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Boutonneuse fever (BF) is an eruptive disease and is classified as a spotted fever, which is endemic in the Mediterranean basin (i.e., Marseille fever or Mediterranean spotted fever) and the Black Sea, caused by Rickettsia conorii, with dog ticks being a vector (i.e., Rhipicephalus sanguineus). In Romania, although the first reported outbreak of BF occurred during the summer of 1931 in Constanta, the disease was discovered in 1910. Although the disease has occurred most frequently in the two counties of the Dobruja region (Constanta and Tulcea), a region of the Balkan Peninsula, during the last few years, other counties in southeastern Romania have started to report BF cases. In a period of 9 years, 533 cases were registered in Constanta county, while in a period of 11 years, 339 cases were registered in Bucharest county. In this review, we describe the bacterial tick-borne disease caused by R. conorii in southeastern Romania, focusing on its history and epidemiology, pathophysiology, clinical aspects, diagnosis, treatment and preventive measures in the context of climate changes. Although R. conorii is the principal etiologic agent of BF in southeastern Romania, we should take into consideration that other Rickettsia spp. could be present and involved in disease transmission. [ABSTRACT FROM AUTHOR]

Boutonneuse fever (BF) is an eruptive disease and is classified as a spotted fever, which is endemic in the Mediterranean basin (i.e., Marseille fever or Mediterranean spotted fever) and the Black Sea, caused by Rickettsia conorii, with dog ticks being a vector (i.e., Rhipicephalus sanguineus). In Romania, although the first reported outbreak of BF occurred during the summer of 1931 in Constanta, the disease was discovered in 1910. Although the disease has occurred most frequently in the two counties of the Dobruja region (Constanta and Tulcea), a region of the Balkan Peninsula, during the last few years, other counties in southeastern Romania have started to report BF cases. In a period of 9 years, 533 cases were registered in Constanta county, while in a period of 11 years, 339 cases were registered in Bucharest county. In this review, we describe the bacterial tick-borne disease caused by R. conorii in southeastern Romania, focusing on its history and epidemiology, pathophysiology, clinical aspects, diagnosis, treatment and preventive measures in the context of climate changes. Although R. conorii is the principal etiologic agent of BF in southeastern Romania, we should take into consideration that other Rickettsia spp. could be present and involved in disease transmission.

Introduction: Mediterranean spotted fever is an infectious disease included in the human rickettsiosis group, with its main distribution in the Mediterranean and South European countries. It is an endemic disease in Portugal, with dogs acting as the main domestic reservoir. Children are a particularly vulnerable group due to their close contact with household animals and by frequently playing outdoors. In this study, we aim to describe the local epidemiology and characterize the clinical features and treatment options in a Portuguese endemic region. Materials and Methods: We performed a prospective descriptive study of the Mediterranean spotted fever cases admitted to the paediatrics emergency department of a of a group II hospital, between January 1st 2013 and December 31st 2015. All patients were examined by a physician, who was later asked to fill out a detailed questionnaire regarding clinical presentation, diagnostic attitudes and treatment of their patients. Parents were later interviewed and questioned about post-discharge disease evolution. Results: We registered 32 cases (93.9% reported between July and October). After fever, the most frequent reported symptoms were myalgia (37.5%), abdominal pain (25%) and headache (25%). Exanthema was present in 84.4% of cases by the third day of fever: maculonodular (53.1%), papular (37.5%) and macular (9.4%). Eschars were found in 59% of patients, with regional lymphadenopathy present in 46.9% of cases. Azithromycin (84.4%) and doxycycline (15.5%) were the selected treatments in our population, with no cases of therapeutic failure or side-effects reported. Conclusion: The incidence of Mediterranean spotted fever is higher in our population in comparison with the rest of the country. Fever, myalgia, abdominal pain and headache were the most common presenting symptoms, while exanthema was the predominant cutaneous finding. Azithromycin was the preferred treatment and it proved to be successful and safe in all cases.

