Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1195 Studies of Spotted Fever Rickettsia - Distribution, Detection, Diagnosis and Clinical Context With a Focus on Vectors and Patients in Sweden KATARINA WALLMÉNIUS ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-554-9512-1 UPPSALA urn:nbn:se:uu:diva-280667 2016 Dissertation presented at Uppsala University to be publicly examined in Hörsalen, Klinisk Mikrobiologi, Akademiska sjukhuset, Ing D1, Dag Hammarskjöldsväg 17, Uppsala, Wednesday, 4 May 2016 at 09:15 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish. Faculty examiner: Professor Fredrik Elgh (Umeå University, Faculty of Medicine). Abstract Wallménius, K. 2016. Studies of Spotted Fever Rickettsia - Distribution, Detection, Diagnosis and Clinical Context. With a Focus on Vectors and Patients in Sweden. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1195. 77 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-9512-1. The spotted fever rickettsia, Rickettsia helvetica, is an endemic tick-borne bacteria in Sweden. It causes infections in humans, manifested as aneruptive fever, headache, arthralgia and myalgia, and sometimes an inoculation eschar or a rash. There have also been two known cases of human infections with R. felis in Sweden. The present thesis starts by investigating dispersal of ticks and Rickettsia spp. by migrating birds flying from Africa to Europe. Almost 15,000 birds were searched and 734 ticks collected, mainly of the species Hyalomma marginatum complex. Almost half (48%) of the ticks were infected with Rickettsia spp., 96% of which was R. aeschlimannii, the remaining R. africae and undefined species. The next study focused on questing ticks over a large area in Sweden and determining the prevalence of Rickettsia spp., Anaplasma spp. and Coxiella burnetii. Rickettsia spp. was found in 9.5-9.6% of the ticks and A. phagocytophilum in 0.7%; no C. burnetii was found. The last three papers in the thesis focused on the clinical presentation of rickettsiosis, the symptoms associated with the infection in general and particularly in patients with neurological complications. A tick-exposed population in Sweden was investigated to gain a better understanding of symptoms due to rickettsioses, also in relation to co-infections with other tick-borne bacteria. Based on symptoms, it was not possible to distinguish what pathogen caused the infections. Most patients had erythema migrans, some had serological reactions to Rickettsia spp., Borrelia spp. or co-infections by Rickettsia spp., Borrelia spp. and/or Anaplasma spp. In the fourth and fifth papers, we found associations between antibodies against Rickettsia spp. and sudden deafness (in 10-24% of patients) and facial nerve paralysis (in 8.3-25% of patients). In three patients R. felis was detected in the cerebrospinal fluids. Briefly, the thesis helps to clarify our knowledge about tick dispersal, shows a narrower prevalence estimate of Rickettsia spp. in Swedish ticks, and illuminates symptoms of rickettsioses and co-infections with other tick-borne infections. It also shows that presence of erythema migrans may be explained by more than Lyme disease and indicates a possible association between rickettsiosis and sudden deafness and facial nerve paralysis. Keywords: tick-borne infections, co-infections, ticks, Ixodes ricinus, zoonosis, Rickettsia helvetica, migrating birds, Bell’s pares, erythema migrans, Rickettsia aeschlimannii, sudden deafness, facial nerve paralysis, Hyalomma marginatum, Rickettsia africae, western blot, PCR, serology Katarina Wallménius, Department of Medical Sciences, Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Katarina Wallménius 2016 ISSN 1651-6206 ISBN 978-91-554-9512-1 urn:nbn:se:uu:diva-280667 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-280667) In nature there are neither rewards nor punishments; there are only conse- quences Robert Green Ingersoll Stop bugging me… List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Wallménius K., Barboutis C., Fransson T., Jaenson T.G.T., Lindgren P-E., Nyström F., Olsen B., Salaneck E., Nilsson K. (2014) Spotted fever Rickettsia species in Hyalomma and Ix- odes ticks infesting migratory birds in the European Mediterra- nean area. Parasites & Vectors, 10(7):318 II Wallménius K.*, Pettersson J.H.-O.*, Jaenson T.G.T., Nilsson K. (2012) Prevalence of Rickettsia spp., Anaplasma phago- cytophilum, and Coxiella burnetii in adult Ixodes ricinus ticks from 29 study areas in central and southern Sweden. Ticks and Tick-borne Diseases, 3(2):100-106 III Lindblom A.*, Wallménius K.*, Norberg M., Forsberg P., Eli- asson I., Påhlson C., Nilsson K. (2013) Seroreactivity for spot- ted fever rickettsiae and co-infections with other tick-borne agents among habitants in central and southern Sweden. Euro- pean Journal of Clinical Microbiology, 32(3):317-23 IV Nilsson K., Wallménius K., Hartwig S., Norlander T., Påhlson C. (2014) Bell’s palsy and sudden deafness associated with Rickettsia spp. infection in Sweden. A retrospective and pro- spective serological survey including PCR findings. European Journal of Neurology, 21(2):206-214 V Wallménius K., Påhlson C., Nilsson K. Immunofluorescence and Western Blot analysis for presence of antibodies against Rickettsia spp. and Borrelia spp. in serum from patients diag- nosed with peripheral facial palsy. A retrospective serological survey. Preliminary manuscript *Authors have contributed equally and share first authorship. Reprint of Paper II was made with permission from Elsevier GmbH. Related Papers Nilsson K., Wallménius K., Påhlson C. (2011) Coinfection with Rickettsia helvetica and Herpes Simplex Virus 2 in a Young Woman with Meningoen- cephalitis. Case Rep Infect Dis. doi: 10.1155/2011/469194 Madsen K., Wallménius K., Fridman Å., Påhlson C., Nilsson K. Uveitis associated with Rickettsia species infection in Sweden. A prospective sero- logical survey. Submitted Contents Introduction ................................................................................................... 11 Emerging zoonotic infections ................................................................... 11 Tick-borne infections in humans ......................................................... 13 Rickettsia .................................................................................................. 14 Genetic characteristics ......................................................................... 14 Vectors ................................................................................................. 16 Reservoirs ............................................................................................ 19 Distribution .......................................................................................... 21 Rickettsioses ........................................................................................ 24 Rickettsia helvetica .............................................................................. 28 Rickettsia felis ...................................................................................... 29 Diagnostic tools ................................................................................... 30 Treatment ............................................................................................. 34 Aims .............................................................................................................. 36 Material and methods .................................................................................... 37 Samples .................................................................................................... 37 DNA analysis ........................................................................................... 38 Serological methods ................................................................................. 42 Results and discussion .................................................................................. 45 Migrating birds as carriers of ticks infected with Rickettsia species over large geographical distances ............................................................. 45 Prevalence of Rickettsia spp. and Anaplasma spp. in Ixodes ricinus ticks in Sweden ......................................................................................... 47 Seroreactivity for spotted fever rickettsia and co-infections with other tick-borne agents among tick exposed people in central and southern Sweden ..................................................................................................... 48 Bell’s palsy and sudden deafness may be associated with rickettsiosis in some patients ........................................................................................ 50 Concluding remarks ...................................................................................... 52 Acknowledgments......................................................................................... 54 Sammanfattning på svenska .......................................................................... 56 References ..................................................................................................... 59 Abbreviations 17kDa 17 kilo Dalton surface antigen bp base pair BLAST Basic local alignment search tool CCHF Crimean-Congo hemorrhagic fever DEBONEL Dermacentor-borne necrosis