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BORSA initially described non- References heteroresistant strains of S. aureus 1. Vandenesch F, Naimi T, Enright MC, Lina massiliae with oxacillin MIC <2 mg/L, which G, Nimmo GR, Heffernan H, et al. produce ample β-lactamases and are Community-acquired methicillin-resistant Human Isolation rendered fully susceptible to PRP by Staphylococcus aureus carrying Panton- β-lactamase-inhibitors (4,6). Sub- Valentine leukocidin genes: worldwide To the Editor: The number of new emergence. Emerg Infect Dis. sequent BORSA strains described rickettsial species that cause diseases 2003;9:978–84. in humans is rapidly increasing (1). have had higher oxacillin MICs (4–8 2. National Committee for Clinical mg/L) (4). The proportion of BORSA Laboratory Standards. Performance stan- Moreover, many of the species first among clinical isolates of S. aureus dards for antimicrobial susceptibility test- described in have been recently ing. Fifteenth informational supplement. varies (1.4%–12.5%) but is usually shown to be pathogenic. Of the 10 NCCLS document M100-S15. Wayne (PA): species or subspecies found to be ?5% (4,10). A BORSA infection out- The Committee; 2005. break among dermatology patients 3. Ip M, Lyon DJ, Chio F, Enright MC, Cheng pathogens after 1984, a total of 7 were with severe skin diseases has also AF. Characterization of isolates of methi- first isolated from ticks (2). We report cillin-resistant Staphylococcus aureus from been reported (10). Postulated resist- the first isolation of Rickettsia massil- Hong Kong by phage typing, pulsed-field iae from a patient. The bacterium was ance mechanisms include overpro- gel electrophoresis, and fluorescent ampli- duction of conventional penicillinas- fied-fragment length polymorphism analy- isolated in Sicily in 1985 and identi- es, production of an inducible, plas- sis. J Clin Microbiol. 2003;41:4980–5. fied in 2005. 4. Chambers HF. Methicillin resistance in mid-mediated, membrane-bound A 45-year-old man was hospital- staphylococci: molecular and biochemical ized in Palermo, Italy, on June 6, methicillinase, and in some cases, basis and clinical implications. Clin point mutations of penicillin-binding- Microbiol Rev. 1997;10:781–91. 1985, for fever and a rash. He had proteins (4). The clinical importance 5. Brown DF. Detection of methicillin/ been febrile since May 25 and did not oxacillin resistance in staphylococci. J of BORSA is unknown since early respond to antimicrobial drug treat- Antimicrob Chemother. 2001;48(Suppl ment using cefamezin, a first-genera- clinical/animal data suggest treatment 1):65–70. efficacy of PRP (against strains with 6. Varaldo PE. The “borderline methicillin- tion cephalosporin. On examination, MIC <2 mg/L) (4,6,9). Whether susceptible” Staphylococcus aureus. J he had a necrotic eschar on his right Antimicrob Chemother. 1993;31:1–4. BORSA with higher oxacillin MICs ankle, a maculopapular rash on his 7. Naimi TS, LeDell KH, Como-Sabetti K, palms and soles (online Appendix (4–8 mg/L) will respond equally well Borchardt SM, Boxrud DJ, Etienne J, et al. to PRP is less clear. Further studies Comparison of community- and health Figure 1, available at http://www.cdc. into the treatment of BORSA, includ- care-associated methicillin-resistant gov/ncidod/EID/vol12no01/05-0850- Staphylococcus aureus infection. JAMA. ing pharmacokinetic considerations, G1.htm), and slight hepatomegaly. 