Background/Aim. Mediterranean spotted fever (MSF) belongs to Rickettsioses, the Spotted fever group (SFG). The causal agent is Rickettsia conorii conorii and the transmission to humans occurs through dog tick Rhipicephalus sanguineus bites. The aim of this study was to describe clinical and laboratory characteristics in patients with severe form of Mediterranean spotted fever admitted to Bulgarian university hospital in endemic region. Methods. A retrospective study was conducted at Stara Zagora University Hospital (Southeastern Bulgaria) between April 2015 and August 2016. During the analyzed period, 58 cases had clinical and laboratory data for MSF. Serological tests were applied for the etiological diagnosis. MSF-specific immunoglobulin (IgM) and IgG antibodies were detected in serum by indirect immunoenzyme assay (ELISA IgG/IgM, Vircell, Spain) – R. conorii ELISA IgG sensitivity 85%, specificity 100% and R. conorii ELISA IgM sensitivity 94%, specificity 95%. Statistical analysis was made by MS Excel 2007 and SPSS Statistics, version 19.0. Results. Eighteen patients presented as severe forms. The predominant gender of them were males (78%) and 22% were females. The median age of the analyzed group was 55 years (range: 14– 78 years). Ten patients developed hepatic disorder while 4 had neurological signs. Laboratory data showed thrombocytopenia in 15 patients, mean value of platelet (PLT) count for the whole group was 108.6 ± 53.8 × 109/L. Liver enzymes were elevated with mean value of aspartate aminotransferase (AST) 161.4 ± 90.1 IU/L and alanine aminotransferase (ALT) 163.9 ± 81.5 IU/L. Acute phase reactant as C-reactive protein (CRP) had mean value of 140.3 mg/L (range: 9–230 mg/L). Kidney function was impaired in some cases; the mean value of creatinine for the studied group was 134.7 μmol/L (range: 78–313 μmol/L) and mean value of urea was 9.6 mmol/L (range: 4.2–27.4 mmol/L). Conclusion. Bulgaria is an endemic area for tick-borne diseases. Cases of MSF are reported annually. Severe forms of MSF are not rare. Typical clinical and laboratory markers for severity should be actively searched for. Early diagnosis and proper treatment is the key to avoid complications and enable patient recovery.

Objectives: Mediterranean spotted fever (MSF) is a tick-borne endemic disease caused by Rickettsia conorii conorii and transmitted to humans by the brown dog tick Rhipicephalus sanguineus. It is characterized by fever, maculopapular rash and a tick bite skin lesion "tache noire". The disease affects all age groups and usually has mild to moderate course. It has long been considered a benign infection. However, very severe "malignant" forms with fatal outcome strongly influenced by the patients' age were also observed. We aimed to reveal the features of MSF in children by comparing them with some of the disease patterns in adults.Methods: Our prospective study data are based on the monitoring of all inpatients of the Clinic of Infectious Diseases in Plovdiv City and environs, the largest MSF endemic region in Bulgaria. The total number of patients admitted and treated for MSF over a study period of 10 years is 549, the incidence reaching 9.44/100,000. MSF is confirmed by antibody response to a specific antigen measured by indirect immunofluorescence assay (IFA). IgG ≥ 128 and/or IgM > 64 were considered to be indicative of acute infection.Results: Eighty-five (15.48%) patients were children up to 14 years of age and 464 (84.52%) were aged 15-85 years. The skin lesion "tache noire" was present in 73.68% of children, and in 76.93% of the older age groups; symptoms as anorexia, nausea, vomiting, abdominal pain, and diarrhoea were more frequent in children, till general weakness and malaise was prevalent in adults. Children accounted approximately for 70% of the disease mild forms. No lethality was registered in this age group. Even though there were isolated cases of severe and malignant forms, children did not undergo the fatal complications seen in adults.Conclusion: Knowledge of the peculiarities of MSF in children will contribute to children's health protection, timely diagnose and disease prevention. [ABSTRACT FROM AUTHOR]

The objective of this study is to evaluate the characteristics and outcome of elderly patients with Mediterranean spotted fever (MSF). This study was a prospective observational cohort study of all adult cases with confirmed MSF treated in a teaching hospital (1984–2015) to compare the characteristics of elderly patients (> 65 years) with younger adults. We identified 263 adult patients with MSF, and 53 (20.2%) were elderly. Severe MSF was more frequent in the elderly (26.4% vs. 10.5%; p = 0.002). Gastrointestinal symptoms, impaired consciousness, lung infiltrate, oedema, acute hearing loss, raised alanine transaminase, hyponatremia, and thrombocytopenia occurred more frequently in elderly patients, and arthromyalgia occurred less frequently. Most patients were treated with a single-day doxycycline regimen (two oral doses of 200 mg for 1 day). All patients recovered uneventfully. Fever disappeared 2.55 ± 1.16 days after treatment initiation in elderly patients, and the remaining symptoms disappeared after 3.65 ± 1.42 days. These figures were similar to non-elderly patients. Severe MSF was more frequent in elderly patients. Some clinical manifestations occurred with different frequencies in the elderly compared with younger patients. Single-day doxycycline therapy is an effective and well-tolerated treatment for MSF in elderly patients. [ABSTRACT FROM AUTHOR]

