margins, and the Fullerton, CA, USA). Total DNA was tient in Italy who had Mediterranean spleen was not enlarged. Laboratory extracted from blood and the eschar spotted fever (4); the second case was evaluation indicated blood cell counts by GenElute Mammalian Genomic in a patient in southern France who had and liver and kidney function within DNA Miniprep (Sigma-Aldrich, St. spotted fever and acute loss of vision reference limits, mild elevation of Louis, MO, USA). To detect Rick- (5); and the third case was in a woman inflammatory markers (C-reactive ettsia spp. DNA, we tested nucleic in Argentina who had fever, a palpable protein 1.2 mg/dL [reference <0.5 acids by PCR with a set of primers that purpuric rash, and tache noire (3). We mg/dL]), and elevated erythrocyte amplify a 256-bp region of the gene report a case of R. massiliae infection sedimentation rate (43 mm/h). Ul- encoding the 17-kDa antigen (6). that resulted in scalp eschar and neck trasonography of the neck confirmed To obtain information about Rick- lymphadenopathy. the presence of numerous, enlarged, ettsia spp., we amplified regions of On May, 10, 2012, a 13-year-old oval lymph nodes (maximum 17 mm) the genes gltA (7,8), ompA (7), and boy was examined for headache, high with hilar vascularity within normal ompB (9). PCR products were puri- fever, and right painful neck and oc- limits. A scalp eschar biopsy sample fied by the Wizard SV Gel and PCR cipital swelling. Six days earlier, a tick and acute- and convalescent-phase Clean-up System (Promega, Madison, had been removed from the top of his (day 30) serum samples were sent to WI, USA), quantified, and sent for se- scalp, after which signs and symptoms the Istituto Zooprofilattico Sperimen- quencing to Macrogen Inc. (Amster- arose and gradually worsened. tale della Sicilia. dam, the Netherlands).

