LETTERS restricted to plasma for fractionation. Robert J. Harley, Hiu-Tat Chan, 9. Mansuy JM, Bendall R, Legrand- Some protection against blood dona- Jerry A. Holmberg, Abravanel F, Saune K, Miedouge M, Ellis V, et al. Hepatitis E virus antibod- tions from HEV-infected persons may and Helen M. Faddy ies in blood donors, France. Emerg Infect occur because HEV and malaria are co- Author affiliations: Australian Red Cross Dis. 2011;17:2309–12. http://dx.doi.org/ endemic to many countries. Our find- Blood Service, Kelvin Grove, Queensland, 10.3201/eid1712.110371 10. Bendall R, Ellis V, Ijaz S, Ali R, ings showed a higher HEV seropreva- Australia (A.C. Shrestha, R.L.P. Flower, Dalton H. A comparison of two commer- lence among donors with prior malaria K.M. Rooks, R.J. Harley, H.M. Faddy); cially available anti-HEV IgG kits and or diarrhea deferrals; thus, malaria- and The University of Queensland, St. Lucia, a re-evaluation of anti-HEV IgG serop- diarrhea-related screening questions Queensland, Australia (A.C. Shrestha, revalence data in developed countries. J Med Virol. 2010;82:799–805. http:// may reduce contributions from donors H.M. Faddy); Australian Red Cross Blood dx.doi.org/10.1002/jmv.21656 with travel-associated HEV infection. Service, Osborne Park, Western Australia, Our findings showed HEV expo- Australia (C.R. Seed, A.J. Keller); Austra- Address for correspondence: Helen M. Faddy, sure in travelers and nontravelers, sug- lian Red Cross Blood Service, West Mel- Research and Development, Australian Red gesting the possibility of imported and bourne, Victoria, Australia (H.-T. Chan); and Cross Blood Service, PO Box 145, Kelvin locally acquired HEV in Australia. Pri- Grifols, Emeryville, California, USA Grove, Queensland 4059, Australia; email: or HEV exposure was higher in donors (J.A. Holmberg) [email protected] who were temporarily excluded from DOI: http://dx.doi.org/10.3201/eid2011.140412 donating blood on previous donation attempts, suggesting the current man- References agement strategy in Australia is par- tially effective in minimizing any risk 1. Dalton HR, Bendall R, Ijaz S, Banks M. of HEV transmission through blood Hepatitis E: an emerging infection in transfusion. However, the presence of developed countries. Lancet Infect HEV IgG in donors who reported no Dis. 2008;8:698–709. http://dx.doi.org/ 10.1016/S1473-3099(08)70255-X overseas travel and/or no prior related 2. Kamar N, Bendall R, Legrand-Abravanel deferrals, coupled with the knowledge F, Xia NS, Ijaz S, Izopet J, et al. Hepatitis E. that asymptomatic infection is possible, Lancet. 2012;379:2477–88. http://dx.doi. suggests that additional safety precau- org/10.1016/S0140-6736(11)61849-7 cinaedi Infection 3. Colson P, Coze C, Gallian P, Henry M, tions may be warranted. De Micco P, Tamalet C. Transfusion- of Abdominal Aortic associated hepatitis E, France. Emerg Aneurysm, Japan Infect Dis. 2007;13:648–9. http://dx.doi. Acknowledgments org/10.3201/eid1304.061387 To the Editor: Infected ab- We thank Australian Red Cross Blood 4. Nelson KE. Transmission of hepatitis Service staff in Donor Services and Manu- E virus by transfusion: what is the risk? dominal aortic aneurysm (IAAA) facturing, especially A. Fadel, L. Lycett, Transfusion. 2014;54:8–10. http://dx.doi. is uncommon, but life-threatening; B. Fisher, and R. Rodda. We also thank L. org/10.1111/trf.12504 the mortality rate ranges from 25% 5. Cowie BC, Adamopoulos J, Carter K, to 30% (1,2). Identification of the Danzig and J. Linnen for assistance with Kelly H. Hepatitis E infections, Victoria, transcription-mediated amplification assay Australia. Emerg Infect Dis. 2005; 11:482– is essential for diagno- testing; and J. Fryk, P. Kiely, and H. Yang 4. http://dx.doi.org/10.3201eid1103. 040706 sis and treatment. Previous studies for technical assistance. 