Emerging rickettsioses of the Thai-Myanmar border. (Dispatches).To investigate the presence of rickettsioses Rickettsioses Often severe infectious diseases caused by several diverse and specialized bacteria, the rickettsiae and rickettsia-like organisms. The best-known rickettsial diseases infect humans and are usually transmitted by parasitic arthropod vectors. in rural residents of the central Thai-Myanmar border, we tested the blood of 46 patients with fever. Four patients had murine typhus murine typhus n. A comparatively mild, acute, endemic form of typhus caused by the microorganism Rickettsia typhi, transmitted from rats to humans by fleas and characterized by fever, headache, and muscular pain. Also called endemic typhus. , three patients had scrub typhus scrub typhus: see rickettsia; typhus. , and eight patients had spotted fever spot·ted fever n. A tick typhus caused by Rickettsia rickettsii, such as Rocky Mountain spotted fever. spotted fever Rocky Mountain spotted fever, see there group rickettsioses, including the first case of Rickettsia rickettsia (rĭkĕt`sēə), any of a group of very small microorganisms, many disease-causing, that live in vertebrates and are transmitted by bloodsucking parasitic arthropods such as fleas, lice (see louse), and ticks. felis infection reported in Asia. ********** Human rickettsioses known to occur in Thailand include mainly murine typhus and scrub typhus. Murine typhus is caused by Rickettsia typhi and is primarily maintained by fleas such as Xenopsylla cheopis, with various rodents reservoirs (1). Scrub typhus is caused by Orientia tsutsugamushi Orientia tsutsugamushi obligately intracellular bacteria that cause scrub typhus in humans and many small feral mammals, especially rodents and occasionally dogs. (formerly named R. tsutsugamushi), which is transmitted by the bites of the larvae Larvae, in Roman religion Larvae: see lemures. of several species of trombiculid mites (commonly called "chiggers chiggers Harvest mites, red mites Dermatology Larvae of the family Trombiculidae, genus Eutrombicula–southern US, Trombicula–Europe which causes skin infestation Habitat Berry patches, tall grass, weeds, woods. Cf Chiggers. ") (2). Spotted fever group (SFG SFG StanCorp Financial Group SFG San Francisco Giants (baseball team) SFG Special Forces Group SFG Sum Frequency Generation SFG Square Foot Gardening SFG Symmetrical Field Geometry (JBL speaker technology) ) rickettsioses are associated with arthropods, mainly ticks but mites and fleas as well (3,4). In Thailand, few reports of serologically documented cases of SFG rickettsioses have been published (5). Although the specific etiologic agents of these diseases have not been identified, several SFG rickettsiae have been identified from ticks in Thailand. Thai tick typhus tick typhus n. Any of various tick-borne rickettsial diseases identified by their immunological reactions and, in some cases, by their pathogenicity. Rickettsia TT-118 was isolated from a pool of ticks in the 1970s (6). Despite its name, its pathogenic role in Thailand is not known. However, Stenos et al. have suggested that TT-118 is a strain of R. honei, an emerging pathogen emerging pathogen Public health Any pathogen that ↑ incidence of an epidemic outbreak Examples Cryptosporidium, E coli O157:H7, Hantavirus, multidrug resistant pneumococci, vancomycin-resistant enterococci. See Emergent disease. prevalent on Flinders Island Flinders Island, Australia: see Furneaux Group. , Australia (7). Further, a rickettsia identified as R. honei type strain has also been recently detected by molecular methods in Thai Ixodes granulatus (8). In addition, several previously unrecognized rickettsiae of unknown pathogenicity have been detected from Ixodes and Dermacentor ticks, including species known to bite humans (8,9). Thailand's Sangkhlaburi District (Kanchanaburi Province Kanchanaburi (Thai: กาญจนบุรี) is the largest of the central provinces (changwat) of Thailand. ) is a major gateway on the central part of the Thai-Myanmar border where newly arrived migrants from Myanmar become established as farm or factory laborers. There, the local Thai people This article is about Thailand's ethnic majority. For other Tai ethnic groups, see Tai peoples. The Thai (or Tai) are the main ethnic group of Thailand and are part of the larger Tai ethnolinguistic peoples found in Thailand and adjacent countries in , as well as Karen, Mon, and Burmese migrants, are commonly bitten by arthropods when working in the fields or at home. Scrub typhus has been previously reported in the province (10). Murine typhus was also described as a cause of fever in refugee camps along the Thai-Myanmar border (11). However, a serosurvey undertaken in 1997 suggested that residents of Sangkhlaburi were commonly exposed not only to the agents of scrub typhus and murine typhus but also to SFG rickettsiae and agents of human ehrlichioses (12). Here, we provide for the first time a more precise indication of rickettsioses in febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever. feb·rile adj. Of, relating to, or characterized by fever; feverish. patients from Sangkhlaburi. The Study This study was