Introduction: Mediterranean spotted fever (MSF) is a spotted fever group (SFG) rickettsiosis caused by Rickettsia conorii endemic in Mediterranean countries as well as in countries around the Black Sea. In Southeastern Romania MSF is endemic, with an overall incidence of 4.2 per 100,000 population, established for 2016 by the National Center for Disease Prevention and Control. Diagnosis of MSF is complex, based on clinical, epidemiological and laboratory data. Objectives: The aim of the study is to describe the usefulness of molecular tests in MSF diagnosis, as well as to provide the first molecular characterization of R. conorii subspecies conorii responsible for MSF in Romania. Methods: Molecular biology assays (nested PCR) were used for testing serum samples collected from 20 patients with MSF serologically confirmed. Results: Molecular diagnosis of MSF was performed by nested PCR assays on rompA and rompB genes, and was confirmed by sequencing of obtained amplicons. Molecular analysis based on a rompA gene fragment allowed placing the isolate detected in the sera collected from a Romanian patient with fatal MSF in the same cluster with other R. conorii subspecies conorii isolates. Conclusions: We present the first data on the use of molecular tools for the early diagnosis of MSF, as well on molecular identification of R. conorii subspecies responsible for MSF in five counties in Southeastern Romania. [ABSTRACT FROM AUTHOR]

Mediterranean spotted fever (MSF) is a tick-borne disease caused by Rickettsia conorii. The classic clinical triad comprises high fever, an inoculation eschar, and a maculopapular non-pruritic rash. Serological testing is the most frequently used diagnostic method. Treatment involves antibiotics, preferably doxycycline. A two-day-old neonate developed sepsis and a skin rash. There was a high index of suspicion for MSF because the mother and four of her children were diagnosed with MSF in synchronization with the clinical presentation of this neonate. As far as one knows, congenital rickettsia as a cause of early neonatal sepsis has not been reported. However, limited data were reported using animal models. There are several challenges regarding its diagnosis and the selection of proper antibiotics for this age group. This paper discusses the challenges of its diagnosis, treatment, and impact on the neonate, this paper also reviews the literature regarding placental transmission of Rickettsia conorii. To the best of our knowledge, this is the first case study reporting that the early neonatal sepsis is caused by R. conorii (the Moroccan strain) in Jordan. Physicians caring for pregnant women and neonates living in areas with endemic MSF should consider the possibility of MSF in febrile patients and initiate early appropriate treatment based on a high index of suspicion. [ABSTRACT FROM AUTHOR]

We report a series of 5 case-patients who had Israeli spotted fever, of whom 2 had purpura fulminans and died. Four case-patients were given a diagnosis on the basis of PCR of skin biopsy specimens 3-4 days after treatment with doxycycline; 1 case-patient was given a diagnosis on the basis of seroconversion. Rickettsia spp. from the 2 case-patients who died were sequenced and identified as Rickettsia conorii subsp. israelensis. Purpura fulminans has been described in association with R. rickettsii and R. indica, but rarely with R. conorii subsp. israelensis. [ABSTRACT FROM AUTHOR]

Introducere. Febra butonoasă (FB) este o boală infecţioasă emergentă în România, evoluând în sudul ţării, după cum reiese din rata incidenţei înregistrată în ultimii ani, conform studiilor noastre anterioare de epi- demiologie descriptivă. Ne-am propus să evaluăm prevalenţa anticorpilor specifici IgG Rickettsia conorii într-un eşantion de populaţie generală din aria afectată. Metode. S-a efectuat un studiu de seroprevalenţă prin metoda ELISA pe 301 probe de ser colectate din aria de sud a României; aria cea mai afectată de FB. Unul din criteriile de selecţie a fost absenţa semnelor şi simptomelor caracteristice bolii în perioada de evoluţie sezonieră a FB. Analiza statistică. Datele au fost prelucrate statistic cu softul SPSS V.19 (indicatori tendinta centrala, dispersie, frecventa si teste de comparare). Rezultate. Rezultatele serologice au arătat o rata de pozitivitate generală de 25.2% cu cea mai mare rată de pozitivitate la grupul de populaţie de peste 60 de ani 34,21% din totalul probelor de ser (63,6% pentru judeţul Tulcea şi 55.56% pentru Bucureşti). Concluzii. Confirmând ipoteza că FB îmbracă un caracter endemic în sudul României, bazată pe studiile noastre anterioare, studiul de faţă a adus argumente în sprijinul necesităţii de a introduce un program naţional de supraveghere în scopul cunoaşterii reale a incidenţei, managementului şi controlului FB în ţara noastră. După cunoştintele noastre, acesta este primul studiu de seroprevalenţă a anticorpilor specifici IgG Rickettsia conorii în România.