6. Cleland A, Smith L, Crossan C, have shown that species of the gen- Blatchford O, Dalton HR, Scobie L, et al. era Salmonella, Staphylococcus, and Hepatitis E virus in Scottish blood donors. The Australian government fully Vox Sang. 2013;105:283–9. http://dx.doi. Streptococcus are the most common funds the Australian Red Cross Blood Ser- org/10.1111/vox.12056 associated with IAAA, but vice for the provision of blood products 7. Dalton HR, Fellows HJ, Gane EJ, a causative organism is not identified and services to the Australian community. Wong P, Gerred S, Schroeder B, et al. Hep- in 14%–40% of patients (1,2). He- atitis E in New Zealand. J Gastroenterol This study was conducted under approval Hepatol. 2007;22:1236–40. http://dx.doi. licobacter cinaedi has mainly been from the Blood Service Human Research org/10.1111/j.1440-1746.2007.04894.x isolated from immunocompromised Ethics Committee. 8. Xu C, Wang RY, Schechterly CA, Ge S, patients with bacteremia, , Shih JW, Xia NS, et al. An assessment and septic (3,4). Here, we of hepatitis E virus (HEV) in US blood Ashish C. Shrestha, donors and recipients: no detectable report 3 cases of IAAA caused by H. Clive R. Seed, HEV RNA in 1939 donors tested and no cinaedi detected by 16S ribosomal Robert L.P. Flower, evidence for HEV transmission to 362 RNA (16S rRNA) gene analysis. Kelly M. Rooks, prospectively followed recipients. Trans- The 3 patients (case-patients 1–3) fusion. 2013;53:2505–11. http://dx.doi. Anthony J. Keller, org/10.1111/trf.12326 were referred to Tohoku University

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Hospital, Sendai, Japan, for surgical and amplification of the gyrB gene selection of antimicrobial drugs and treatment of IAAA in 2013. None region that is specific to H. cinaedi surveillance of its antimicrobial sus- had a history of disease known to (6,7). In samples from the 3 patients, ceptibility profile are required. cause . Because there were mutations of the 23S rRNA During November 2012–Novem- their abdominal aneurysms enlarged gene and amino acid substitutions in ber 2013, 8 patients underwent their rapidly, all 3 patients underwent re- GyrA related to and fluo- first operation for IAAA at the uni- section of the aneurysm and exten- roquinolone resistance, respectively versity hospital. We used 16S rRNA sive local debridement and irrigation. (6,8). After identifying the patho- gene analysis of surgical tissues and Histopathologic examination of the gen, we selected antimicrobial agents culture of blood and tissue specimens surgical specimens revealed severe based on the reported drug suscep- to detect pathogens (data not shown). atherosclerosis and , tibility profile of H. cinaedi (6,8). Identification of H. cinaedi in 3 of 8 consistent with a diagnosis of IAAA. The patients survived and are being patients suggests that it could be a For each case-patient, blood culture followed up as outpatients. Clinical prevalent pathogen related to IAAA. (BacT/ALERT; bioMérieux Industry, and molecular characteristics of the 3 Taking such information into consid- Tokyo, Japan) was negative, as was cases of IAAA with H. cinaedi infec- eration could affect the prognosis of culture of surgically removed tis- tion are shown in the Table. many patients. Accordingly, tissue sue on HK semisolid agar (Kyokuto Although the high negative cul- should be cultured while consider- Pharmaceutical Industrial Co., Ltd., ture rate for pathogens causing IAAA ing H. cinaedi infection in patients Tokyo, Japan) at 35°C under aerobic had been explained by prolonged with IAAA. H. cinaedi colonizes the conditions for 7 days for enrichment preoperative antimicrobial drug ther- , and bacterial of microorganisms, and on choco- apy (2), another possibility is that H. translocation may lead to bacteremia late agar at 35°C under 5% CO2 for cinaedi may be a causative organism. associated with mucosal damage (4). 