based at the Armed Forces Research Institute of Medical Sciences (AFRIMS AFRIMS Armed Forces Research Institute of Medical Sciences (US, HHS & DoD) AFRIMS Air Force Records Information Management System AFRIMS Air Force Restoration Information Management System )--Kwai River Christian Hospital Clinical Center, Sangkhlaburi District, Kanchanaburi Province, Thailand. (The protocol was approved by the Human Subjects Research Review Board of the U.S. Army, Ethical Review Committee for Research in Human Subjects of the Thai Ministry of Public Health, and Scientific Review Committee of AFRIMS.) Patients were selected from those enrolled and sampled from June 1999 to February 2002 in an on-going "fever study," which focuses on the etiology of undifferentiated febrile illnesses (oral temperature >38[degrees]C or history of fever within the past 48 h) in local residents [greater than or equal to] 20 years of age. Criteria leading to the suspicion of rickettsioses included 1) a rash or eschar eschar /es·char/ (es´kahr) 1. a slough produced by a thermal burn, by a corrosive application, or by gangrene. 2. tache noire. es·char n. , 2) arthropod arthropod Any member of the largest phylum, Arthropoda, in the animal kingdom. Arthropoda consists of more than one million known invertebrate species in four subphyla: Uniramia (five classes, including insects), Chelicerata (three classes, including arachnids and horseshoe bites or recent exposure to the jungle, 3) a negative Giemsa-stained malaria smear, and 4) serum specimens that tested positive by enzyme-linked immunosorbent assay enzyme-linked immunosorbent assay n. ELISA. Enzyme-linked immunosorbent assay (ELISA) A diagnostic blood test used to screen patients for AIDS or other viruses. (ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent. ELISA n. ) for SFG--specific immunoglobulin (Ig) M (PanBio, Brisbane, Australia) or dot-ELISA for total Ig of R. rickettsii or R. typhi (PanBioINDX, Baltimore, MD). Serum specimens were sent to the Unite des Rickettsies in Marseille for specific diagnosis of rickettsioses. Serologic testing was performed by indirect immunofluorescence Noun 1. indirect immunofluorescence - a method of using fluorescence microscopy to detect the presence of an antigen indirectly fluorescence microscopy - light microscopy in which the specimen is irradiated at wavelengths that excite fluorochromes (IF) on acute-phase (day 0) and convalescent-phase (approximately day 21) samples. Serum specimens were tested by using a panel of 13 rickettsial rickettsial /rick·ett·si·al/ (ri-ket´se-al) pertaining to or caused by rickettsiae. rick·ett·si·al adj. Relating to, or caused by a member of the genus Rickettsia. antigens, including SFG rickettsiae (R. conorii Indian, R. japonica japonica (jəpŏn`əkə): see quince; camellia. , R. honei, R. helvetica, R. slovaca, AT1 Rickettsia [13], R. felis, "R. heilongjiangii") typhus typhus, any of a group of infectious diseases caused by microorganisms classified between bacteria and viruses, known as rickettsias. Typhus diseases are characterized by high fever and an early onset of rash and headache. group rickettsiae (R. typhi), Orientia tsutsugamushi (strain Gilliam, Kato, Karp, and Kawazaki), Anaplasma phagocytophilum Anaplasma phagocytophilum (formerly Ehrlichia phagocytophila) is a gram-negative bacterium that is fairly unique in its trophism to neutrophils. It causes Human granulocytic anaplasmosis. , Ehrlichia chaffeensis, and Coxiella burnetii Coxiella burnetii Infectious disease The single species of genus Coxiella, family Rickettsiaceae, a short, rod-shaped bacterium; it is global in distribution, causes Q fever, spreads by aerosol, primarily infects cattle, sheep, goats, multiplies well in the . The rationale for the antigen screening panel included the presence of the strains in Asia and results of previous serosurveys for A. phagocytophilum and E. chaffeensis. The standard procedure was followed for the use of Western blot Western blot A technique developed in 1979 that is used to confirm ELISA results. HIV antigen is purified by electrophoresis and attached by blotting to a nylon or nitrocellulose filter. and cross-adsorption studies to complete the IF assay at the Unite des Rickettsies (14,15). An immunofluorescence Immunofluorescence A technique that uses a fluorochrome to indicate the occurrence of a specific antigen-antibody reaction. The fluorochrome labels either an antigen or an antibody. assay was considered positive for 1) IgG with titers [greater than or equal to] 128 and/or IgM titers [greater than or equal to] 64 for R. conorii; and 2) for IgG titers [greater than or equal to] 64 and/or IgM titers [greater than or equal to] 32 for other rickettsial antigens. When cross-reactions were noted between several rickettsial antigens, the standard procedure comprised three steps: 1) A rickettsial antigen was considered to represent the agent of infection when titers of IgG and/or IgM antibody against this antigen were at least two serial dilution higher than titers of IgG and/or IgM antibody against other rickettsial antigens. 