LETTERS rural southwestern United States (10) References Address for correspondence: Pilar Foronda, and a strain of pathogenic B. elizabe- Institute of Tropical Diseases and Public 1. Kamani J, Morick D, Mumcuoglu Y, Health of the Canary Islands, University of thae, a bacteria that can cause human Harrus S. Prevalence and diversity of endocarditis, in the Huayllacallán Val- Bartonella species in commensal rodents La Laguna, Avda. Fco. Sanchez s/n, 38203, ley in Peru (3). and ectoparasites from Nigeria, west Tenerife, Canary Islands, Spain; email: Because most identified Barton- Africa. PLoS Negl Trop Dis. 2013;7: [email protected] e2246. http://dx.doi.org/10.1371/journal. ella spp. have been reported as infec- pntd.0002246 tious agents for humans, our results 2. Gage KL, Kosoy MY. Natural his- should prompt public health concern. tory of plague: perspectives from However, our findings require further more than a century of research. Annu Rev Entomol. 2005;50:505–28. investigation about the pathogenic- http://dx.doi.org/10.1146/annurev. ity of these Bartonella genotypes. ento.50.071803.130337 The detection of both pathogens in 3. Birtles RJ, Canales J, Ventosilla P, intradomestic and peridomestic areas Alvarez E, Guerra H, Llanos-Cuentas A, et al. Survey of Bartonella species Buruli Ulcer where humans are in close contact infecting intradomicillary animals in with rodents could indicate that the the Huayllacallán Valley, Ancash, Peru, Disease in Republic incidence of both diseases in humans a region endemic for human bartonel- of the Congo from Echarate District might be un- losis. Am J Trop Med Hyg. 1999;60: 799–805. To the Editor: Buruli ulcer, which derestimated. 4. Parola P, Shpynov S, Montoya M, Lopez M, Houpikian P, Zeaiter Z, et al. is caused by the Mycobacterium ulcer- This study was supported by Agen- First molecular evidence of new Barton- ans bacterium, is a severe disabling cia Española para la Cooperación In- ella spp. in fleas and a tick from Peru. Am necrotic disease of the skin, occur- J Trop Med Hyg. 2002;67:135–6. ternacional y el Desarrollo under Pro- ring mainly in swampy rural areas of 5. Billeter SA, Gundi VA, Rood MP, grama de Cooperación Interuniversitaria Kosoy MY. Molecular detection and western and central Africa. This tropi- (A1/037176/11), the Spanish Ministry of identification of Bartonella species cal disease is neglected, despite being Foreign Affairs and Cooperation (proj- in Xenopsylla cheopis (Siphonaptera: the third most common mycobacterial Pulicidae) collected from Rattus norvegicus ect Red de Investigación Colaborativa disease of humans, after tuberculosis in Los Angeles, California. Appl Environ de Centros de Enfermedades Tropicales; Microbiol. 2011;77:7850–2. http://dx.doi. and leprosy. The disease has become RD06/0021/0005); and the Spanish Min- org/10.1128/AEM.06012-11 substantially more frequent over the istry of Health, Madrid. A.M.-A. was 6. Hinnebusch J, Schwan TG. New meth- past decade, particularly around the od for plague surveillance using poly- supported by a PhD grant from Agencia Gulf of Guinea, and has been detected merase chain reaction to detect Yer- Canaria de Investigación, Innovación y sinia pestis in fleas. J Clin Microbiol. or suspected in at least 31 countries Sociedad de la Información. M.A.Q.-R. 1993;31:1511–4. (1). Clinical diagnosis of Buruli ulcer was supported by a research contract from 7. Kosoy MY, Regnery R, Tzianabos T. disease should be confirmed by PCR, Distribution, diversity, and host specificity Centro de Excelencia Internacional–Plata- as recommended by the World Health of Bartonella in rodents from the south- forma Atlantica para el Control de las En- eastern United States. Am J Trop Med Organization (WHO); and case-pa- fermedades Tropicales. Hyg. 1997;57:578–88. tients should be treated with rifampin/ 8. Chan KS, Kosoy M. Analysis of streptomycin daily for 8 weeks (thera- multi-strain Bartonella pathogens py available since 2004), combined, if Aarón Martin-Alonso, in natural host populationdo they Mayday Soto, Pilar Foronda, behave as species or minor genetic necessary, with surgery. Elsa Aguilar, variants? Epidemics. 