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Concept: Rickettsia

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BACKGROUND: Although an initial IFA-IgG titer greater or equal to 1/64 or 1/128 is considered positive in presumptive diagnosis, in clinical practice in an endemic setting for rickettsioses in Sri Lanka, some patients with IFA-IgG titer of 1/128 for either spotted fever group (SFG) or scrub typhus (ST) did not respond to treatment. FINDINGS: To determine a clinically helpful diagnostic algorithm, IFA-IgG results of serologically confirmed treatment responders were analyzed in relation to duration of illness at sampling.Of 146 suspected SFG, 3 responders of 25 patients had titers <=1/128 with < 7 days of illness while all 9 with titers >=1/256 responded (false negative with 1/256 cutoff was 12%, false positive was 0%). For illness > 7 days, the false negative and positive rates were 4.3% (3/59) and 11.3% (6/53). Of 115 suspected ST, false negative and positive rates with >=1/256 cutoff at <7 days of illness were (2/15) and 0% (0/8) respectively while > 7 days, false negative and positive rates were 2% (1/51) and 0% (0/42). CONCLUSIONS: For clinical decision making, duration of illness at sampling is important in interpreting serology results in an endemic setting. If sample is obtained <=7 day of illness, an IgG titer of <=1/128 requires a follow up sample in the diagnosis and > 7 days of illness, a single >=1/256 titer is diagnostic for all ST and 90% of SFG.

Concepts: Epidemiology, Infectious disease, Rickettsia, Rocky Mountain spotted fever, Sri Lanka, Inequality, Typhus, Equality

27

Scrub typhus is a lethal human disease transmitted by larval trombiculid mites (i.e., chiggers) that have been infected with the rickettsia Orientia tsutsugamushi. In total, 21 chigger species are known from Taiwan. We update the checklist of chiggers of Taiwan based on an intensive survey of shrew and rodent hosts in grasslands and agricultural fields in lowland Taiwan, coupled with surveys of forests in one mountainous site and an opportunistic examination of submitted host specimens. Three new species of chiggers, Gahrliepia (Gateria) lieni sp. n., Gahrliepia (Gateria) minuta sp. n., and Gahrliepia (Gateria) yilanensis sp. n., as well as 23 newly recorded chigger species, were discovered. Accordingly, recorded chigger species of Taiwan more than doubled from 21 to 47 species. Two new species and nine newly recorded chigger species were discovered in forests in one mountainous site in northeastern Taiwan, suggesting that many more chigger species may be uncovered, particularly in mountainous Taiwan. Further studies should also investigate O. tsutsugamushi infection in different chigger species to assess its risks to human health.

Concepts: Rickettsia, Acari, Typhus, Trombiculidae, Scrub typhus, Orientia tsutsugamushi, Harvest mite, Gahrliepia

27

Rickettsial agents, including those in the genera Anaplasma, Ehrlichia, Neorickettsia, and Rickettsia, are important and common vector-borne pathogens of dogs and cats. Disease induced by these organisms ranges from clinically inapparent to severe and potentially fatal. However, laboratory confirmation of a rickettsial etiology can be complicated by a number of factors, including the wide spectrum of disease induced by these organisms, an often low and widely fluctuating level of organism present in infected animals, cross-reactions on serologic and molecular assays, and the presence of co-infections. Correct diagnosis is most likely to be reached when multiple diagnostic strategies, including careful microscopic examination of stained blood films or tissues, both specific and broad serologic tests, and a suite of molecular detection assays, are used in concert. Accurate interpretation of diagnostic tests requires awareness of the likelihood for multiple agents, including novel organisms, to be responsible for the results seen in a given patient. This review provides an overview of current strategies used to diagnose rickettsial infections in dogs and cats.

Concepts: Bacteria, Biology, Virus, Diagnosis, Infection, Greek loanwords, Rickettsiales, Rickettsia

27

Rhipicephalus sanguineus, commonly known as the brown dog tick, is one of the most widely distributed species of tick. In dogs, it can cause anemia and provide the transmission of pathogenic microorganisms such as Babesia canis, Ehrlichia canis, Hepatozoon canis, Anaplasma platys, and Mycoplasma haemocanis. To man, it can transmit the intracellular parasites Rickettsia rickettsii and Rickettsia conorii, the causative agents of the Rocky Mountain spotted fever in the Americas and Mediterranean and spotted fever in Europe and North Africa. Its control is performed by applying synthetic formulations composed of pyrethroids; however, continued use of these products results in environmental damage and acquisition of resistance. Alternatively, studies with botanical insecticides have been increasingly recurrent. Therefore, this study aimed to test the efficacy of essential oil of Tagetes patula, a ruderal species widely described in the literature for its insecticidal properties, in engorged females of R. sanguineus by the adults immersion test (AIT) and impregnated paper disk test (IPDT). The essential oil used, through gas chromatography coupled to mass spectrometry, revealed the presence of 55 compounds, being the 4-vinyl guaiacol and gamma terpinene the majority ones. The AIT compared to the IPDT was more efficient in inhibiting oviposition of tick; however, the eggs laid by the females submitted to saturated atmosphere with essential oil, from IPDT, not hatched, interrupted their development cycle. Besides being a pioneer work, the results presented here contributes to new researches, aiming the incorporation of essential oil in an acaricide for use in the environment.

