LETTERS (6). The sequence is distinct from a DOI: 10.3201/eid1412.080944 Human Case of small number of sequences derived from rabies viruses in Vietnam, which References Bartonella alsatica suggests that China is a stronger can- Lymphadenitis 1. Smith JS, Fishbein DB, Rupprecht CE, didate for the source of the virus than Clark K. Unexplained rabies in three To the Editor: Lymph node en- her native country. immigrants in the United States: a vi- Although the case history could rologic investigation. N Engl J Med. largement is a common medical prob- not provide evidence for interaction 1991;324:205–11. lem that is usually caused by bacterial, 2. Grattan-Smith PJ, O’Regan WJ, Ellis PS, with a dog while her family was in viral, fungal, or protozoal agents (1). O’Flaherty SJ, McIntyre PB, Barnes CJ. A Malignancies or lymphoproliferative Hong Kong Special Administrative second Australian case, with a long incuba- Region, rabies was endemic within tion period. Med J Aust. 1992;156:651–4. diseases are often found, especially in the colony at the time that the pa- 3. McColl KA, Gould AR, Selleck PW, elderly patients (1). Bartonella hense- Hooper PT, Westbury HA, Smith JS. tient’s family was resident. From 1980 lae, the main causative agent of cat- Polymerase chain reaction and other labo- scratch disease (CSD), appears to be through 1984, 5 human cases were re- ratory techniques in the diagnosis of long corded (9). Only 2 case-patients had incubation rabies in Australia. Aust Vet the most common organism respon- clear evidence of a dog bite; histories J. 1993;70:84–9. DOI: 10.1111/j.1751- sible for lymphadenopathy in adults 0813.1993.tb03282.x for the remaining 3 cases provided no and children (1). CSD has also been 4. Fraser GC, Hooper PT, Lunt RA, Gould AR, rarely associated with B. quintana (2). evidence for an animal bite. From 1956 Gleeson LJ, Hyatt AD, et al. Encephalitis to 1979, Hong Kong had been free of caused by a Lyssavirus in fruit bats in Aus- Recently, the epidemiology of B. quin- rabies, but the disease had reentered tralia. Emerg Infect Dis. 1996;2:327–31. tana as an emerging source of human 5. Hanna JN, Carney IK, Smith GA, Tan- the colony shortly after its incidence infection has changed because it has nenberg AEG, Deverill JE, Botha JA, et been isolated from the dental pulp of had increased in the neighboring Chi- al. Australian bat lyssavirus infection: a nese province of Guangdong. If Hong second human case, with a long incuba- a domestic cat (3). Feral cats have also Kong was where the young girl was tion period. Med J Aust. 2000;172:597–9. been found to be infected by B. quin- 6. Zhang Y-Z, Xiong C-L, Zou Y, Wang infected, it would indicate an incuba- tana (4). We report a human case of B. D-M, Jiang R-J, Xiao Q-Y, et al. Mo- alsatica lymphadenopathy. tion period of 4.5–6 years. lecular characterisation of rabies virus Such long incubation periods are isolates in China during 2004. Virus A 79-year-old woman came to a rare for rabies virus infections. An ear- Res. 2006;121:179–88. DOI: 10.1016/j. hospital in Agen, France, in Febru- virusres.2006.05.010 lier epidemiologic study of 177 cases ary 2008 with a large painless axillary 7. Yamagata J, Ahmed K, Khawplod P, Man- mass that she had noticed 10 days ear- in Amritsar, India, demonstrated that nen K, Xuyen DK, Loi HH, et al. Molecu- rabies developed within 6 months of lar epidemiology of rabies in Vietnam. lier. She reported that ≈1 month earlier exposure in 90% of human cases (10). Microbiol Immunol. 2007;51:833–40. she was scratched on her fi nger while 8. Johnson N, Black C, Smith C, Un H, However, the thorough documentation butchering a wild rabbit. On examina- McElhinney LM, Aylan O, et al. Rabies tion, she did not have any other spe- of a small number of cases (1,2) sug- emergence among foxes in Turkey. J Wildl gests that clinicians need to be aware Dis. 2003;39:262–70. cifi c fi ndings. Blood cell counts and of the importance of including travel 9. Wong TW, Chan PK, Fung KP. Human levels of liver enzymes were normal. rabies in Hong Kong: a case review. Ann history over several years in cases of A large necrotic lymph node was sur- Acad Med Singapore. 1987;16:633–5. gically removed the next day. Her con- unexplained encephalitis. 10. Lakhanpal U, Sharma RC. An epide- miological study of 177 cases of human dition was treated with doxycycline This work was supported by the rabies. Int J Epidemiol. 