836 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 5, May 2013 LETTERS

Obtained sequences were aligned Antonio Cascio, gence for portions of two rickettsial genes. and analyzed by using Bioedit Alessandra Torina, J Bacteriol. 1991;173:1576–89. 9. Choi YJ, Jang WJ, Ryu JS, Lee SH, software (Ibis Biosciences, Carls- Mariella Valenzise, Park KH, Paik HS, et al. Spotted fever bad, CA, USA) and ClustalW ver- Valeria Blanda, group and group rickettsioses sion 2.0.10 (www.ebi.ac.uk/clustalw). Natalia Camarda, in humans, South Korea. Emerg In- DAMBE (http://dambe.bio.uottawa. Sara Bombaci, Chiara Iaria, fect Dis. 2005;11:237–44. http://dx.doi. org/10.3201/eid1102.040603 ca/dambe.asp) and MEGA (www. Filippo De Luca, 10. Zhu Y, Fournier PE, Eremeeva M, megasoftware.net) software were and Malgorzata Wasniewska Raoult D. Proposal to create subspecies used to obtain similarity percentages Author affiliations: University of Messina, of based on multi- among analyzed sequences. To char- locus sequence typing and an emended Messina, Italy (A. Cascio, A. Torina, M. Va- description of Rickettsia conorii. BMC acterize Rickettsia spp., we used nu- lenzise, N. Camarda, S. Bombaci, F. De Microbiol. 2005;5:11. http://dx.doi. cleotide sequence identity to reference Luca, M. Wasniewska); Istituto Zooprofilat- org/10.1186/1471-2180-5-11 strains (10). tico Sperimentale della Sicilia, Palermo, Convalescent-phase serum was Italy (A. Torina, V. Blanda); and Azienda Address for correspondence: Antonio Cascio, positive for R. conorii; IgG titer Ospedaliera Piemonte-Papardo, Messina Programma di Infettivologia Speciale, Medicina was 64. Sequence analysis of puri- (C. Iaria) Tropicale e delle Migrazioni e Parassitologia, fied PCR products obtained from Policlinico “G. Martino,” Via Consolare Valeria n. DOI: http://dx.doi.org/10.3201/eid1905.121169 the eschar identified the isolate as R. 1, 98125 Messina, Italia; email: [email protected] massiliae. With respect to the refer- References ence strain R. massiliae, pairwise nucleotide sequence identity was 1. Angelakis E, Pulcini C, Waton J, Imbert 99% for the gltA gene (GenBank ac- P, Socolovschi C, Edouard S, et al. Scalp cession no. JN043507), 99% for the eschar and neck lymphadenopathy caused by henselae after tick bite. Clin ompA gene (accession no. JQ480842), Infect Dis. 2010;50:549–51. http://dx.doi. and 97% for the ompB gene org/10.1086/650172 Mycobacterium (accession no. AF123714). Phyloge- 2. Parola P, Rovery C, Rolain JM, Brouqui P, tuberculosis netic analysis (online Technical Ap- Davoust B, Raoult D. Rickettsia slovaca and R. raoultii in tick-borne rickettsioses. Complex in pendix, wwwnc.cdc.gov/EID/article/ Emerg Infect Dis. 2009;15:1105–8. http:// 19/5/12-1169-Techapp1.pdf) also dx.doi.org/10.3201/eid1507.081449 Remains of confirmed the identity of the Rickett- 3. García-García JC, Portillo A, Nunez 18th–19th Century sia species. MJ, Santibanez S, Castro B, Oteo JA. A patient from Argentina infected with Slaves, Brazil Considering the diagnosis of R. Rickettsia massiliae. Am J Trop Med Hyg. massiliae infection and the patient 2010;82:691–2. http://dx.doi.org/10.4269/ To the Editor: Nineteenth centu- who had acute vision loss (5), this ajtmh.2010.09-0662 ry Rio de Janeiro, Brazil, was marked patient was called back for a fundus 4. Vitale G, Mansuelo S, Rolain JM, Raoult by increased illness and deaths from D. Rickettsia massiliae human isolation. examination, which showed no chang- Emerg Infect Dis. 2006;12:174–5. http:// tuberculosis (TB). By the twentieth es. At the time of this visit, a small dx.doi.org/10.3201/eid1201.050850 century, it was still believed that most area of alopecia at the eschar site was 5. Parola P, Socolovschi C, Jeanjean L, Bi- TB cases in the Americas originated observed (Figure). Unfortunately, tam I, Fournier PE, Sotto A, et al. Warmer from Europe; the “virgin soil” hypoth- weather linked to tick attack and emer- the tick had been discarded and was gence of severe rickettsioses. PLoS Negl esis for African (1) and Amerindian not available for genus and species Trop Dis. 2008;2:e338. http://dx.doi. populations was accepted. However, identification. org/10.1371/journal.pntd.0000338 modern and archeological DNA evi- The presence of R. massiliae in 6. Tzianabos T, Anderson BE, McDade JE. dence confirms the wide distribution Detection of DNA in Italy demonstrates that this Rickettsia clinical specimens by using polymerase of Mycobacterium tuberculosis com- species can cause scalp eschar and chain reaction technology. J Clin Micro- plex (MTC) and TB in the Old and neck lymphadenopathy. Further stud- biol. 1989;27:2866–8. New Worlds. ies are needed to complete the list of 7. Oteo JA, Portillo A, Santibanez S, Blanco Rio de Janeiro was a main entry JR, Perez-Martinez L, Ibarra V. Cluster of microorganisms that can cause this cases of human infection port for millions of Africans captured condition and to understand if they from southern Europe (Spain) diagnosed by for the slave trade. Pretos Novos (New can be associated with minor find- PCR. J Clin Microbiol. 2006;44:2669–71. Blacks) Cemetery (PNC; 1769–1830) ings (e.g., alopecia, painful eschar, http://dx.doi.org/10.1128/JCM.00366-06 was created in Rio de Janeiro as a 8. Regnery RL, Spruill CL, Plikaytis BD. high fever). Genotypic identification of rickettsiae and burial ground for the many slaves estimation of intraspecies sequence diver- who died at market. Comingled bone

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 5, May 2013 837 Article DOI: http://dx.doi.org/10.3201/eid1905.121169 Scalp Eschar and Neck Lymphadenopathy Caused by Rickettsia massiliae

Technical Appendix

Technical Appendix Figure. Phylogenetic analysis of Rickettsia spp. Evolutionary history was inferred by using the neighbor-joining method for ompA gene, ompB gene, and gltA gene. “Human” indicates 13- year-old boy with scalp eschar and neck lymphadenopathy caused by Rickettsia massiliae.

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