Concepts: Rickettsia, Rocky Mountain spotted fever, Acari, Babesiosis, Dog health, Rhipicephalus sanguineus, Boutonneuse fever, Tagetes patula

25

In South Korea, scrub typhus is one of the most common rickettsial diseases. The number of scrub typhus patients has increased in South Korea, a total of 69,210 cases were reported from 2001 to 2013. The seasonality and relation of scrub typhus cases to latitude were analyzed in this article using data obtained from the National Notifiable Diseases Surveillance System website of the Korea Centers for Disease Control and Prevention. The incidence of scrub typhus tended to increase in the later months, especially October-December, over the years. In general, lower latitudes were associated with a later peak incidence. Our results suggest for the first time that the monthly observed incidence tended to increase in the later months of the year as the latitude decreased, and on a yearly basis in Korea.

Concepts: Epidemiology, Infectious disease, Earth, Rickettsia, Season, Typhus, Year, Latitude

15

We characterized the epidemiology of typhus group rickettsiosis in Texas, USA. During 2003-2013, a total of 1,762 cases were reported to the state health department. The number of diagnosed cases and geographic expansion increased over time. Physician awareness is critical to diagnose and effectively treat rickettsial infections.

Concepts: Infectious disease, Virus, United States, Rickettsia, U.S. state, Barack Obama, American Civil War, Typhus

11

Twelve patients with murine typhus were identified in Galveston, Texas, USA, in 2013. An isolate from 1 patient was confirmed to be Rickettsia typhi. Reemergence of murine typhus in Galveston emphasizes the importance of vector control and awareness of this disease by physicians and public health officials.

Concepts: Epidemiology, Rickettsia

10

Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.

Concepts: Health care, Medicine, Public health, Health, Epidemiology, Disease, United States, Rickettsia

4

Spotted fever group (SFG) Rickettsia species are etiologic agents of a wide range of human infections from asymptomatic or mild infections to severe, life-threatening diseases. In the United States, recent passive surveillance for SFG rickettsiosis shows an increased incidence and decreased severity of reported cases. The reasons for this are not well understood; however, we hypothesize that less pathogenic rickettsiae are causing more human infections, while the incidence of disease caused by more pathogenic rickettsiae, particularly Rickettsia rickettsii, is relatively stable. During the same period, the range of Amblyomma americanum has expanded. Amblyomma americanum is frequently infected with Candidatus Rickettsii amblyommii, a SFG Rickettsia of unknown pathogenicity. We tested our hypothesis by modeling incidence rates from 1993 to 2013, hospitalization rates from 1981 to 2013, and case fatality rates from 1981 to 2013 regressed against the presence of A. americanum, the decade of onset of symptoms, and the county of residence. Our results support the hypothesis, and we show that the expanding range of A. americanum is associated with changes in epidemiology reported through passive surveillance. We believe epidemiological and acarological data collected on individual cases from enhanced surveillance may further elucidate the reasons for the changing epidemiology of SFG rickettsiosis.

Concepts: Epidemiology, Disease, Infectious disease, Infection, Rickettsia, Rocky Mountain spotted fever, Amblyomma americanum, Rickettsia rickettsii

3

Epidemic typhus is an infectious disease caused by the bacterium Rickettsia prowazekii and transmitted by body lice (Pediculus humanus corporis). This disease occurs where conditions are crowded and unsanitary. This disease accompanied war, famine, and poverty for centuries. Historical and proxy climate data indicate that drought was a major factor in the development of typhus epidemics in Mexico during 1655-1918. Evidence was found for 22 large typhus epidemics in central Mexico, and tree-ring chronologies were used to reconstruct moisture levels over central Mexico for the past 500 years. Below-average tree growth, reconstructed drought, and low crop yields occurred during 19 of these 22 typhus epidemics. Historical documents describe how drought created large numbers of environmental refugees that fled the famine-stricken countryside for food relief in towns. These refugees often ended up in improvised shelters in which crowding encouraged conditions necessary for spread of typhus.

Concepts: Epidemiology, Infectious disease, Rickettsia, Famine, Head louse, Body louse, Louse, Epidemic typhus