Mediterranean spotted fever (MSF) is endemic in Italy, where Rickettsia conorii subsp . conorii was thought to be the only pathogenic rickettsia and Rhipicephalus sanguineus the vector and main reservoir. R. conorii subsp . israelensis , which belongs to the R. conorii complex, is the agent of Israeli spotted fever (ISF); apart from Israel, it has also been found in Italy (Sicily and Sardinia) and in different regions of Portugal. We describe here two severe cases of ISF which occurred in otherwise healthy Italian adults. Their characteristics are analyzed and discussed in the light of other 91 cases found through a systematic review of international literature. [ABSTRACT FROM AUTHOR]

Introduction: Mediterranean spotted fever (MSF) is a zoonotic disease caused by Rickettsia conorii. In Spain, deficiencies in the official reporting result in misreporting of this disease. This study aims to describe the clinical and temporal-spatial characteristics of MSF hospitalizations between 1997 and 2014. Materials and methods: We performed a retrospective descriptive study using the Hospitalization Minimum Data Set (CMBD). All CMBD’s hospital discharges with ICD-9 CM code 082.1 were analyzed. Hospitalization rates were calculated and clinical characteristics were described. Spatial distribution of cases and their temporal behavior were also assessed. Results: A total of 4,735 hospitalizations with MSF diagnosis were recorded during the study period, out of which 62.2% were male, mean age of 48. Diabetes mellitus, alcohol dependence syndrome, and chronic liver disease occurred in 10.8%, 2.4% and 2.8% hospitalizations, respectively. The median annual hospitalization rate showed a decreasing trend from a maximum of 12.9 in 1997 to a minimum rate of 3.1 in 2014. Most admissions occurred during the summer, showing a significant annual seasonal behavior. Important regional differences were found. Discussion: Although MSF hospitalization rates have decreased considerably, it remains a public health problem due to its severity and economic impact. Therefore, it would be desirable to improve its oversight and surveillance. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to describe the epidemiological patterns of Mediterranean spotted fever (MSF) as well as its treatment and outcomes in children in south Jordan. Methodology: A retrospective observational study was conducted from June 2013 to December 2015. Data regarding demographics, clinical presentation, laboratory findings, treatment, and outcomes were collected. Results: In total, 35 male and 20 female patients (mean age: 6 years ± 3.6) were included. The incidence of MSF was 7.9 cases/100,000 inhabitants/year; MSF affected 89% of individuals in the summer, 74.5% of those living in a rural area with tent housing, and 100% of those who had contact with animals. All cases presented with fever, and 94.5% had a skin rash. Serological tests were positive in 87.2% of cases, and Rickettsia conorii (the Moroccan strain) was present in all positive cases. All cases had thrombocytopenia, but none had leukocytosis. Hyponatremia was present in 71% of cases, and 49%, 61.8%, and 72.7% had increased urea, alanine transaminase, and aspartate aminotransferase levels, respectively. Doxycycline was administered to all patients, with a cure rate of 96.4% and mortality rate of 3.6%. Conclusions: MSF caused by R. conorii (the Moroccan strain) is prevalent in Jordan, and contact with animals is the route of transmission. The patients' responses to doxycycline were excellent. A high index of suspicion, early diagnosis, and specific treatment considerably decrease mortality. MSF should be considered as a possible cause of febrile disease in those with a rash and in those living in rural areas. [ABSTRACT FROM AUTHOR]

Objective: To report a rare case of maculopapular rash on the scalp in a patient with Mediterranean spotted fever (MSF).Clinical Presentation and Intervention: A 58-year-old woman with breast cancer and chemotherapy-induced alopecia contracted MSF. Her clinical features were typical, except for a maculopapular rash covering the scalp. The diagnosis of MSF was confirmed by immunofluorescent assay. The disease had a favorable course and the patient was discharged in good condition.Conclusion: The rash on the scalp described in this report enriches our knowledge on the clinical characteristics of MSF. [ABSTRACT FROM AUTHOR]