48 h. We then used 16S rRNA gene Earlier research has suggested that H. However, the route of transmission analysis to identify a pathogen. We cinaedi infections can remain undi- and reason most H. cinaedi infections extracted DNA from resected tissues agnosed or be incorrectly diagnosed have been reported in Japan are un- using a QIAamp DNA Mini kit (QIA- because of difficulty in isolating this clear. To clarify the relationship be- GEN K.K., Tokyo, Japan), amplified microorganism (9). H. cinaedi grows tween H. cinaedi and IAAA, further it using PCR, and sequenced it using slowly under microaerophilic condi- clinical and epidemiologic studies are universal primers for 16S rRNA (5). tions, but no current standard labora- needed. Meanwhile, we recommend We used the EzTaxon-e Database for tory methods result in a diagnosis of clinical consideration of H. cinaedi sequence analysis (http://eztaxon-e. this pathogen (6,7,9). We isolated H. infection, use of appropriate labora- ezbiocloud.net/), which revealed that cinaedi from surgically removed tis- tory procedures to identify cases, and the 16S rRNA gene sequence of bac- sue from case-patient 3 by microaero- development of treatment guidelines. teria in the aneurysmal tissues was philic culture after taking this patho- identical to that of H. cinaedi. gen into consideration. For diagnosis Dr Kakuta is an infectious disease For case-patient 3, we cultured mi- of H. cinaedi infections, methods and infection control doctor at Tohoku croaerophilic tissue at 35°C using Tryp- leading to accurate identification by University Hospital, Sendai, Japan. Her ticase Soy Agar II with 5% sheep blood clinical microbiological laboratories research interests are clinical infectious (Kyokuto Pharmaceutical Industrial are needed. Currently, H. cinaedi is diseases, infection control, and antimicro- Co.) and an Anaero Pouch-MicroAero identified by molecular analysis of the bial resistance. (Mitsubishi Gas Chemical Co., Inc., 16S rRNA gene (6,7,10). In addition, Tokyo, Japan) to detect H. cinaedi. We matrix-assisted laser desorption/ Risako Kakuta, observed bacterial colonies, after Gram ionization–time-of-flight mass Hisakazu Yano, staining, which showed gram-negative spectrometry (MALDI-TOF MS) Hajime Kanamori, spiral rods. By 16S rRNA gene analy- (10), may become a useful tool for Takuya Shimizu, sis, we confirmed that the isolate was this purpose. Yoshiaki Gu, Masumitsu Hatta, H. cinaedi. Standard breakpoints of antimi- Tetsuji Aoyagi, Shiro Endo, For each of the 3 case-patients, crobial drugs for H. cinaedi have not Shinya Inomata, Chihiro Oe, species identification was further been defined, but all isolates in this Koichi Tokuda, Daiki Ozawa, confirmed by sequence analysis of study had mutations that indicated re- Hitoshi Goto, Yukio Katori, 23S ribosomal RNA (23S rRNA) sistance to and fluoroqui- and Mitsuo Kaku (DNA Data Bank of Japan: http:// nolones. For adequate treatment for blast.ddbj.nig.ac.jp/blastn?lang = ja) H. cinaedi infections, guidelines for DOI: http://dx.doi.org/10.3201/eid2011.140440

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Table. Clinical characteristics of 3 patients with Helicobacter cinaedi infected abdominal aortic aneurysms and molecular characteristics of isolates, Japan* Characteristic Case-patient 1 Case-patient 2 Case-patient 3 Age, y/sex 64/M 59/M 62/M Underlying diseases Hypertension, hyperlipidemia None History of myocardial infarction Risk factors for infection None None None Clinical signs and symptoms Fever, back pain Fever, abdominal pain Low back pain before surgery CT results Site of aneurysm Infrarenal abdominal, bilateral Infrarenal abdominal, bilateral Infrarenal abdominal common iliac, internal iliac, L common iliac femoral, aortic arch† Inflammatory findings around + + + aneurysms Maximum leukocyte count/L)/C- 10,600/25.3 9,100/6.05 7,050/ 5.29 reactive protein , mg/dL before operation Surgical management In situ grafting In situ grafting In situ grafting Microbiological diagnosis Blood culture – – – Tissue culture – – +‡ rRNA gene sequence similarity, %§ 16S 99.8 99.6 99.6 23S 99.8 99.8 99.8 Amplification of gyrB specific to + + + H. cinaedi Aneurysms in which H. cinaedi Infrarenal abdominal, L common Infrarenal abdominal Infrarenal abdominal was identified iliac, R internal iliac, L femoral MLST ST15 (CC7) ST10 (CC9) ST10 (CC9) Mutation of 23S rRNA gene and 2018 AG and T84I D88G 2018 AG and T84I 2018 AG and T84I amino acid substitutions in GyrA Antimicrobial therapy dosage and duration Before admission Ceftriaxone, 2 g/d, and Piperacillin/tazobactam, 4.5 Oral antimicrobial agent, 4 d levofloxacin, 500 mg/d, for 2 d g/d for 12 d; faropenem