2) When the difference in titers between several antigens was lower than two dilutions, Western blot assays were performed. A rickettsial antigen was considered to represent the agent of the infection when acute-phase or convalescent-phase sera reacted only with the specific proteins of this antigen. 3) When Western blot assays were not diagnostic, cross-absorption studies were performed: IgG/IgM titers had to be [greater than or equal to] 128/32. Specific diagnosis criteria after cross-absorption studies included a) IF serologic test results positive for a single antigen or b) a Western blot assay showing an exclusive reactivity with specific proteins of a sole agent. From June 1999 to February 2002, 46 patients were selected to be specifically tested for rickettsioses. These 46 patients were empirically treated by a 7-day doxycycline doxycycline /doxy·cy·cline/ (dok?se-si´klen) a semisynthetic broad-spectrum tetracycline antibiotic, active against a wide range of gram-positive and gram-negative organisms; used also as d. calcium and d. hyclate. regimen (200 mg/d). Rickettsioses were serologically confirmed in 15 (33%) patients by evidence of seroconversion seroconversion /se·ro·con·ver·sion/ (-con-ver´zhun) the change of a seronegative test from negative to positive, indicating the development of antibodies in response to immunization or infection. , IgM at significant titers, or both. Three patients (nos. 1-3) had scrub typhus caused by O. tsutsugamushi. Serum specimens from patients 1 and 3 provided the highest titers against Gilliam and Karp strains, and serum from patient 2 had titers against Gilliam strain only. No further study was conducted to identify the strain responsible for the disease. Two of these patients had returned from a trip into the jungle, and the third became sick several days after cutting grass in the fields. One patient was initially thought to have bacterial meningitis bacterial meningitis Acute bacterial meningitis Neurology Meningeal inflammation caused by bacteria which, if untreated, is often fatal, or associated with significant sequelae Epidemiology 60% are community-acquired–CM, 40% nosocomial–NM Predisposing and had been treated unsuccessfully by a broad-spectrum third-generation cephalosporin cephalosporin (sĕf'əlōspôr`ĭn), any of a group of more than 20 antibiotics derived from species of fungi of the genus Cephalosporium and closely related chemically to penicillin. Cephalosporins, e.g. for 3 days before doxycycline was started. Four patients (nos. 4-7) had murine typhus caused by R. typhi. All had fever and unspecific Adj. 1. unspecific - not detailed or specific; "a broad rule"; "the broad outlines of the plan"; "felt an unspecific dread" broad general - applying to all or most members of a category or group; "the general public"; "general assistance"; "a general rule"; signs. The patients recalled no arthropod bite, and none had a rash. Eight cases were SFG rickettsioses (nos. 8-15). Of the patients with SFG rickettsioses, only one (no. 9) had fever, eschar, and rash. One patient (no. 13) had an eschar at a tick bite site, and another had a rash (no.15). Others presented with unspecific signs. Cross-reactions were noted mostly within the SFG rickettsia antigens. One patient (no. 8) with SFG rickettsioses seroconverted to R. felis, indicated by high level of antibody titers. Further, although IgG titers were more than two serial dilutions higher than those for R. typhi, Western blot assay was performed to confirm IF findings. Two patients (nos. 9 and 10) were shown to have the highest titers to R. conorii strain Indian. Five patients (nos. 11-15) had the highest titers to R. helvetica. For patients 4, 9, 10, 13, and 15, IF results showed differences lower than two dilutions in IgG titers, IgM titers, or both, between several antigens. Thus, IF assays were completed by Western blot and with cross-absorption studies for patient 4 (Table). No cases of infection due to C. burnetii or ehrlichioses were diagnosed in the 46 tested patients. Conclusions In this study, we report rickettsioses in Sangkhlaburi, including the first case of R. felis infection reported in Asia. R. felis is an emerging pathogen responsible for fleaborne spotted fever. R. felis was likely first detected (as R. ctenocephali) in European cat fleas (Ctenocephalides felis) in 1918 (16), then rediscovered in 1990 in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. (17). R. felis was then cultivated and characterized as a unique SFG rickettsia (18). Its pathogenic role was recently demonstrated in patients with serologic se·rol·o·gy n. pl. se·rol·o·gies 1. The science that deals with the properties and reactions of serums, especially blood serum. 2. evidence of infection in Brazil, France, and Germany. R. felis DNA DNA: see nucleic acid. DNA or deoxyribonucleic acid One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. has also been detected in sera in Texas, Mexico, Brazil, and Germany (19). This rickettsia has also been recently detected in fleas in Brazil, Africa, Spain, and France (20). Further, during an entomologic en·to·mol·o·gy n. The scientific study of insects. en  to·mo·log survey, R. felis--like rickettsiae were
detected in fleas collected in Sanghklaburi (P. Parola, unpub, data).