Using a large, passive, clinic-based surveillance program in Iquitos, Peru, we characterized the prevalence of rickettsial infections among undifferentiated febrile cases and obtained evidence of pathogen transmission in potential domestic reservoir contacts and their ectoparasites. Blood specimens from humans and animals were assayed for spotted fever group rickettsiae (SFGR) and typhus group rickettsiae (TGR) by ELISA and/or PCR; ectoparasites were screened by PCR. Logistic regression was used to determine associations between patient history, demographic characteristics of participants and symptoms, clinical findings and outcome of rickettsial infection. Of the 2,054 enrolled participants, almost 2% showed evidence of seroconversion or a 4-fold rise in antibody titers specific for rickettsiae between acute and convalescent blood samples. Of 190 fleas (Ctenocephalides felis) and 60 ticks (Rhipicephalus sanguineus) tested, 185 (97.4%) and 3 (5%), respectively, were positive for Rickettsia spp. Candidatus Rickettsia asemboensis was identified in 100% and 33% of the fleas and ticks tested, respectively. Collectively, our serologic data indicates that human pathogenic SFGR are present in the Peruvian Amazon and pose a significant risk of infection to individuals exposed to wild, domestic and peri-domestic animals and their ectoparasites. [ABSTRACT FROM AUTHOR]

Background: Rickettsia africae, the etiological agent of African tick bite fever, is widely distributed in sub-Saharan Africa. Contrary to reports of its homogeneity, a localized study in Asembo, Kenya recently reported high genetic diversity. The present study aims to elucidate the extent of this heterogeneity by examining archived Rickettsia africae DNA samples collected from different eco-regions of Kenya. Methods: To evaluate their phylogenetic relationships, archived genomic DNA obtained from 57 ticks a priori identified to contain R. africae by comparison to ompA, ompB and gltA genes was used to amplify five rickettsial genes i.e. gltA, ompA, ompB, 17kDa and sca4. The resulting amplicons were sequenced. Translated amino acid alignments were used to guide the nucleotide alignments. Single gene and concatenated alignments were used to infer phylogenetic relationships. Results: Out of the 57 DNA samples, three were determined to be R. aeschlimanii and not R. africae. One sample turned out to be a novel rickettsiae and an interim name of “Candidatus Rickettsia moyalensis” is proposed. The bonafide R. africae formed two distinct clades. Clade I contained 9% of the samples and branched with the validated R. africae str ESF-5, while clade II (two samples) formed a distinct sub-lineage. Conclusions: This data supports the use of multiple genes for phylogenetic inferences. It is determined that, despite its recent emergence, the R. africae lineage is diverse. This data also provides evidence of a novel Rickettsia species, Candidatus Rickettsia moyalensis. [ABSTRACT FROM AUTHOR]

Mediterranean spotted fever (MSF) is an infectious disease endemic in the southern regions of Italy, with an incidence of about 400 cases/year. The bacteria responsible of the disease is Rickettsia conorii, transmitted to humans by Rhipicephalus sanguineus, the common dog tick. The infection usually manifests with a characteristic symptomatologic triad: fever, exanthema and the so called tache noire, which is the typical eschar at the site of the tick bite. Immunoglobulin M (IgM) and IgG enzymelinked immunosorbent assay and the gold standard micro-immunofluorescent assay, allow serological diagnosis. We report the case of a man suffering from MSF, whose atypical presentation and false-negative diagnostic tests delayed consistently diagnosis and therapy. Afterwards we review the literature about this topic. [ABSTRACT FROM AUTHOR]

Background: The Gulf Coast tick (Amblyomma maculatum) is an arthropod vector of Rickettsia parkeri, the causative agent of American boutonneuse fever and an infectious agent of public health significance. In this study, we evaluated the biological significance of the superoxide dismutases (SODs) of A. maculatum in hematophagy and R. parkeri colonization within the tick host. Methods: An RNA interference approach was used to measure the functional roles of tick SODs (Cu/Zn-SOD and Mn-SOD) in R. parkeri colonization of the tick vector. Total microbial load, R. parkeri infection rate, and compensatory mechanisms by tick genes were examined using quantitative polymerase chain reaction (PCR) and quantitative reverse-transcriptase PCR assays. SOD enzymatic activity assays and malondialdehyde (MDA) lipid peroxidation were employed to determine the redox states in the tick tissues. Results: Knockdown of the Cu/Zn-SOD gene caused the upregulation of Mn-SOD in transcript levels. Single and dual knockdowns of the SOD genes caused an increase in MDA lipid peroxidation while SOD enzymatic activities did not show a significant change. Mn-SOD knockdown resulted in a substantial increase in the microbial load; however, Cu/Zn-SOD transcript depletion prompted an upsurge in the midgut bacterial load, and significantly decreased the bacterial load in salivary gland tissues. Additionally, Cu/Zn-SOD transcript silencing led to significantly fewer R. parkeri DNA copy numbers in both tick tissues (midguts and salivary glands). Conclusions: SOD enzymes play an important function in the regulation of bacterial communities associated with tick vectors and also in the defense mechanisms against the damage caused by reactive oxygen species within the tick. Knockdown experiments increased the levels of total oxidative stress in ticks, revealing the interplay between SOD isozymes that results in the transcriptional regulation of tick antioxidants. Moreover, the tick's Cu/Zn-SOD aids in the colonization of R. parkeri in tick tissues providing evidence of A. maculatum's vectorial success for a spotted fever group rickettsial pathogen. [ABSTRACT FROM AUTHOR]