1985;14:614–7. (200 mg) for 3 weeks. Department for Environment, Food and DOI: 10.1093/ije/14.4.614 Our laboratory received a frag- Rural Affairs (Defra, UK) through grant ment of the lymph node of the patient Address for correspondence: Nicholas Johnson, SE0423. and a portion of the rabbit that had been Rabies and Wildlife Zoonoses Group, WHO cooked, boiled as a terrine, and stored Collaborating Centre for Rabies and Rabies- Nicholas Johnson, in a freezer at –20°C in the home of Related Viruses, Veterinary Laboratories the patient. DNA was extracted from Anthony Fooks, Agency – Weybridge, Woodham Lane, Surrey and Kenneth McColl these specimens by using a QIAamp KT15 3NB, UK; email: [email protected]. Tissue Kit (QIAGEN, Hilden, Ger- Author affi liations: World Health Organiza- gsi.gov.uk many). The DNA was used as a tem- tion Collaborating Centre for Rabies and plate in 3 described PCRs specifi c for Rabies-Related Viruses, Weybridge, UK a portion of the B. alsatica 16S–23S (N. Johnson, A. Fooks); and Australian Ani- intergenic spacer (ITS) region, ftsZ mal Health Laboratory, Geelong, Victoria, gene, and 16S rDNA (5). All results Australia (K. McColl) Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 12, December 2008 1951 LETTERS for the lymph node were positive for Immunohistologic staining was Author affi liations: Université de la Méditer- B. alsatica, and amplifi cation products used to demonstrate B. alsatica in ranée, Marseille, France (E. Angelakis, H. of the expected size were obtained the lymph node. Immunohistochemi- Lepidi, J.-M. Rolain, D. Raoult); and Centre from this extract. Sequences obtained cal analysis was performed by using Hospitalier d’Agen, Agen, France (A. Canel, shared 100% similarity with the cor- a monoclonal antibody against B. al- P. Rispal, F. Perraudeau, I. Barre) responding 16S rDNA, ITS region, satica with an immunoperoxidase kit DOI: 10.3201/eid1412.080757 and ftsZ gene fragment of B. alsatica. previously described (7). Briefl y, after However, the terrine specimen was deparaffi nization, the tissue section References negative for 16S rDNA, the ITS re- was incubated with polyclonal-specif- gion, and the ftsZ gene. All negative ic antibody to B. alsatica (8) diluted 1. Rolain JM, Lepidi H, Zanaret M, Triglia controls showed typical results. B. al- 1:1,000 in phosphate-buffered saline. JM, Michel G, Thomas PA, et al. Lymph satica have not been tested or found in Immunodetection was performed with node biopsy specimens and diagnosis of cat-scratch disease. Emerg Infect Dis. our laboratory for several years. biotinylated immunoglobulins, perox- 2006;12:1338–44. B. quintana subsp. Oklahoma, idase-labeled streptavidin (HistoStain 2. Raoult D, Drancourt M, Carta A, Gastaut B. henselae subsp. Houston (ATCC Plus Kit; Zymed, Montrouge, France), JA. Bartonella (Rochalimaea) quintana 49882), B. vinsonii subsp. berkhoffi and amino-ethyl-carbazole as sub- isolation in patient with chronic adenop- athy, lymphopenia, and a cat. Lancet. (URBVAIE25), B. vinsonii subsp. ar- strate. Slides were counterstained with 1994;343:977. DOI: 10.1016/S0140- upensis (ATCC 700727), and B. alsat- Mayer hematoxylin for 10 min. Loca- 6736(94)90102-3 ica (CIP 105477 T) strains were used tion of bacteria was superimposable 3. La VD, Tran-Hung L, Aboudharam G, for immunofl uorescence and Western on that in the Warthin-Starry–stained Raoult D, Drancourt M. Bartonella quin- tana in domestic cat. Emerg Infect Dis. blotting assays (5). A serum sample specimens, and clusters of microor- 2005;11:1287–9. taken at admission was negative for ganisms were seen in the infl amma- 4. Breitschwerdt EB, Maggi RG, Sigmon B, B. alsatica by immunofl uorescence tory areas (online Appendix Figure, Nicholson WL. Isolation of Bartonella assay. This result was accepted be- panel D). quintana from a woman and a cat fol- lowing putative bite transmission. J Clin cause serologic results may be nega- We report lymphadenitis caused Microbiol. 2007;45:270–2. DOI: 10.1128/ tive during the onset of the disease by B. alsatica. Our fi nding was con- JCM.01451-06 (6). Western blotting with Bartonella fi rmed by molecular, serologic, and 5. Raoult D, Roblot F, Rolain JM, Besnier spp. antigens (5) was positive for B. staining methods. Bartonella spp. are JM, Loulergue J, Bastides F, et al. First isolation of Bartonella alsatica from a alsatica and after adsorption, only B. zoonotic agents that infect erythro- valve of a patient with endocarditis. J Clin alsatica antigens retained all antibod- cytes of mammals in which they cause Microbiol. 2006;44:278–9. DOI: 10.1128/ ies (online Appendix Figure, panel chronic bacteremia (9). B. alsatica JCM.44.1.278-279.2006 A, available from www.cdc.gov/EID/ was fi rst identifi ed in 1999 in Alsace, 6. Maurin M, Rolain JM, Raoult D. Com- parison of in-house and commercial slides content/14/12/1951-appF.htm).