These data suggest that R. felis infection is endemic in Sanghklaburi
and perhaps globally.Murine typhus, a mild disease with nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. signs (21), was found in four of our patients. Although this disease has a worldwide distribution, it is often unrecognised, and documented cases are rarely reported. The classic triad See C-I-A. of fever, headache, and skin rash is observed in <15% of cases (22). For example, our four patients did not have a rash. Arthralgia arthralgia /ar·thral·gia/ (ahr-thral´jah) pain in a joint. ar·thral·gia n. Severe pain in a joint. Also called arthrodynia. , myalgia myalgia /my·al·gia/ (mi-al´jah) muscular pain.myal´gic epidemic myalgia see under pleurodynia. my·al·gia n. , and respiratory and gastrointestinal symptoms (as demonstrated by one of our patients) are frequent (21,22). Regarding disease transmission, although rats and mice are very common within and around houses in the villages, our patients did not report contact with rat fleas or a flea bite. In this study, seven patients with SFG rickettsioses may have been infected by R. helvetica (five patients) or R. conorii Indian strain (two patients), according to IF assays completed for some cases by Western blot and cross-adsorption studies. R. helvetica is an emerging pathogen known to be prevalent in Europe (23) and Japan (13). In both areas, R. helvetica is associated with Ixodes ticks, which are also found in Thailand, although they have not previously been reported in Sangkhlaburi (24). R. conorii Indian is known as an agent of tick-borne rickettsioses prevalent in India, where it is associated with the dog tick (Rhipicephalus sanguineus) (25), which is found worldwide. However, an unknown Rickettsia sp. that is cross-reactive with R. conorii Indian and R. helvetica could also be responsible for the cases reported here. In particular, we have recently detected, by polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is , Rickettsia spp. from ticks that have bitten people in the Sangkhlaburi area, including Dermacentor auratus and Dermacentor sp. larvae (9). The pathogenic role of these rickettsiae has yet to be demonstrated. Scrub typhus is essentially an occupational disease among rural residents in the Asia-Pacific region (2). This disease is often underdiagnosed or misdiagnosed when the classic eschar at the chigger chigger, minute, six-legged, reddish larva of the harvest mite, one of various red bugs widely distributed throughout the world and common in the S United States. bite sites and the rash are absent, as reported for two of our three patients (2). The severity of the disease varies from asymptomatic to fatal (up to 30%). Delayed or inappropriate treatment such as with third-generation cephalosporins Cephalosporins Definition Cephalosporins are medicines that kill bacteria or prevent their growth. Purpose Cephalosporins are used to treat infections in different parts of the body—the ears, nose, throat, lungs, sinuses, and , as reported for one of our patients, is associated with a severe outcome. The four major serotypes studied here have been shown to have sufficient cross-reactivity with antigens from other strains to be used for serologic diagnostic testing Diagnostic testing Testing performed to determine if someone is affected with a particular disease. Mentioned in: Von Willebrand Disease . In our patients, although the highest titers were obtained by using O. tsutsugamushi strain Gilliam antigens, other strains that share common epitopes and cross-react with this strain could be involved. Patients with rickettsioses may have isolated fever or fever with nonspecific clinical and laboratory findings. These diseases are easily misdiagnosed because rash or eschar (the hallmark for rickettsial diseases) is absent, the diseases are not recognized by local physicians, or the diseases have never been reported in the area. More studies are needed on tropical rickettsioses, in particular, molecular detection or rickettsial isolation from patient samples, complemented by detailed case reports. Studying possible vectors and animal reservoirs would provide estimates of the degree of zoonotic potential zoonotic potential n. The potential for animal infections to be transmissible to humans. . Ultimately, such studies will provide the basis for determining prevalence of rickettsiosis rickettsiosis /rick·ett·si·o·sis/ (ri-ket?se-o´sis) infection with rickettsiae. rick·ett·si·o·sis n. Infection with Rickettsia bacteria. in the tropics tropics, also called tropical zone or torrid zone, all the land and water of the earth situated between the Tropic of Cancer at lat. 23 1-2°N and the Tropic of Capricorn at lat. 23 1-2°S. and their effects on public health.