sodium hydrate, 600 mg/d for 10 d After admission Doripenem, 1.5 g/d for 22 d, and Piperacillin/tazobactam, 4.5 Doripenem, 1.5 g/d for 28 d vancomycin, 3.0 g/d, for 14 d g/d for 28 d After identification of pathogen Sulbactam/ampicillin, 3.0 g/d, Continuation of Continuation of doripenem and minocycline, 100 mg/d for piperacillin/tazobactam 25 d At discharge Oral amoxicillin, 1,500 mg/d, Oral amoxicillin, 1,500 mg/d, Oral amoxicillin, 1,500 mg/d, and minocycline, 200 mg/d , until and minocycline, 200 mg/d, and minocycline, 200 mg/d, follow-up visit until follow-up visit until follow-up visit Postoperative complications None None None Outcome Survived Survived Survived *CT, computed tomography; +, positive; –, negative; L, left; R, right; MLST, multilocus sequence typing; ST, sequence type; CC, clonal complex; A, adenine; G, guanine; T, threonine; I, isoleucine; D, aspartic acid; G, glycine. †Aortic arch was replaced 5 weeks after the abdominal operation. ‡Species unidentifiable under microaerophilic conditions. §Compared with the type strain of H. cinaedi (CCUG 18818).

References 3. Lasry S, Simon J, Marais A, Pouchot J, sequences of Bacillus cereus strains isolat- Vinceneux P, Boussougant Y. Helico- ed from outbreaks of hospital infection are 1. Miller DV, Oderich GS, Aubry MC, bacter cinaedi septic arthritis and bactere- highly similar to Bacillus anthracis. Diagn Panneton JM, Edwards WD. Surgi- mia in an immunocompetent patient. Clin Microbiol Infect Dis. 2011;70:307–15. cal pathology of infected aneurysms of Infect Dis. 2000;31:201–2. http://dx.doi. http://dx.doi.org/10.1016/j.diagmicrobio. the descending thoracic and abdomi- org/10.1086/313930 2011.02.012 nal aorta: clinicopathologic correla- 4. Araoka H, Baba M, Kimura M, Abe M, 6. Rimbara E, Mori S, Matsui M, Suzuki S, tions in 29 cases (1976 to 1999). Hum Inagawa H, Yoneyama A. Clinical char- Wachino J, Kawamura Y, et al. Molecular Pathol. 2004;35:1112–20. http://dx.doi. acteristics of bacteremia caused by epidemiologic analysis and antimicro- org/10.1016/j.humpath.2004.05.013 Helicobacter cinaedi and time required for bial resistance of Helicobacter cinaedi 2. Laohapensang K, Aworn S, Orrapi S, blood cultures to become positive. J Clin isolated from seven hospitals in Japan. Rutherford RB. Management of the infect- Microbiol. 2014;52:1519–22. http:// J Clin Microbiol. 2012;50:2553–60. http:// ed aortoiliac aneurysms. Ann Vasc Dis. dx.doi.org/10.1128/JCM.00265-14 dx.doi.org/10.1128/JCM.06810-11 2012;5:334–41. http://dx.doi.org/10.3400/ 5. Zhang J, van Hung P, Hayashi M, 7. Minauchi K, Takahashi S, Sakai T, avd.oa.12.00014 Yoshida S, Ohkusu K, Ezaki T. DnaJ Kondo M, Shibayama K, Arakawa Y,

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et al. The nosocomial transmission of through ingestion of raw pig liver sau- the sample was tested 10 weeks after Helicobacter cinaedi infections in im- sages (figatellu [plural: figatelli]) in the family lunch, the daughter’s HEV munocompromised patients. Intern Med. 2010;49:1733–9. http://dx.doi.org/10.2169/ southeastern France. viral load was too low to enable se- internalmedicine.49.3649 The index case-patient was a quence characterization and clustering 8. Tomida J, Oumi A, Okamoto T, Morita Y, 45-year-old woman from Hyères of HEV strains. Three other family Okayama A, Misawa N, et al. Compara- (southeastern France) who had no members were IgG positive for HEV, tive evaluation of agar dilution and broth microdilution methods for sus- underlying medical condition. She indicating previous HEV infection. ceptibility testing of Helicobacter cinaedi. visited her general practitioner on Leftover sausages had been kept frozen Microbiol Immunol. 2013;57:353–8. http:// December 17, 2013, reporting 3 days and were available for HEV testing. dx.doi.org/10.1111/1348-0421.12044 of weakness. Acute hepatitis was HEV RNA was detectable from 9. Oyama K, Khan S, Okamoto T, Fujii S, Ono K, Matsunaga T, et al. Identification diagnosed 2 days later on the basis the leftover sausages, and HEV se- of and screening for human Helicobacter of elevated liver enzymes (alanine quences were amplified in 2 different cinaedi infections and carriers via nested aminotransferase 1,265 IU/L [refer- genomic regions (ORF1: RNA-depen- PCR. J Clin Microbiol. 