LETTERS at symptom onset, but results for Acknowledgments 8. Valiente Moro C, De Luna CJ, Tod A, patient serum samples cultured We thank V. Rupeš for parasitologic Guy JH, Sparagano OAE, Zenner L. The poultry red mite (Dermanyssus gallinae): under the same conditions as the analysis, A. Valkoun for serologic analysis a potential vector of pathogenic agents. homogenized parasites remained of specifi c antibodies to Rickettsia and Exp Appl Acarol. 2009;48:93–104. negative. Signifi cant titers of IgG Coxiella spp., D. Kafková for collection doi:10.1007/s10493-009-9248-0 against B. quintana and B. henselae of patient data, and E. Kodytková for 9. Valiente Moro C, Thioulouse J, Chauve C, Normand P, Zenner L. Bacterial taxa asso- or IgG seroconversion in paired serum manuscript review. ciated with the hematophagous mite Der- samples were observed for all patients manyssus gallinae detected by 16S rRNA except the grandfather (Table). Oto Melter, Mardjan Arvand, PCR amplifi cation and TTGE fi ngerprint- Oral clarithromycin and ing. Res Microbiol. 2009;160:63–70. Jiří Votýpka, doi:10.1016/j.resmic.2008.10.006 doxycycline were administered to and Dagmar Hulínská 10. Reeves WK, Dowling APG, Dasch GA. the children and adults, respectively, Author affi liations: Charles University, Rickettsial agents from parasitic Derma- nyssoidea (Acari: Mesostigmata). Exp for 10 days. The apartment was Prague, Czech Republic (O. Melter); repeatedly treated with insecticide, Appl Acarol. 2006;38:181–8. doi:10.1007/ Zentrum für Gesundheitsschutz, Dillenburg, s10493-006-0007-1 and the hole in the roof was repaired, Germany (M. Arvand); and National Institute leading to eradication of the mites. of Public Health, Prague (J. Votýpka, D. Address for correspondence: Oto Melter, The few dead and dry mites that were Hulínská) Department of Medical Microbiology, 2nd available for additional parasitologic Medical Faculty, Charles University, V Úvalu DOI: http://dx.doi.org/10.3201/eid1801.110186 analysis were mounted in Swan 84, 150 06 Prague 5—Motol, Prague, Czech mounting medium (information References Republic; email: [email protected] about the medium is available from the authors), but no characteristics 1. Drancourt M, Mainardi JL, Brouqui P, allowing differentiation between Vandenesch F, Carta A, Lehnert F, et al. species of the genus Dermanyssus Bartonella (Rochalimaea) quintana en- docarditis in three homeless men. N Engl were recognized during examination J Med. 1995;332:419–23. doi:10.1056/ by light microscopy. Failed attempts NEJM199502163320702 were made to trap pigeons that had 2. Comer JA, Paddock CD, Childs JE. Urban lived on the roof of the apartment or in zoonoses caused by Bartonella, Coxiella, Ehrlichia, and Rickettsia species. Vec- Urban Transmission the same city; however, samples from tor Borne Zoonotic Dis. 2001;1:91–118. of Human African trapped synanthropic pigeons from doi:10.1089/153036601316977714 the north (n = 20) and central (n = 3. Breitschwerdt EB, Hegarty BC, Hancock Trypanosomiasis, 33) part of the country were negative SI. Sequential evaluation of dogs naturally infected with Ehrlichia canis, Ehrlichia Gabon for Bartonella spp. by the culture chaffeensis, Ehrlichia equi, Ehrlichia ew- To the Editor: We describe a and amplifi cation methods described ingii, or Bartonella vinsonii. J Clin Micro- above. Recurrent fever reported by biol. 1998;36:2645–51. confi rmed case of human African adult patients resolved in 3 months, 4. Anderson B, Sims K, Regnery R, Robinson trypanosomiasis (HAT) in an L, Schmidt MJ, Goral S, et al. Detection of and all patients made a full clinical expatriate returning to France from Rochalimaea henselae DNA in specimens Gabon after a probable tsetse fl y bite recovery. Laboratory fi ndings for the from cat scratch disease patients by PCR. patients were followed for 6 months J Clin Microbiol. 1994;32:942–8. in the urban setting of Libreville. after symptom onset (Table). 