LETTERS

2. Arez AP, Snounou G, Pinto J, Sousa CA, an eschar around the attachment site. cial; neither of these syndromes can be Modiano D, Ribeiro H, et al. A clonal Plas- The patient was aware of the risk of associated with a specific causative modium falciparum population in an iso- tick-transmitted disease; after remov- agent without microbiologic identifi- lated outbreak of malaria in the Republic of Cabo Vorde. Parasitology 1999;118:347– ing the tick, immediately self-pre- cation. Our findings demonstrate that 55. scribed doxycycline. No further Rickettsia species first encountered in 3. Mungai M, Tegtmeier G, Chamberland M, symptoms developed. However, as a tick surveys are associated with Parise M. Transfusion-transmitted malaria precaution, the patient went to a local human disease, and we should not in the United States from 1963 through clinic, where a skin biopsy was taken assume that some Rickettsia species 1999. N Engl J Med 2001;344:1973–8. 4. Slinger R, Giulivi A, Bodie-Collins M, from the eschar. This sample, together not have a pathogenic potential. Hindieh F, St. John R, Sher G, et al. Trans- with the removed tick, was submitted fusion-transmitted malaria in Canada. to our laboratory. DNA extracts, pre- Anne-Marié Pretorius* CMAJ 2001;164:377–9. pared from an eschar biopsy and the and Richard J. Birtles† 5. Benito A, Rubio JM. The usefulness of the tick, were incorporated into a poly- seminested malaria-PCR to screen blood *University of the Free State, Bloemfontein, donors at risk in Spain. Emerg Infect Dis merase chain reaction (PCR) assay South Africa and †University of Liverpool, 2001;7:1068. specifically targeting a fragment of the Liverpool, England 6. Zucker JR. Changing patterns of autochth- rickettsial ompA (2). Sequence analy- onous malaria transmission in the United sis of the amplification products References States: a review of recent outbreaks. Emerg showed both to be identical and to 1. Raoult D, Fournier P-E, Fenollar F, Jense- Infect Dis 1996;2:37–43. share >99% similarity with the ompA nius M, Prioe T, De Pina JJ, et al. Rickettsia africae, a tick-borne pathogen of travelers of R. aeschlimannii, a species not pre- to sub-Saharan Africa. N Engl J Med viously associated with human dis- 2001;344:1504–10. ease. Unfortunately, blood samples 2. Roux V, Fournier P-E, Raoult D. Differen- Rickettsia could not be collected at the time the tiation of spotted fever group rickettsiae by aeschlimannii: patients first had symptoms; thus, sequencing and analysis of restriction frag- ment length polymorphism of PCR ampli- investigation of a disseminated infec- A New Pathogenic fied DNA of the gene encoding the protein tion by PCR and serologic testing was rOmpA. J Clin Microbiol 1996;34:2058– Spotted Fever not possible. 65. Group Rickettsia, Although genotypically indistin- 3. Beati L, Meskini M, Thiers B, Raoult D. guishable organisms had previously Rickettsia aeschlimannii sp. nov., a new South Africa spotted fever group rickettsia associated been detected in Hyalomma mar- with Hyalomma marginatum ticks. Int J ginatum collected in Portugal and Syst Bacteriol 1997;47:548–54. To the Editor: Spotted fever Zimbabwe, R. aeschlimannii was first 4. Parola P, Inokuma H, Camicas J-L, Brou- group rickettsiae are increasingly rec- characterized following its isolation qui P, Raoult D. Detection and identifica- ognized as agents of disease in resi- from H. marginatum ticks in Morocco tion of spotted fever group rickettsiae and dents of and tourists to South Africa ehrlichiae in African ticks. Emerg Infect (3) and recently in Niger (4). This Dis 2001;7:1014–7. (1). To date, two species, Rickettsia encounter was the first demonstration conorii and R. africae, which cause of its presence in South Africa and in Mediterranean spotted fever (MSF) Rhipicephalus ticks. and African tick-bite fever (ATBF), A lack of suitable clinical material Age as a Risk respectively, have been associated prevented full evaluation of the patho- with human disease in the region; genic potential of R. aeschlimannii in Factor for ATBF is more frequently associated this patient and prompt antibiotic Cutaneous Human with travel (1). As different antibiotic intervention may have prevented evo- regimens are recommended for the lution of the syndrome. Nonetheless, Anthrax: Evidence two syndromes, differentiating MSF that R. aeschlimannii was transmitted from Haiti, from ATBF is important. Increasing to the patient and established a local evidence shows that the syndromes infection leading to eschar formation 1973–1974 can usually be differentiated through provides clear, albeit preliminary, evi- To the Editor: Few cases of clinical manifestations and epidemio- dence of its virulence. Until further anthrax have been reported in chil- logic characteristics (1). cases are encountered, allowing better dren, in part because most exposures We recently encountered a South characterization of the clinical mani- to Bacillus anthracis occur in work- African patient who, on returning festations associated with R. aeschli- place settings. Questions about the from a hunting and fishing trip, dis- mannii infection and considering the susceptibility of children to B. anthra- covered a Rhipicephalus appendicula- agent capable of inducing either MSF cis infection were raised when cutane- tus tick attached to his right thigh and or ATBF-like manifestations is cru- ous anthrax developed in a 7-month-