Table. Clinical and laboratory data of patients with rickettsioses on
the Thai-Myanmar border
Clinical signs accompanying fever
Patient Age/ A.
no. sex bite R E N
Scrub typhus
1 29/M Not No No Yes
noticed
2 50/F Yes Yes (b) Yes No
3 32/M Yes No No Yes
Murine typhus
4 28/F No No No
5 35/M Not No No No
noticed
6 37/F Not No No No
noticed
7 20/F Not No No No
noticed
SFG rickettsioses
8 70/F No No No
9 50/M Not Yes (c) Yes Yes
noticed
10 45/M No No Yes
11 35/M Tick bite No Yes No
12 37/F A. No No No
removed
from ear
13 20/F Tick bite No Yes No
14 55/F No No No
15 29/M Yes (b) No No
Immunofluorescence
Clinical signs accompanying serologic testing
fever (a) IgG/IgM early
IgG/IgM late
SFG rickettsia
antigens
Patient Age/
no. sex Other Rh
Scrub typhus
1 29/M Headache, stupor, 0/16
meningism, 0/16
thrombocytopenia,
[up arrow] ALT
2 50/F Chills, myalgia, 0/32
vomiting, 0/32
thrombocytopenia,
[up arrow] GGT [up arrow] ALT
3 32/M Headache, 0/16
myalgia, cough, 16/16
thrombocytopenia,
[up arrow] GGT [up arrow] ALT
Murine typhus
4 28/F Chills, headache, 16/128
vomiting, myalgia, (e)
cough, 16/64 (e)
thrombocytopenia
5 35/M Chills, headache, 0/64
[up arrow] ALT 16/128
6 37/F Chills, headache, 16/64
myalgia, vomiting, 128/64
thrombocytopenia,
[up arrow] GGT [up arrow] ALT
7 20/F Headache, back 0/128
pain 16/64
SFG rickettsioses
8 70/F Chills, headache, 0/32
vomiting, 32/32
hepatomegaly,
leukopenia
9 50/M Chills, abdominal 64/8 (d)
pain, confusion, 64/16
thrombocytopenia
10 45/M Vomiting, 16/32 (d)
diarrhea, hepato- 64/32
splenomegaly
11 35/M Chills, headache, 64/256
vomiting, myalgia, 16/128
cough,
splenomegaly,
[up arrow] GGT [up arrow] ALT
12 37/F Chills, headache, 0/16
vomiting, myalgia, 128/32
cough, [up arrow] GGT
[up arrow] ALT
13 20/F Headache, chills, 32/16 (d)
myalgia 64/16
14 55/F Chills, headache, 16/32
myalgia, diarrhea, 128/16
thrombocytopenia
15 29/M Chills, headache, 16/16
myalgia, cough, 64/64 (d)
thrombocytopenia,
[up arrow] GGT [up arrow] ALT
Immunofluorescence serologic testing (a)
IgG/IgM early IgG/IgM late
SFG rickettsia antigens
Patient Age/
no. sex Rc Rjap Rhon Rslo
Scrub typhus
1 29/M 0/0 0/16 0/8 0/0
0/0 0/16 0/8 0/0
2 50/F 0/0 0/32 0/16 0/0
0/0 0/32 0/16 0/0
3 32/M 0/0 0/0 0/8 0/0
0/0 16/16 0/8 0/0
Murine typhus
4 28/F 16/64 16/8 16/16 16/16
16/64 0/0 16/64 16/8
5 35/M 0/64 0/8 0/64 0/0
16/256 0/8 0/64 0/0
6 37/F 32/8 0/0 16/0 16/0
32/0 32/0 128/0 128/8
7 20/F 0/64 0/0 0/32 0/0
0/64 0/64 0/64 0/164
SFG rickettsioses
8 70/F 0/32 0/0 0/8 0/0
9 50/M 128/16 (d) 32/0 (d) 32/0 (d) 32/0 (d)
128/16 32/0 64/0 128/0
10 45/M 64/32 (d) 16/32d 16/0 (d) 16/16 (d)
64/32 32/16 32/16 16/16
11 35/M 0/16 16/8 16/25 0/64
16/32 0/8 6 0/64
16/12
8
12 37/F 0/0 0/0 0/0 0/0
0/0 64/0 32/16 16/32
13 20/F 32/0 (d) 32/0 (d) 64/0 (d) 32/8 (d)
32/0 64/0 128/0 64/8