2010;2:165–72. Although confirmed cases of http://dx.doi.org/10.1016/j.epidem.2010. Guillermo Bonnet, Buruli ulcer disease have been re- 08.002 ported in all countries neighboring Rosa Pacheco, 9. Hinnebusch BJ, Gage KL, Schwan TG. Basilio Valladares, Estimation of vector infectivity rates for the Republic of the Congo (hereafter and Maria A. Quispe-Ricalde plague by means of a standard curve- called Congo) (2–4), only 1 report of based competitive polymerase chain Author affiliations: University of La Laguna, a confirmed case in Congo has been reaction method to quantify Yersinia published (5) (Figure, panel A). Dur- Canary Islands, Spain (A. Martin-Alonso, P. pestis in fleas. Am J Trop Med Hyg. Foronda, G. Bonnet, B. Valladares, M. A. 1998;58:562–9. ing 2007–2012, a total of 573 clinical 10. Iralu J, Bai Y, Crook L, Tempest B, Quispe-Ricalde); and National University of cases of Buruli ulcer disease were re- Simpson G, McKenzie T, et al. Rodent- San Antonio Abad, Cusco, Peru (M. Soto, ported to WHO by the National Lep- associated Bartonella febrile illness, rosy, Buruli Ulcer and Yaws Control E. Aguilar, R. Pacheco) southwestern United States. Emerg Infect Dis. 2006;12:1081–6. http://dx.doi. Program in Congo. We report 108 DOI: http://dx.doi.org/10.3201/eid2006.131194 org/10.3201/eid1207.040397 cases (19% of all cases reported) that 1070 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 20, No. 6, June 2014 LETTERS Figure. Buruli ulcer–endemic areas in the Republic of the Congo (RC) and neighboring countries. A) Buruli ulcer cases have been reported in all countries neighboring RC. CAR, Central African Republic; DR Congo, Democratic Republic of the Congo. B) RC (representing the white area in panel A). The numbers indicate the 7 departments or communes (of 12 total) where PCR-positive cases of Buruli ulcer disease were diagnosed. 1, Kouilou Department; 2 Pointe Noire Commune; 3, Niari Department; 4, Bouenza Department; 5, Pool Department; 6, Brazzaville Commune; 7, Cuvette Department. C) Kouilou Department (department 1 in panel B). Most Buruli ulcer case- patients from Kouilou Department were living close to the Kouilou River. Stars indicate locations of health centers that treat Buruli ulcer disease; circles indicate areas where persons with Buruli ulcer disease were identified. A color version of this figure is available online (wwwnc.cdc.gov/eid/article/20/6/13-1498-F1.htm) were confirmed, in accordance with were treated in accordance with WHO Noire Commune (2%) or Brazzaville WHO recommendations, by quan- recommendations (8): antibiotic treat- Commune (3%) (Figure, panel B). titative PCR, the most sensitive and ment (rifampin/streptomycin) plus The distribution of Buruli ulcer specific testing method available (6). surgery if necessary. All patients with cases in Congo is unusual. The Kou- The National Leprosy, Buruli Ul- nonconfirmed cases were treated ac- ilou River region was most affected, cer, and Yaws Control Program, with cording to the alternative diagnosis but several other areas, all in southern the support of the Raoul Follereau reached by the clinician. Congo, have confirmed Buruli ulcer Foundation (Paris, France), performed Our findings show that Buruli ul- patients. Cuvette Department is the 1 passive and active surveillance of Bu- cer disease affects persons in several exception; although it is in northeast- ruli ulcer in Congo during 2007–2012. of Congo’s administrative divisions ern Congo, this department did have a Fine-needle aspirate or swab samples (Figure, panel B); of the 108 patients, cluster of cases. The cases in Cuvette were obtained from patients with sus- 77 (71%) were from Kouilou Depart- were identified (and the infections pected Buruli ulcer and sent to Angers ment (Figure, panel C). The village of were diagnosed and treated) during ac- University Hospital (Angers, France) residence was recorded for 55of these tive research into Buruli ulcer during for confirmation by quantitative PCR 77 patients, 46 (84%) of whom lived 2009–2010. (Note that there has been as described (6,7). Of the 283 samples in 9 villages along the Kouilou River, no survey in this region since 2010.) analyzed, 114 (40%) from 108 differ- encompassing an area of ≈50 km × 20 Buruli ulcer is also endemic in ent patients were PCR positive. Of the km: Madingo-Kayes, Kanga, Louk- some areas of the countries neighbor- 114 PCR-positive samples, 20 (18%) ouala, Mfilou, Koubotchi, Mboukou- ing Congo. In the Democratic Repub- were fine-needle aspirate samples and massi, Tchisseka, Magne, and Loaka lic of the Congo, the disease is highly 94 (82%) were swab samples (at least villages. This disease-endemic area in- endemic in the Bas Congo region, 2 swabs/lesion). The 108 case-patients cludes 2 lakes, Dinga and Nanga, both which shares a border with depart- included 60 (56%) female and 48 of which are fed by the Kouilou River. ments in southern Congo where the (44%) male patients; 56% of the case- The remaining 31 (29%) confirmed disease is endemic (9). By contrast, patients were <15 years of age. The patients (i.e., those not living in Kou- the small cluster of cases diagnosed in most common clinical form of the ilou Department) lived in Niari De- Cuvette Department in northeastern disease (86% of cases) was the ulcer- partment (9%), Bouenza Department Congo seems to be isolated from oth- ative stage with edema or plaque. All (6.5%), Pool Department (3%), or Cu- er areas where the disease is known to confirmed Buruli ulcer case-patients vette Department (5.5%) or in Pointe be endemic. Emerging Infectious Diseases • www.cdc.gov/eid • Vol.