O presente artigo é uma atualização sobre a ocorrência e diagnóstico das riquetsioses existentes no Brasil e Portugal, com o objetivo de incentivar e incrementar a vigilância epidemiológica dessas doenças nos dois países. Realizou-se levantamento bibliográfico e foram apresentados dados não publicados de laboratórios e serviços de epidemiologia. Os resultados descreveram a ocorrência das riquetsioses no Brasil e Portugal, inclusive aquelas recém-descritas, advindas de riquétsias de potencial patogênico ainda incerto. Os métodos diagnósticos atualmente empregados foram discutidos. Como em outros países, as riquetsioses parecem assumir crescente importância em saúde pública. Relegadas a um plano secundário por muitas décadas, o interesse por essas infecções tem aumentado nos dois países, mas ainda carece de investigação para esclarecer seu real significado em saúde pública.The present study is an update review on the occurrence and diagnosis of rickettsial diseases in Brazil and Portugal, aiming at promoting their epidemiological surveillance in both countries. A literature review was carried out and unpublished data of laboratories and surveillance systems were presented. The results described the occurrence of rickettsial diseases and infections in Brazil and Portugal, including other new and still poorly understood rickettsial infections. Current diagnostic methods were discussed. As in many other countries, rickettsial diseases and infections seem to be an emerging public health problem. Treated as a minor problem for many decades, the interest in these infections has increased in both countries but further studies are needed to establish their role as a public health problem.

Objective: To describe a rare case of acute Q fever with tache noire.Clinical Presentation and Intervention: A 51-year-old man experienced acute Q fever showing tache noire, generally considered a pathognomonic sign of Mediterranean spotted fever (MSF) and MSF-like illness, but not a clinical feature of Q fever. The patient was treated with doxycycline 100 mg every 12 h.Conclusion: In the Mediterranean area, tache noire should be considered pathognomonic of MSF but it should not rule out Q fever. Clinical diagnosis should be supported by accurate laboratory diagnostic tests to guide proper management. [ABSTRACT FROM AUTHOR]

Bacteria of the genera Rickettsia and Orientia (family rickettsiaceae , order r ickettsiales ) cause rickettsioses worldwide, and are transmitted by lice, fleas, ticks and mites. In Europe, only Rickettsia spp. cause rickettsioses. With improvement of hygiene, the risk of louse-borne rickettsiosis (epidemic typhus) is low in Europe. Nevertheless, recrudescent form of Rickettsia prowazekii infection persists. There could be an epidemic typhus outbreak if a body lice epidemic occurs under unfavorable sanitary conditions. In Europe, endemic typhus or Rickettsia typhi infection, transmitted by rats and fleas, causes febrile illness. At the beginning of this century, flea-borne spotted fever cases caused by Rickettsia felis were diagnosed. Flea-borne rickettsiosis should be suspected after flea bites if fever, with or without rash, is developed. Tick-borne rickettsioses are the main source of rickettsia infections in Europe. Apart from Rickettsia conorii , the Mediterranean Spotted Fever (MSF) agent, other Rickettsia spp. cause MSF-like: Rickettsia helvetica , Rickettsia monacensis , Rickettsia massiliae or Rickettsia aeschlimannii . In the 1990s, two ‘new’ rickettsioses were diagnosed: Lymphangitis Associated Rickettsiosis (LAR) caused by Rickettsia sibirica mongolitimonae , and Tick-Borne Lymphadenopathy/ Dermacentor -Borne-Necrosis-Erythema-Lymphadenopathy/Scalp Eschar Neck Lymphadenopathy (TIBOLA/DEBONEL/SENLAT), caused by Rickettsia slovaca , Candidatus Rickettsia rioja and Rickettsia raoultii . Lastly, European reports about mite-borne rickettsiosis are scarce. [ABSTRACT FROM AUTHOR]

