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Isolation of Francisella Tularensis from Skin Ulcer After a Tick Bite, Austria, 2020

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Isolation of Francisella Tularensis from Skin Ulcer After a Tick Bite, Austria, 2020 microorganisms Case Report Isolation of Francisella tularensis from Skin Ulcer after a Tick Bite, Austria, 2020 Mateusz Markowicz 1,*, Anna-Margarita Schötta 1 , Freya Penatzer 2, Christoph Matscheko 2, Gerold Stanek 1, Hannes Stockinger 1 and Josef Riedler 2 1 Center for Pathophysiology, Infectiology and Immunology, Institute for Hygiene and Applied Immunology, Medical University of Vienna, Kinderspitalgasse 15, A-1090 Vienna, Austria; [email protected] (A.-M.S.); [email protected] (G.S.); [email protected] (H.S.) 2 Kardinal Schwarzenberg Klinikum, Kardinal Schwarzenbergplatz 1, A-5620 Schwarzach, Austria; [email protected] (F.P.); [email protected] (C.M.); [email protected] (J.R.) * Correspondence: [email protected]; Tel.: +43-1-40160-33023 Abstract: Ulceroglandular tularemia is caused by the transmission of Francisella tularensis by arthro- pods to a human host. We report a case of tick-borne tularemia in Austria which was followed by an abscess formation in a lymph node, making drainage necessary. F. tularensis subsp. holarctica was identified by PCR and multilocus sequence typing. Keywords: tularemia; Francisella tularensis; tick; multi locus sequence typing Depending on the transmission route of Francisella tularensis, tularemia can present Citation: Markowicz, M.; Schötta, as a local infection or a systemic disease [1]. Transmission of the pathogen takes place A.-M.; Penatzer, F.; Matscheko, C.; by contact with infected animals, by bites of arthropods or through contaminated water Stanek, G.; Stockinger, H.; Riedler, J. and soil. Hares and wild rabbits are the main reservoirs of the pathogen in Austria [2]. Isolation of Francisella tularensis from According to the Austrian Agency for Food and Health Safety, an accumulation of fatal Skin Ulcer after a Tick Bite, Austria, cases in hares was observed in the district of Salzburg in 2018 [3]. We report a case of 2020. Microorganisms 2021, 9, 1407. ulceroglandular tularemia after a tick bite which occurred in Austria in the same district. https://doi.org/10.3390/ Knowledge about local epidemiology of tularemia is crucial for correct diagnosis and microorganisms9071407 treatment, given the wide range of various pathogens which can be transmitted by ticks to humans. Academic Editor: Marina Santic 1. The Patient Received: 10 June 2021 At the end of June 2020, a 10-year-old boy from the district of Salzburg experienced a Accepted: 25 June 2021 Published: 29 June 2021 tick bite on his neck. The boy was playing near a rabbit hatch, but he had no contact with the animals. On the same day when the tick was removed, he was subfebrile, and the site Publisher’s Note: MDPI stays neutral of the tick bite appeared swollen and red. The skin lesion suggested a local infection, and with regard to jurisdictional claims in treatment with amoxicillin for 10 days was started. However, a few days later, ulceration published maps and institutional affil- on the site of the tick bite and submandibular lymphadenopathy developed (Figure1). iations. Physical examination revealed small, circumscribed, raised redness with a central crust on day 8 after the tick bite. Purulent discharge was sent for routine microbiological testing and methicillin-resistant Staphylococcus epidermidis was cultured. Sonography showed an enlarged left lymph node at the caudal parotid pole with no signs of abscess and several reactive lymph nodes in the left vascular nerve sheath. The treatment was changed to Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. topical fusidic acid and alcohol-based wound cleaning. Two and a half weeks after the This article is an open access article tick bite, the patient developed abscessing lymphadenopathy, and the antibiotic treatment distributed under the terms and was changed to ampicillin/sulbactam. Abscess drainage became necessary, but no growth conditions of the Creative Commons of pathogens was observed in a conventional culture. At this time point, the laboratory Attribution (CC BY) license (https:// diagnostic tests revealed a moderately elevated leukocyte count (11.2/nL), a normal red cell creativecommons.org/licenses/by/ and platelet count, a normal C-reactive protein and unremarkable liver function parameters. 