14 55/F 16/16 16/16 16/16 16/16
16/16 16/16 16/16 64/0
15 29/M 16/16 32/16 32/16 16/0
32/32 (d) 32/32 (d) 32/32 64/64 (d)
(d)
Immunofluorescence serologic testing (a)
IgG/IgM early IgG/IgM late
SFG rickettsia antigens
Patient Age/ R. typhi
no. sex AT1 Rheil Rfel antigen
Scrub typhus
1 29/M 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
2 50/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
3 32/M 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
Murine typhus
4 28/F 0/0 0/32 0/0 64/128 (e)
0/0 0/8 0/0 32/32 (e)
5 35/M 0/0 0/32 0/0 16/256
0/0 0/128 0/0 512/256
6 37/F 0/0 0/0 0/0 64/8
32/8 32/0 0/0 512/256
7 20/F 0/0 0/0 0/0 0/64
0/8 0/0 0/0 128/256
SFG rickettsioses
8 70/F 0/0 0/0 0/0 0/0
0/0 0/0 1024/ 0/256 (d)
256 (d)
9 50/M 0/0 16/0 (d) 0/0 0/0
0/0 32/8 0/0 0/0
10 45/M 0/0 16/8 (d) 0/0 0/16 (d)
0/0 32/16 0/0 16/32
11 35/M 0/32 32/32 0/0 0/256
16/8 0/16 0/0 0/256
12 37/F 0/8 0/8 0/0 0/32
0/0 32/16 0/0 0/64
13 20/F 0/0 0/0 32/0 (d) 0/0
0/0 0/0 64/0
14 55/F 16/16 16/0 32/0 0/0
16/16 64/0 64/0 0/0
15 29/M 32/16 16/0 16/16 0/0
32/32 64/64 64/64 0/0
(d) (d) (d)
Immunofluorescence serologic testing (a)
IgG/IgM early IgG/IgM late
Orientia tsutsugamushi
Patient Age/
no. sex G Kw Kp K
Scrub typhus
1 29/M 0/32 0/8 0/8 0/0
256/32 0/8 256/3 0/0
2 50/F 128/64 0/0 0/0 0/0
128/16 0/0 0/0 0/0
3 32/M 0/0 0/0 0/0 0/0
512/128 0/0 512/0 0/0
Murine typhus
4 28/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
5 35/M 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
6 37/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
7 20/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
SFG rickettsioses
8 70/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
9 50/M 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
10 45/M 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
11 35/M 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
12 37/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
13 20/F 512/0 0/0 0/0 0/0
512/0
14 55/F 0/0 0/0 0/0 0/0
0/0 0/0 0/0 0/0
15 29/M 256/0 256/0 0/0 0/0
256/0 256/0 0/0 0/0
Abbreviations: A., arthropod; Ig, immunoglobulin; R, rash; E, eschar;
N, nodes; Rh, Rickettsia helvetica; Rc, R. conorii Indian; Rjap, R.
japonica; Rhon, R. honei; Rslo, R. slovaca; AT1, Rickettsia strain AT1
from Japan; Rheil, "R. heilongjiangii"; Rfel, R. felis; G, strain
Gilliam; Kw, strain Kawazaki; Kp, strain Karp; Ko, strain Kato.
(a) Immunofluorescence assay was completed by Western blot and
cross-adsorption as described in the text. For typhus and spotted fever
group antigens, the rickettsia considered potentially responsible for
the infection are in bold type.
(b) Maculopapular over chest and back.
(c) Vesiculous on the legs.
(d) Antigens and sera used for Western blot assays.
(e) Antigens and sera used for Western blot and cross-adsorption
assay's.