5. Arvand M, Schäd SG. Isolation of Bar- This case indicates a possible urban tonella henselae DNA from the peripheral The fact that the suspected transmission of HAT in Gabon and blood of a patient with cat scratch disease stresses the need for entomologic vector was a hematophagous mite up to 4 months after the cat scratch in- (Dermanyssus sp.), a parasite of jury. J Clin Microbiol. 2006;44:2288–90. studies in Libreville. synanthropic pigeons and a suspected doi:10.1128/JCM.00239-06 HAT is endemic to sub-Saharan 6. Massung RF, Slater KG. Comparison of vector of other bacterial pathogens Africa. Trypanosoma brucei PCR assays for detection of the agent of rhodesiense (eastern Africa) and T.b. (8,9), and that the 16S rRNA Bartonella human granulocytic ehrlichiosis, Ana- spp. gene was detected in mites plasma phagocytophilum. J Clin Mi- gambiense (western Africa) parasites (Steatonyssus sp. from the superfamily crobiol. 2003;41:717–22. doi:10.1128/ are transmitted to humans by tsetse fl ies JCM.41.2.717-722.2003 Dermanyssoidea) (10) remains a of the Glossina morsitans group (T.b. 7. Hulinska D, Votypka J, Plch J, Vlcek E, rhodesiense) and of the G. palpalis challenge for additional study. Pigeons Valešová M, Bojar M, et al. Molecular and probably played the role of accidental microscopical evidence of Ehrlichia spp. group (T.b. gambiense), which are host in this outbreak, but the source of and Borrelia burgdorferi sensu lato in pa- found only in Africa. T.b. gambiense tients, animals and ticks in the Czech Re- represents >90% of all reported cases the infection remains unclear. public. New Microbiol. 2002;25:437–48.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 1, January 2012 165 LETTERS of HAT worldwide. HAT has always and gammaglobulins (23.9 g/L). A case reported here, the tsetse bite been a travel-associated disease. It is a thick-blood smear showed no malaria likely occurred in the urban setting of rare cause of fever, cutaneous lesions, parasites but a few trypomastigotes Libreville. and neurologic signs in travelers of Trypanosoma spp. PCR of The patient did not report returning from disease-endemic areas blood identifi ed T.b. gambiense. A occupational exposure to tsetse bites and involves T.b. rhodesiense in 70% cerebrospinal fl uid sample showed outside Libreville during the previous of the cases, resulting mostly from an moderate elevation of total proteins year. He occasionally went in Pointe exposure during safari in game parks (0.43 g/L) and albumin (291 mg/L), Denis during weekends but did not (1,2). 11 leukocytes, and no IgM elevation. remember having been bitten by a A 58-year-old previously healthy Direct examination and PCR showed tsetse fl y. Although the patient did not Portuguese man who worked in no trypanosome in the cerebrospinal identify the insect in his garden, the Gabon for 13 years for a French fl uid. Specifi c antibodies were chronology of his clinical history and company was admitted to the tropical found in the blood by indirect the presence of a typical chancre at the and infectious diseases ward because immunofl uorescence (titer 200). place of the insect bite that occurred of a 2-month history of intermittent Biopsies of 2 skin lesions (thigh, before symptoms provide strong fever, fatigue, and a 10-kg weight back) showed a lymphoplasmocytic arguments in favor of this hypothesis. loss. The patient recalled a painful vasculitis consistent with cutaneous The bite occurred during the morning unidentifi ed insect bite on his right locations of HAT; no parasite was hours, in the patient’s home garden thigh 2 months before in his garden observed in situ. The patient was in the Lalala area of Libreville in Libreville (Lalala quarter). A 8-cm, treated successfully with a 7-day (0.357568N, 9.475365E) near the indurated, erythematous, and painful course of pentamidine. The case was Ogombié River. This area is located plaque (chancre) progressively reported to World Health Organization 125 km and 75 km from the Bendje developed (Figure) in the following Control of Neglected Tropical and Noya HAT foci, respectively. weeks after the assumed insect bite. Diseases Department. Two studies provided evidence When admitted to