4.0/). Serologic testing for tick-borne infections was carried out and elevated antibodies to Microorganisms 2021, 9, 1407. https://doi.org/10.3390/microorganisms9071407 https://www.mdpi.com/journal/microorganisms Microorganisms 2021, 9, 1407 2 of 4 Microorganisms 2021, 9, x FOR PEER F.REVIEW tularensis were found by an agglutination assay (CCPro, Oberdorla, Germany) and ELISA2 of 5 (Virion/Serion, Würzburg, Germany) (Table1). FigureFigure 1.1.Clinical Clinical presentation presentation of of ulceroglandular ulceroglandular tularemia tularemia after after tick tick bite. bite. The The ulceration ulceration on the on sitethe ofsite the of tick the bitetick isbite indicated is indicated by an by arrow. an arrow. Lymphadenopathy Lymphadenopathy visible visible right from right the from inoculation the inoculation site. site. Table 1. Serologic test results of the patient with ulceroglandular tularaemia after the tick bite at the end of June 2020. Physical examination revealed small, circumscribed, raised redness with a central crust on day 8 after21 the July tick 2020 bite. Purulent 5 August discharge 2020 was 10 September sent for routine 2020 microbiological 8 April 2021 F. tularensis (agglutination assay, positivetesting≥ 1:80)and methicillin-resistant 1:160 Staphylococcus 1:320 epidermidis 1:320 was cultured. Sonography 1:160 ≥ F. tularensis IgG (EIA, positiveshowed1:80) an enlarged left 117 lymph node at the 194 caudal parotid >300 pole U/ml with no signs 213of abscess F. tularensis IgM (EIA, positive ≥1:80) 176 214 >400 U/ml 171 R. conorii IgG (IIFT, positiveand≥1:64) several reactive lymph <1:64 nodes in the <1:64 left vascular nerve np. sheath. The treatment np. was R. conorii IgM (IIFT, positivechanged≥1:64) to topical fusidic <1:64 acid and alcohol-based <1:64 wound cleaning. np. Two and a half np. weeks B. henselae IgG (IIFT, positive ≥1:320) 1:1000 1:1000 np. np. Borrelia burgdorferi sl IgG (EIA, positiveafter≥22 the RE/mL) tick bite, the patient 4 developed absc 4essing lymphadenopathy, np. and the np. antibiotic Borrelia burgdorferi sl IgM (EIA, positivetreatment≥22 RE/mL) was changed15 to ampicillin/sulbactam 39. Abscess drainage np. became necessary, np. but no growth of pathogensnp.: notwas performed. observed in a conventional culture. At this time point, the laboratory diagnostic tests revealed a moderately elevated leukocyte count (11.2/nL), a normalRickettsia red cellspp. and infection platelet wascount, ruled a normal out by anC-reactive immunofluorescence protein and unremarkable assay (Focus Diag- liver nostics,function Cypress, parameters. CA, USA),Serologic and testing a PCR for from tick-borne skin crust infections obtained was from carried the site out of and the tickele- bitevated yielded antibodies a negative to F. tularensis result. As were infection found with by anF. agglutination tularensis was assay suspected, (CCPro, whole Oberdorla, blood andGermany) the skin and crust ELISA were (Virion/Serion, subjected to PCR Würzburg, testing. Germany) A real-time (Table PCR kit1). (NZYTech, Lisboa, Portugal) targeting the succinate dehygdrogenase (sdhA) gene was used. The DNA isolate Table 1. Serologic test resultsfrom of the the skin patient specimen with ulceroglandular yielded a positive tularaemia result, after while the tick the bite blood at the was end negative. of June 2020. To further characterize the subspecies, multilocus sequence typing (MLST) was attempted as previ- ously described [4]. This MLST21 July scheme 2020 employs 5 August seven 2020 genes. 10 September Only three out2020 of 8 these April seven 2021 F. tularensis (agglutinationgenes assay, (tpiA, positive trpE ≥ and1:80) uup) yielded1:160 a specific result1:320 after sequencing1:320 and were submitted1:160 F. tularensis IgG (EIA,to GenBankpositive ≥ (Acc.1:80) No. MZ031935-MZ031937).117 When194 comparing>300 the obtainedU/ml sequences213 to F. tularensis IgM (EIA,the positive NCBI database ≥1:80) by BLAST search176 (https://blast.ncbi.nlm.nih.gov/Blast.cgi214 >400 U/ml , accessed171 R. conorii IgG (IIFT,on positive 1 March ≥1:64) 2021), we identified<1:64 the skin sample<1:64 as containing F. tularensisnp. subsp. holarctica.np. R. conorii IgM (IIFT,The positive final treatment ≥1:64) with ciprofloxacin<1:64 500 mg<1:64 b.i.d. for 10 days wasnp. highly effective,np. and B. henselae IgG (IIFT,a rapidpositive resolution ≥1:320) of symptoms1:1000 was achieved.1:1000 Written consent tonp. publish the reportnp. was Borrelia burgdorferi sl IgG (EIA,obtained positive from ≥22 the RE/mL) mother of the patient.4 4 np. np. Borrelia burgdorferi sl IgM (EIA, positive ≥22 RE/mL) 15 39 np. np. 2. Conclusions np.: not performed. In Europe, F. tularensis subsp. holarctica is the only agent of tularemia among the four otherRickettsia known subspecies spp. infection of the was zoonotic ruled bacterium out by an recognized immunofluorescence worldwide [ 5assay]. Given (Focus the low Di- seroprevalenceagnostics, Cypress, to F. tularensisCA, USA),of 0.5%and ina PCR healthy from individuals skin crust [6 obtained] and sporadic from casesthe site reported of the eachtick bite year yielded [7,8], the a infectionsnegative result. may be As considered infection rarewith in F. Austria. tularensis Based was onsuspected, the registry whole of blood and the skin crust were subjected to PCR testing. A real-time PCR kit (NZYTech, Lisboa, Portugal) targeting the succinate dehygdrogenase (sdhA) gene was used. The DNA isolate from the skin specimen yielded a positive result, while the blood was nega- Microorganisms 2021, 9, 1407 3 of 4 the Federal Ministry of Labour, Social Affairs, Health and Consumer Protection [7], the mean number of cases per year reported from 2015 to 2019 was 11 (range 4–20 cases per year). Most cases were reported in Lower Austria, Upper Austria and Tyrol.
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