874 Emerging Infectious Diseases • Vol. 8, No. 8, August 2002 LETTERS old child in New York City in 2001 mined. Although cases of animal reflecting the primary skin contact after he was taken to visit his mother’s anthrax were rarely reported in Haiti point of the organism, was similar in workplace (1). No cases of anthrax because of a weak surveillance sys- all age groups. However, determining were reported in persons <24 years of tem, 96 (26%) of 368 Haitian goatskin whether the various age groups had age in the 1979 inhalational anthrax handicraft items were found to be con- differences in skin contact exposure outbreak in the Soviet city of Sverd- taminated with B. anthracis during the leading to infection is difficult. The lovsk, despite a presumed general 1974 investigation, suggesting that affected rural population lived in population exposure (2). Such reports animal infections were not uncommon extreme poverty, typically in small have led some investigators to postu- (4). Therefore, the source of the infec- huts with dirt floors and no safe water late that young persons may be less tion may have been meat and other supply or latrine. Malnutrition was susceptible to anthrax than older products of value salvaged by local epidemic, and nothing edible was dis- persons. residents from anthrax-infected ani- carded. The crowded living conditions In 1974, the Center for Disease mals. limited opportunities to maintain basic Control reviewed records on the Age was reported for 366 of the personal hygiene and made it likely occurrence of human anthrax in Dis- 446 patients in District Sanitaire des that exposure to B. anthracis–contam- trict Sanitaire des Cayes, Haiti, as part Cayes (Table). The distribution of inated materials was similar across all of an investigation of cutaneous anthrax cases by age group was gener- age groups. These previously unpub- anthrax in a Florida woman exposed ally similar to that of the general pop- lished age-specific anthrax attack rates to spore-contaminated goatskin drums ulation, except the proportion of cases from Haiti suggest that adults and she purchased in Haiti (3). In 1973, a in the 15- to 44-year age group was children have similar susceptibility to total of 387 cases (7.6 per 10,000 pop- lower than the proportion of persons cutaneous anthrax. ulation) were clinically diagnosed in in that age group in the general popu- District Sanitaire des Cayes; another lation (p<0.03; chi square). In 124 Arnold F. Kaufmann 59 cases occurred in the first 4 months patients for whom information was and Andrew L. Dannenberg of 1974. All cases were the cutaneous available, the cutaneous lesion was Centers for Disease Control and Prevention form; gastrointestinal and inhalational located on the head or neck (60 Atlanta, Georgia, USA anthrax are rarely, if ever, diagnosed patients [48%]), the arm (31 [25%]), in Haiti. The source of infection in the trunk (23 [19%]), and the leg (12 References these 446 patients could not be deter- [10%]); this anatomic distribution, 1. Centers for Disease Control and Preven- tion. Update: investigation of anthrax asso- Table. Reported ages of persons with cutaneous anthrax, District Sanitaire des Cayes, Haiti, ciated with intentional exposure and 1973–74 interim public health guidelines, October 2001. MMWR Morb Mortal Wkly Rep Anthrax patients General population 2001;50:889–93. Age group (yrs) No. (%) No. (%) Cases per 10,000 persons 2. Meselson M, Guillemin J, Hugh-Jones M, <1 15 (4.1) 16,361 (3.2) 9.2 Langmuir A, Popova I, Shelokov A, et al. The Sverdlovsk anthrax outbreak of 1979. 1–4 49 (13.4) 59,291 (11.6) 8.3 Science 1994;266:1202–8. 5–14 96 (26.2) 120,532 (23.5) 8.0 3. Center for Disease Control. Cutaneous anthrax acquired from imported Haitian 15–44 135 (36.9) 235,164 (45.8) 5.7 drums—Florida. MMWR Morb Mortal 45–64 58 (15.8) 64,882 (12.7) 8.9 Wkly Rep 1974;23:142,147. 4. Center for Disease Control. Follow-up on >65 13 (3.6) 16,669 (3.2) 7.8 cutaneous anthrax acquired from imported All ages 366 512,899 7.1 Haitian drums—Florida. MMWR Morb Mortal Wkly Rep 1974;23:224.

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