2012;50:3893–900. ence <35 IU/L]) and bilirubin (65 dent RNA polymerase and ORF2), as http://dx.doi.org/10.1128/JCM.01622-12 10. Taniguchi T, Sekiya A, Higa M, Saeki Y, μmol/L [reference <17 μmol/L]). Se- described previously (2). Comparison Umeki K, Okayama A, et al. Rapid iden- rum markers for acute hepatitis A, B, with the index case-patient’s sequenc- tification and subtyping of Helicobacter and C; cytomegalovirus; and Epstein- es showed 100% nt identity for both cinaedi strains by intact-cell mass spec- Barr virus were negative. Jaundice regions (Figure). Samples of food and trometry profiling with the use of ma- trix-assisted laser desorption ionization- appeared on December 19, and the samples from the index case-patient time of flight mass spectrometry. J Clin patient was referred to the Medical were analyzed in 2 independent labo- Microbiol. 2014;52:95–102. http://dx.doi. Unit of Hyères for additional investi- ratories to avoid any cross-contamina- org/10.1128/JCM.01798-13 gations. A serum sample collected on tion. The level of contamination of the December 20 tested positive for HEV figatellu was ≈4.8 104 copies of HEV Address for correspondence: Risako Kakuta, RNA; viral load was 3.3 log IU/ RNA/g of sausage (3). Department of Infection Control and Laboratory 10 mL (Ceeram, La Chapelle sur Erdre, Figatellu, a dried sausage, contains Diagnostics, Tohoku University Graduate France), and IgM and IgG against 30% pork liver and no heating step oc- School of Medicine, 1-1 Seiryomachi, Aoba-ku, HEV were found (Wantai, Beijing, curs during its manufacture. Usually Sendai 980-8574, Japan; email: kakuta-r@med. China), which led to the diagnosis of deep cooking is recommended on the tohoku.ac.jp acute hepatitis E. The HEV genotype package, but consumers might not fol- was 3f, as determined from the phy- low the cooking recommendation; also, logenetic analysis of a portion of the figatelli can be sold in small local shops open reading frame (ORF) 2 (2). The with no label. In the instance reported index case-patient recovered by the here, the figatellu was sold without any end of January; HEV viremia was un- warning label and was eaten raw. detectable on January 17, 2014. That HEV was transmitted The index case-patient and her through ingestion of contaminated Foodborne family regularly ate figatelli (raw pork food is supported by the following Transmission of liver sausages) made in Corsica. The evidence. First, 3 case reports have Hepatitis E Virus patient had most recently eaten figatelli provided direct evidence of HEV at a lunch with 8 family members on transmission through ingestion of from Raw Pork October 28, 2013, seven weeks before contaminated animal food products Liver Sausage, illness onset. After receiving informed with identical or near identical se- France consent, we conducted laboratory in- quences between the patients and the vestigations of samples from the other contaminated food they ate. Two cases To the Editor: The number of family members; tests included HEV occurred in the early 2000s in Japan sporadic autochthonous cases of acute serology and HEV RNA detection in through consumption of grilled wild hepatitis E is increasing in many in- serum and fecal samples. Samples were boar (4) or sashimi of Sika deer (5); dustrialized countries (1). These cases obtained from family members during the third, reported recently in Spain, involve hepatitis E virus (HEV) geno- January 8–21, 2014 (41–54 days after was transmitted through ingestion of types 3 and 4, which are zoonotic. the lunch). Positive HEV IgM and de- pig meat (6). Second, HEV widely in- Although risk for foodborne transmis- tectable HEV RNA were found in the fects domestic pigs and wild boar (7). sion from pork is now recognized, we serum of the index case-patient’s daugh- Third, swine and human HEV strains report here direct HEV transmission ter, who was asymptomatic. Because have genetic similarities and, in

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