2003;290:2976–84. Leukocyte count was normal; he are needed (4). However, high-dose 8. Francis JS, Doherty MC, Lopatin U, β-lactam/β-lactamase inhibitor com- Johnson CP, Sinha G, Ross T, et al. Severe received tetracyclines for 13 days and binations (e.g., ampicillin/sulbactam), community-onset in healthy fully recovered. He seroconverted adults caused by methicillin-resistant as shown in animal models, are at (from 0 to 1:80 between day 11 and Staphylococcus aureus carrying the Panton- day 24) by indirect immunofluores- least as effective as PRP (9). In con- Valentine leukocidin gene. Clin Infect Dis. clusion, our report suggests that mecA 2005;40:100–7. cence to (R. conorii (or PBP2a) detection may help man- 9. Hirano L, Bayer AS. Beta-lactam–beta-lac- spot, bioMérieux, Marcy l’Étoile, tamase-inhibitor combinations are active in age serious, community-acquired, France). experimental endocarditis caused by beta- Four milliliters of heparinized non–multidrug-resistant MRSA infec- lactamase–producing oxacillin-resistant tions because of the potential confu- staphylococci. Antimicrob Agents blood sampled before treatment were 2 sion between BORSA and CA- Chemother. 1991;35:685–90. inoculated in a 25-cm flask contain- 10. Balslev U, Bremmelgaard A, Svejgaard E, MRSA. ing Vero cells and incubated at 33°C Havstreym J, Westh H. An outbreak of bor- in a CO incubator (1). Direct derline oxacillin-resistant Staphylo-coccus 2 Lee Nelson,* Clive S. Cockram,* aureus (BORSA) in a dermatological unit. immunofluorescence test on a sample Grace Lui,* Rebecca Lam,* Microb Drug Resist. 2005;11:78–81. of the patient’s serum was positive 7 Edman Lam,* Raymond Lai,* days later. The strain was stored for and Margaret Ip* Address for correspondence: Margaret Ip, 20 years and tested in 2005 at the *Prince of Wales Hospital, Chinese Department of Microbiology, Prince of Wales Unité des Rickettsies for identifica- University of Hong Kong, Hong Kong SAR, Hospital, Chinese University of Hong Kong, tion, and R. massiliae was identified. People’s Republic of China Ngan Shing St, Hong Kong SAR, People’s DNA was extracted from the cell cul- Republic of China; fax: 852-2647-3227; email: ture supernatant and used as template [email protected] in 2 previously described polymerase

174 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 1, January 2006 LETTERS chain reaction (PCR) assays that tar- This Sicilian index case shows that 2. Matsumoto K, Ogawa M, Brouqui P, Raoult geted a portion of the rickettsial R. massiliae is a human pathogen. It D, Parola P. Transmission of Rickettsia massiliae in the , Rhipicephalus turani- ompA gene as well as a portion of the contraindicates using rifampin to treat cus. Med Vet Entomol. 2005;19:263–70. rickettsial gltA gene (3,4). Mediterranean spotted fever in areas 3. Roux V, Fournier PE, Raoult D. Amplification products of the expect- where R. massiliae is endemic, as it Differentiation of spotted fever group rick- ed size were obtained from this cannot as yet be differentiated from R. ettsiae by sequencing and analysis of restriction fragment length polymorphism extract but from no concurrently conorii infection. R. massiliae is a new of PCR amplified DNA of the gene encod- processed control materials, includ- example of a strain identified in ticks ing the protein rOmpA. J Clin Microbiol. ing 3 negative controls. DNA for several years before its first isola- 1996;34:2058–65. sequencing of the positive PCR prod- tion from a human patient (10). The 4. Roux V, Rydkina E, Eremeeva M, Raoult D. Citrate synthase gene comparison, a new ucts gave 100% identity with R. mas- longest delay was observed for tool for phylogenetic analysis, and its appli- siliae for ompA (GenBank accession , which was isolated cation for the rickettsiae. Int J Syst no. RBU43792) and 99.9% homolo- from ticks in 1939 but not from a Bacteriol. 1997;47:252–61. gy for gltA (GenBank accession no. patient until 2004. Many authors 5. Beati L, Raoult L. Rickettsia massiliae sp.nov., a new spotted fever group rick- RSU 59720). labeled R. parkeri a nonpathogenic ettsia. Int J Syst Bacteriol. 