the hospital, the A total of 328 HAT cases for urban transmission of HAT in patient had a temperature of 39°C, were reported to the World Health Kinshasa (Democratic Republic of anorexia, insomnia, pruritus of the Organization in Gabon during 2000– Congo) and in Bonon (Côte d’Ivoire) left arm, and paresthesia of the hands 2009; most infections were acquired (7,8). Concurrently, some tsetse and feet. Two additional large annular in the mangrove swamp Atlantic coast species, such as G. palpalis, adapt to erythematous macules, centrally pale focus in Noya (Estuaire Province) and high human densities and are found (trypanids), were found on his back some in the focus of Bendje (Ogooué- in the largest urban centers of western (Figure). A subclavicular 0.5-cm Maritime Province) (3). Four of 6 Africa (9). Entomologic studies in lymph node was observed. There was cases of T.b. gambiense imported Libreville should prompt further no hepatosplenomegaly. to Europe during 2005–2009 were investigation into a possible urban His laboratory results showed in expatriates with a travel history transmission of HAT in Gabon, as we moderate anemia (hemoglobin 11.8 to Gabon (1). In the 4 case-patients suspect in the case reported. g/dL) and thrombopenia (134,000 infected in Gabon, an exposure in platelets/mm3) and elevated levels rural forest areas was assessed (4–6; Fabrice Simon, Marie Mura, of C-reactive protein (30.6 mg/L) D. Malvy, pers. comm.). In the fi fth Frédéric Pagès, Gabriel Morand, Philippe Truc, Francis Louis, and Philippe Gautret Author affi liations: Hôpital d’Instruction des Armées Laveran, Marseille, France (F. Simon, M. Mura, G. Morand, P. Gautret); Institut de Médecine Tropicale du Service de Santé des Armées, Marseille (F. Pagès); Institut de Recherche pour le Développement, Montpellier, France (P. Truc); and Organisation de Coordination pour la Lutte contre les Endémies en Afrique Centrale, Yaoundé, Cameroon (F. Figure. Thigh chancre (1) and back trypanids (2 and 3) in a patient with human African Louis) trypanosomiasis infection, Gabon. A color version of this fi gure is available online (wwwnc. cdc.gov/EID/article/18/1/11-1384-F1.htm). DOI: http://dx.doi.org/10.3201/eid1801.111384

166 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 1, January 2012 LETTERS

References Rickettsia felis incubation (37°C for 30 min), slides were washed 3 times, incubated with 1. Gautret P, Clerinx J, Caumes E, Simon Infections, F, Jensenius M, Loutan L, et al. Imported fl uorescein-conjugated antihuman human African trypanosomiasis in Eu- New Zealand IgG, IgM, and IgA (ARRL), and rope, 2005–2009. Euro Surveill. 2009; washed again before examination. 14:pii:19327. To the Editor: Members of All samples were then tested by using 2. Migchelsen SJ, Büscher P, Hoepelman AI, the genus Rickettsia have garnered an IgG IFA kit (Focus Diagnostics, Schallig HD, Adams ER. Human African much attention worldwide in recent trypanosomiasis: a review of non-endemic Cypress, CA, USA) against typhus cases in the past 20 years. Int J Infect Dis. years with the emergence of newly group (TG) R. typhi and spotted fever 2011 Jun 15; [Epub ahead of print]. recognized rickettsioses. In New group (SFG) R. rickettsii. 3. Simarro PP, Cecchi G, Paone M, Franco Zealand, only Rickettsia typhi and TG-positive and SFG-negative JR, Diarra A, Ruiz JA, et al. The Atlas R. felis, belonging to the typhus and of human African trypanosomiasis: a serum samples may represent R. typhi contribution to global mapping of ne- spotted fever groups, respectively, infections, and SFG-positive and TG- glected tropical diseases. Int J Health have so far been found (1). R. typhi, negative serum samples may represent Geogr. 2010;9:9–57. doi:10.1186/1476- primarily transmitted by the oriental R. felis infections. Because R. typhi can 072X-9-57 rat fl ea (Xenopsylla cheopis), has a 4. Bisoffi Z, Beltrame A, Monteiro G, Arz- cross-react with SFG rickettsiae (7), ese A, Marocco S, Rorato G, et al. African worldwide distribution and causes and R. felis with R. typhi (5), results trypanosomiasis gambiense, Italy. Emerg murine typhus in humans (2). At the that are TG positive and SFG positive Infect Dis. 2005;11:1745–7. end of 2009, a total of 47 cases of may be caused by either rickettsiae. 