Acknowledgments We are grateful to the Armed Forces Research Institute of Medical Sciences Fever Study Team and staff of Kwai River Christian Hospital for technical assistance. This work was supported partly by the U.S. Department of Defense--Global Emerging Infections Surveillance and Response System and National Institute of Health Grant AI 39002. During this work, Dr. Parola was supported at different periods by Fondation Bayer Sante, Ministere Francais des Affaires Etrangeres (Programme Lavoisier), Fondation pour la Recherche Medicale, Assistance Publique-Hopitaux de Marseille, Institut de Recherche re·cher·ché adj. 1. Uncommon; rare. 2. Exquisite; choice. 3. Overrefined; forced. 4. Pretentious; overblown. International Servier, Association des Professeurs de Pathologie Infectieuses et Tropicales, and the European Society of Clinical Microbiology and Infectious Diseases. (1) These results were presented in part at the 3rd International Conference on Emerging Infectious Diseases The ICEID or International Conference on Emerging Infectious Diseases is a conference for public health professionals on the subject of emerging infectious diseases. , March 24-27, 2002, Atlanta, Georgia, USA. References (1.) Azad AF, Radulovic S, Higgins JA, Noden BH, Troyer JM. Fleaborne rickettsioses: ecologic considerations. Emerg Infect Dis 1997;3:319-27. (2.) Silpapojakul K. Scrub typhus in the Western Pacific region. Ann Acad Med Singapore 1997;26:794-800. (3.) Raoult D, Roux Roux , Pierre Paul Émile 1853-1933. French bacteriologist. His work with the diphtheria bacillus led to the development of antitoxins to neutralize pathogenic toxins. V. Rickettsioses as paradigms of new or emerging infectious diseases. Clin Microbiol Rev 1997; 10:694-719. (4.) Parola P, Raoult D. Ticks and tickborne bacterial diseases in humans: an emerging infectious threat. Clin Infect Dis 2001;32:897-928. Erratum [Latin, Error.] The term used in the Latin formula for the assignment of mistakes made in a case. After reviewing a case, if a judge decides that there was no error, he or she indicates so by replying, "In nollo est erratum : Clin Infect Dis 2001;33:749 (5.) Sirisanthana T, Pinyopornpanit V, Sirisanthana V, Strickman D, Kelly DJ, Dasch GA. First cases of spotted fever group rickettsiosis in Thailand. Am J Trop Med Hyg 1994;50:682-6. (6.) Robertson RG, Wisseman CL Jr. Tick-borne rickettsiae of the spotted fever group in west Pakistan. II. Serological serological pertaining to or emanating from serology. serological test one involving examination of blood serum usually for antibody. classification of isolates from west Pakistan and Thailand: evidence for two new species. Am J Epidemiol 1973;97:55-64. (7.) Stenos J, Roux V, Walker D, Raoult D. Rickettsia honei sp. nov., the aetiological AE`ti`o`log´ic`al a. 1. Pertaining to ætiology; assigning a cause. Adj. 1. aetiological - of or relating to the philosophical study of causation aetiologic, etiologic, etiological 2. agent of Flinders Island spotted fever in Australia. Int J Syst Bacteriol 1998;48:1399-404. (8.) Kollars TM Jr., Tippayachai B, Bodhidatta D. Short report: Thai tick typhus, Rickettsia honei, and a unique rickettsia detected in Ixodes granulatus (Ixodidae: Acari) from Thailand. Am J Trop Med Hyg 2001;65:535-7. (9.) Parola P, Comet JP, Sanogo YO, Miller RS, van Thien H, Gonzalez JP, et al. Identification of Ehrlichia spp, Anaplasma spp and Rickettsia spp in ticks from the Thai-Myanmar border and Vietnam. J Clin Microbiol 2003;41:1600-8. (10.) Chanyasanha C, Kaeburong K, Chenchittikul M, Sujirarat D. 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Serosurvey of Rickettsiaceae and other disease threats at a sentinel site for emerging infectious diseases. Abstract 433. 