1993;43:839–40. R. massiliae was first isolated from rickettsia during this time (1). In the 6. Cardenosa N, Segura F, Raoult D. Rhipicephalus ticks in Marseilles (5). present case, the human isolate was Serosurvey among Mediterranean spotted It is transmitted transovarially in obtained before the tick isolate but fever patients of a new spotted fever group rickettsial strain (Bar29). Eur J Epidemiol. Rhipicephalus turanicus (2). R. mas- was not further identified. When this 2003;18:351–6. siliae is commonly found in strain was isolated, R. conorii was the 7. Drancourt M, Raoult D. Characterization of Rhipicephalus sanguineus or R. sole Rickettsia sp. found in ticks in mutations in the rpoB gene in naturally turanicus in France, Greece, Spain southern Europe. Moreover, only 1 rifampin-resistant Rickettsia species. Antimicrob Agents Chemother. (identified as Bar 29) (6), Portugal, tickborne pathogenic Rickettsia sp. 1999;43:2400–3. Switzerland, Sicily (D. Raoult, unpub. was believed to circulate in a single 8. Bella F, Espejo-Arenas E, Uriz S, Serrano data), Central Africa, and Mali (2). R. area. Since that time, several tickborne JA, Alegre MD, Tort J. Randomized trial of massiliae may be commonly associat- rickettsial diseases have been shown five-day rifampin versus one-day doxycy- cline therapy for Mediterranean spotted ed with these ticks, which are distrib- to exist in the same area, which fever. J Infect Dis. 1991;164:433–4. uted worldwide. prompted us to retrospectively identify 9. Parola P, Paddock CD, Raoult D. Tick- R. massiliae is grouped phylogeni- this strain. The patient was reexam- borne rickettsioses around the world: cally with Rickettsia rhipicephali and ined in May 2005, after this identifica- emerging diseases challenging old con- cepts. Clin Microbiol Rev. Rickettsia aeschlimannii (online tion. He is healthy and has no remain- 2005;18:719–56. Appendix Figure 2, available at ing antibodies against Rickettsia spp. 10. Paddock CD, Sumner JW, Comer JA, Zaki http://www.cdc.gov/ncidod/EID/vol1 SR, Goldsmith CS, Goddard J, et al. 2no01/05-0850-G2.htm). Giustina Vitale,* Rickettsia parkeri: a newly recognized Serafino Mansueto,* cause of spotted fever in the from this group have a natural resist- United States. Clin Infect Dis. Jean-Marc Rolain,† ance to rifampin that is associated 2004;38:805–11. with an rpoB sequence that is differ- and Didier Raoult† ent from that of other rickettsiae. This *Azienda Ospedaliera Universitaria Address for correspondence: Didier Raoult, Policlinico “P. Giaccone,” Palermo, Italy; isolate was not tested for antimicro- Unité des Rickettsies, CNRS UMR 6020, and †Université de la Méditerranée, bial drug susceptibly (7). Rifampin Marseille, France Faculté de Médecine, Université de la resistance leads us to believe that this Méditerranée, 27 Bd Jean Moulin, 13385 isolate may cause a Mediterranean References Marseille CEDEX 05, France; fax: 33-4-91- spotted fever–like disease that was 1. Raoult D, Roux V. Rickettsioses as para- 38-77-72; email: didier.raoult@medecine. described in children in Spain (7,8). digms of new or emerging infectious dis- univ-mrs.fr Serologic findings were recently eases. Clin Microbiol Rev. 1997;10: reported that showed some patients in 694–719. Barcelona, Spain, with reactions that Instructions for Emerging Infectious Diseases Authors indicate R. massiliae (B29 strain) Letters. Letters commenting on recent articles as well as letters reporting cases, outbreaks, rather than R. conorii (6). However, or original research are welcome. Letters commenting on articles should contain no more than serologic reactions are only presump- 300 words and 5 references; they are more likely to be published if submitted within 4 weeks tive; isolation from a patient is the of the original article's publication. Letters reporting cases, outbreaks, or original research should contain no more than 800 words and 10 references. They may have 1 figure or table required to initially describe a new and should not be divided into sections. All letters should contain material not previously pub- disease (9). lished and include a word count.

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