5. Ezzedine K, Darie H, Le Bras M, Malvy murine typhus had been recorded in D. Skin features accompanying imported Positive reactivity may also represent human African trypanosomiasis: hemo- New Zealand. In contrast, although overseas-acquired rickettsioses. Thus, lymphatic Trypanosoma gambiense infec- the cat fl ea (Ctenocephalides felis) can WB and cross-adsorption assays using tion among two French expatriates with carry R. felis in New Zealand (3), no R. typhi (Wilmington) and R. felis dermatologic manifestations. J Travel human infections have been reported. Med. 2007;14:192–6.. doi:10.1111/j.1708- (URRWXCal2) antigens (Unité des 8305.2007.00114.x However, because R. felis shares Rickettsies, Marseilles, France) were 6. Hope-Rapp E, Moussa Coulibaly O, Kl- a similar clinical profi le to murine used to confi rm any R. typhi or R. felis ement E, Danis M, Bricaire F, Caumes E. typhus, infection can be mistaken for infections (6). Double trypanosomal chancre revealing a suspected case of R. typhi (4). West African trypanosomiasis in a French- Antigens (2 mg/mL) were man living in Gabon. Ann Dermatol Vene- Clinical suspicion of rickettsial solubilized (100°C for 10 min) in 2× reol. 2009;136:341–5. Epub 2009 Feb 26. infection is widely confi rmed by Laemmli buffer (6) and subjected doi:10.1016/j.annder.2008.09.023 serologic tests with the indirect to electrophoresis (20 μg/well; 20 7. Simo G, Mansinsa Diabakana P, Kande immunofl uorescence assay (IFA) being Betu Ku Mesu V, Manzambi EZ, Ollivier mA, 2.5 h) through polyacrylamide G, Asonganyi T, et al. Human African the standard test. However, antibodies gels (12.5% resolving; 4% stacking) trypanosomiasis transmission, Kinshasa, against R. felis in human sera are (BioRad, Hercules, CA, USA). Democratic Republic of Congo. Emerg In- known to cross-react with R. typhi in Resolved antigens were electroblotted fect Dis. 2006;12:1968–70. doi:10.3201/ IFA (5). Western blot (WB) and cross- eid1212.060516 (100 V for 1 h) onto 0.45-μm 8. Courtin F, Dupont S, Zeze DG, Jamon- adsorption assays, in combination with polyvinylidene difl uoride membranes, neau V, Sané B, Coulibaly B, et al. Human IFA, can differentiate between several which were blocked by using 5% African trypanosomiasis: urban transmis- rickettsioses (5,6). We report on the milk–Tris-buffered saline with 0.1% sion in the focus of Bonon (Côte d’Ivoire). trial in New Zealand of WB and cross- Trop Med Int Health. 2005;10:340–6. Tween 20. Each antigen lane was doi:10.1111/j.1365-3156.2005.01398.x adsorption assays for differentiating divided into 2 strips before incubation 9. Courtin F, Sidibé I, Rouamba J, Jamon- retrospectively between past R. typhi (room temperature for 1 h) with neau V, Gouro A, Solano P. Population and R. felis infections and evidence of serum (diluted 1:200). After three growth and global warming: impacts on R. felis infection in persons living in tsetse and trypanosomoses in West Africa. 10-min washes with Tris-buffered Parasite. 2009;16:3–10. the country. saline with 0.1% Tween 20, strips Serum samples were obtained were incubated (room temperature, Address for correspondence: Fabrice Simon, from 24 volunteers from the Institute 1 h) with horseradish peroxidase– Department of Infectious Diseases and Tropical of Environmental Science and conjugated antihuman IgG (1:150,000; Medicine, Laveran Military Teaching Hospital, Research Limited, Porirua, New SouthernBiotech, Birmingham, AL, Bd Alphonse Laveran, BP 60149, 13384 Zealand. Samples were tested using R. USA) and washed again. Enhanced Marseille CEDEX 13, France; email: simon-f@ typhi IFA slides (Australian Rickettsial chemiluminescent detection of bound wanadoo.fr Reference Laboratory [ARRL], horseradish peroxidase (ECL Plus; Geelong, Victoria, Australia). After GE Healthcare, Buckinghamshire,

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