1997. Orlando, Florida, 46th Annual Meeting of the American Society of Tropical Medicine tropical medicine, study, diagnosis, treatment, and prevention of certain diseases prevalent in the tropics. The warmth and humidity of the tropics and the often unsanitary conditions under which so many people in those areas live contribute to the development and and Hygiene. (13.) Fournier PE, Fujita H, Takada N, Raoult D. Genetic identification of rickettsiae isolated from ticks in Japan. J Clin Microbiol 2002;40:2176-81. (14.) La Scola B, Rydkina L, Ndihokubwayo JB, Vene S, Raoult D. Serological differentiation of murine typhus and epidemic typhus epidemic typhus n. A form of typhus characterized by high fever, mental and physical depression, and macular and papular eruptions; it is caused by Rickettsia prowazekii and transmitted by body lice. using cross-adsorption and Western blotting. Clin Diagn Lab Immunol 2000;7:612-6. (15.) La Scola B, Raoult D. Laboratory diagnosis of rickettsioses: current approaches to diagnosis of old and new rickettsial diseases. J Clin Microbiol 1997;35:2715-27. (16.) Sikora H. Beitrage zur Kenntnis der Rickettsien. Arch f Schiffs und Tropenhyg Liepzig 1918;xxii:442-6. (17.) Adams JR, Schmidtmann ET, Azad AF. Infection of colonized Colonized This occurs when a microorganism is found on or in a person without causing a disease. Mentioned in: Isolation cat fleas, Ctenocephalides fells (Bouche), with a rickettsia-like microorganism microorganism /mi·cro·or·gan·ism/ (-or´gah-nizm) a microscopic organism; those of medical interest include bacteria, fungi, and protozoa. . Am J Trop Med Hyg 1990;43:400-9. (18.) La Scola B, Beconi S, Fenollar F, Rolain JM, Roux V, Raoult D. Amended description of Rickettsia felis (Bouyer et al. 2001), a temperature-dependent cultured bacterium. Int J Syst Evol Microbiol 2002;52:2035-41. (19.) Richter J, Fournier PE, Petridou J, Haussinger D, Raoult D. Rickettsia felis infection acquired in Europe and documented by polymerase chain reaction. Emerg Infect Dis 2002;8:207-8. (20.) Rolain JM, Franc M, Davoust B, Raoult D. Molecular detection of pathogenic Bartonella and Rickettsia in cat fleas from France. Emerg Infect Dis 2003;9:338-42. (21.) Silpapojakul K, Chayakul P, Krisanapan S, Silpapojakul K. Murine typhus in Thailand: clinical features, diagnosis and treatment. QJ Med 1993;86:43-7. (22.) Dumler JS, Taylor JP, Walker DH. Clinical and laboratory features of murine typhus in south Texas, 1980 through 1987. JAMA JAMA abbr. Journal of the American Medical Association 1991;266:1365-70. (23.) Fournier PE, Grunnenberger F, Jaulhac B, Gastinger G, Raoult D. Evidence of Rickettsia helvetica infection in humans, eastern France. Emerg Infect Dis 2000;6:389-92. (24.) Tanskul P, Stark HE, Inlao I. A checklist of ticks of Thailand (Acari: Metastigmata: Ixodoidea). J Med Entomol 1983;20:330-41. (25.) Parola P, Fenollar F, Badiaga S, Brouqui P, Raoult D. First documentation of Rickettsia conorii Rickettsia co·no·ri·i n. A bacterium that causes boutonneuse fever in humans. infection (strain Indian tick typhus) in a traveler. Emerg Infect Dis 2001;7:909-10. Address for correspondence: Didier Raoult, Unite des Rickettsies, CNRS CNRS Centre National de la Recherche Scientifique (National Center for Scientific Research, France) CNRS Centro Nacional de Referencia Para El Sida (Argentinean National Reference Center for Aids) UMR UMR Unite Mixte de Recherche (French: Mixed Unit of Research ) UMR University of Missouri - Rolla UMR Upper Mississippi River UMR Uniform Methods and Rules (US Department of Agriculture) UMR Unit Manning Report 6020 IFR IFR abbr. instrument flight rules 48, WHO Collaborative Center for Rickettsial Reference and Research, Faculte de Medecine, 27 Bd Jean Moulin, 13385 Marseille Cedex 5, France; fax: (33) 4 91 83 03 90; email: Didier. Raoult@ medecine.univ-mrs.fr Philippe Parola, * ([dagger])([double dagger]) R. Scott Miller, * Philip McDaniel, ([section]) Sam R. Telford III, ([double dagger]) Jean-Marc Rolain, ([dagger]) Chansuda Wongsrichanalai, * and Didier Raoult ([dagger]) * Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand; ([dagger]) Unite des Rickettsies, Marseille, France; ([double dagger]) Harvard School of Public Health The Harvard School of Public Health is (colloquially, HSPH) is one of the professional graduate schools of Harvard University. Located in Longwood Area of the Boston, Massachusetts neighborhood of Mission Hill, next to Harvard Medical School and Cambridge, Massachusetts, , Boston, Massachusetts, USA; and ([section]) Kwai River Christian Hospital, Sangkhlaburi, Kanchanaburi, Thailand Dr. Parola obtained his M.D. and Ph.D. degrees at the Faculte de Medecine, Marseille, France. This work is part of his postdoctoral research project at the Harvard School of Public Health, Boston, Massachusetts, USA. His research interests include tropical diseases and medical entomology. |
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