Mediterranean spotted fever has long been considered as a benign disease, but associated with septic shock and encephalitis, becomes malignant and potentially fatal. We present the case of a 77 year-old man admitted into the emergency room after tick bite in abdominal region and fever 39.6°C. After admission, a maculopapular rash appears with the achievement of palms and soles associated with behavioral changes and adult respiratory distress syndrome. In intensive care CSF examination revealed 6 nuclear elements and a protein level of 94 mg/dL, and electroencephalogram supported the existence of encephalitis. Rickettsia serology by indirect immunofluorescence showed IgG> 1/640 and IgM=1/80. Septic shock, responded to antibiotic therapy and patient was discharged to long term care. This case demonstrates that a benign and common disease suffered a poor outcome owing to the accelerated clinical course with acute onset and rapid deterioration. [ABSTRACT FROM AUTHOR]

Background: Rickettsia conorii is transmitted by Rhipicephalus sanguineus ticks and causes Mediterranean Spotted Fever (MSF) in humans. Although dogs are considered the natural host of the vector, the clinical and epidemiological significance of R. conorii infection in dogs remains unclear. The aim of this prospective study was to investigate whether Rickettsia infection causes febrile illness in dogs living in areas endemic for human MSF. Methods: Dogs from southern Italy with acute fever (n = 99) were compared with case-control dogs with normal body temperatures (n = 72). Serology and real-time PCR were performed for Rickettsia spp., Ehrlichia canis, Anaplasma phagocytophilum/A. platys and Leishmania infantum. Conventional PCR was performed for Babesia spp. and Hepatozoon spp. Acute and convalescent antibodies to R. conorii, E. canis and A. phagocytophilum were determined. Results: The seroprevalence rates at first visit for R. conorii, E. canis, A. phagocytophilum and L. infantum were 44.8%, 48.5%, 37.8% and 17.6%, respectively. The seroconversion rates for R. conorii, E. canis and A. phagocytophilum were 20.7%, 14.3% and 8.8%, respectively. The molecular positive rates at first visit for Rickettsia spp., E. canis, A. phagocytophilum, A. platys, L. infantum, Babesia spp. and Hepatozoon spp. were 1.8%, 4.1%, 0%, 2.3%, 11.1%, 2.3% and 0.6%, respectively. Positive PCR for E. canis (7%), Rickettsia spp. (3%), Babesia spp. (4.0%) and Hepatozoon spp. (1.0%) were found only in febrile dogs. The DNA sequences obtained from Rickettsia and Babesia PCRs positive samples were 100% identical to the R. conorii and Babesia vogeli sequences in GenBank®, respectively. Febrile illness was statistically associated with acute and convalescent positive R. conorii antibodies, seroconversion to R. conorii, E. canis positive PCR, and positivity to any tick pathogen PCRs. Fourteen febrile dogs (31.8%) were diagnosed with Rickettsia spp. infection based on seroconversion and/or PCR while only six afebrile dogs (12.5%) seroconverted (P = 0.0248). The most common clinical findings of dogs with Rickettsia infection diagnosed by seroconversion and/or PCR were fever, myalgia, lameness, elevation of C-reactive protein, thrombocytopenia and hypoalbuminemia. Conclusions: This study demonstrates acute febrile illness associated with Rickettsia infection in dogs living in endemic areas of human MSF based on seroconversion alone or in combination with PCR. [ABSTRACT FROM AUTHOR]

Summary Background Zoonoses are human infectious diseases caused by pathogens that primarily infect animals. Mediterranean Spotted Fever (MSF) represents one such example, affecting the Mediterranean region, in which household animals can be immune-carriers of infected ticks. Materials and methods We retrospectively analysed the incidence and the clinical and laboratory features of MSF caused by R.Conorii in children admitted to the Paediatric Operative Unit from 1987 to 2010, for persistent fever and generalised macular-popular erythematous lesions. Clinical, immunological and serological parameters of 55 cases of Rickettsia infections observed in children between 2 and 11 years of age were collected. Results We found an increasing incidence of MSF in childhood from 1987 to 2010. Diagnosis of MSF at the moment of hospital admission was done in 16 patients (29.09%). The presence of the typical Tache noire was observed in 16 cases out of 55 patients (29.09% of cases). We noticed a different representation of R. conorii antigens in serological testing over the time period of the study, corresponding to overall higher incidence rates for infection in the latter years. We also observed a higher incidence of infection in those years in which all four antigens were found positive at serum testing with respect to those years in which only two of the four antigens were observed (1987-1990: 0-16%; 2007-2010: 0.46%; P<0.005). Conclusions These changes in R. conorii antigenicity may be the cause of higher pathogenicity in this parasite, perhaps linked to increased immigration along with consequent changes in the epidemiology of infectious diseases in host countries. [ABSTRACT FROM AUTHOR]

Ticks are important vectors for Rickettsia spp. of the spotted fever group all around the world. Rickettsia conorii is the etiological agent of boutonneuse fever in the Mediterranean region and Africa. Tick identification was based on morphological features and further characterized using the 16S rRNA gene. The ticks were individually tested using pan- Rickettsia real-time-PCR for screening, and 23S-5S intergenic spacer region, 16S rDNA, gltA, sca4, ompB, and ompA genes were used to analyze the Rickettsia positive samples . Rickettsia conorii ssp. caspia was detected in tick collected in Zambia for the first time, thus demonstrating the possibility of the occurrence of human disease, namely Astrakhan fever, due to this Rickettsia ssp. in this region of Africa. The prevalence of R. conorii ssp. caspia was 0.06% (one positive tick out of 1465 tested ticks) and 0.07% (one positive tick out of 1254 tested Rh. sanguineus). [ABSTRACT FROM AUTHOR]

Scrub typhus is a commonly encountered rickettsial disease of the Indian subcontinent. In India, scrub typhus is being now reported from several areas where it was previously unknown. We report clinical profile and complications of an outbreak of scrub typhus in children from the north Indian state of Uttarakhand. a region not previously known to have endemic disease. We describe the results of a prospective observational study of children with scrub typhus, at a tertiary hospital during the year 2013. The diagnosis was confirmed serologically by an IgM ELISA test. Sixty-two children were diagnosed with scrub typhus. All presented with fever. Other common symptoms were vomiting (59%), facial swelling (53%), cough (24%), abdominal pain (35%), breathlessness (26%) and decreased urine output (21 %). High grade fever (> 101 °F) was recorded in 95% of the children. Other common signs observed in cases of scrub typhus were hepatomegaly (77%), splenomegaly (63%), edema (37%). tender lymphadenopathy (42%) and hypotension (35%). An eschar was observed in 23% of patients. Meningoencephalitis (30.6%), severe thrombocytopenia (27.4%), shock (17.7%), hepatitis (16.1%) and acute kidney injury (11.3%) were the most commonly encountered complications. Eighty-seven percent of children became afebrile within 48 hours of initiating an appropriate antibiotic. Median time to defervescence was 24 hours. The overall mortality rate was 6.4%. Pediatricians should keep a high index of suspicion for scrub typhus in any febrile child having a maculopapular rash, hepatosplenomegaly, lymphadenopathy, thrombocytopenia and features suggestive of capillary leak. Pending serological confirmation, early empirical therapy with doxycycline or azithromycin should be started, as delay in treatment would result in life threatening complications. [ABSTRACT FROM AUTHOR]

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We describe the geographical and temporal distribution of boutonneuse fever (MSF) cases in Romania in the 2000 to 2008 interval. All cases of boutonneuse fever recorded nationwide during the 2000 - 2008 interval came from the South of Romania and have exclusively evolved as sporadic cases. Highest incidence rate was registered in 2001 in Constanta (44.2% 000). Boutonneuse fever cases were recorded since May to October with a peak in August (38% of cases). Patients were living mainly in urban areas (80%). Most affected age group was 45-54 years (25%). Predominant clinical form of disease was the mild form (58%) and in 99.5% of cases the outcome was favorable. In the studied interval there were two deaths from boutonneuse fever. Of reported cases, 96% recognized the tick exposure by coming into contact with parasitized dogs (92%) or other domestic animals (3%). Exposure was most common at home (60%), but 4% of boutonneuse fever cases had professional exposure. The geographical distribution of boutonneuse fever cases reported in Southern Romania between 2000 - 2008 overlaps the vectors distribution, while temporal distribution was respecting the maximum activity interval of vectors. However, a trend of extending the reporting interval was noticed, as our cases reporting interval was starting from May compared with the June-September previous pattern. Sporadic case pattern evolution of boutonneuse fever cases demonstrated persistent natural reservoirs (foci) of infected ticks in Southern Romania. [ABSTRACT FROM AUTHOR]