Rocky Mountain spotted fever (RMSF), a tick-borne zoonosis caused by Rickettsia rickettsii, is among the deadliest of all infectious diseases. To identify the distribution of various genotypes of R. rickettsii associated with fatal RMSF, we applied molecular typing methods to samples of DNA extracted from formalin-fixed, paraffin-embedded tissue specimens obtained at autopsy from 103 case-patients from seven countries who died of RMSF. Complete sequences of one or more intergenic regions were amplified from tissues of 30 (29%) case-patients and revealed a distribution of genotypes consisting of four distinct clades, including the Hlp clade, regarded previously as a non-pathogenic strain of R. rickettsii. Distinct phylogeographic patterns were identified when composite case-patient and reference strain data were mapped to the state and country of origin. The phylogeography of R. rickettsii is likely determined by ecological and environmental factors that exist independently of the distribution of a particular tick vector.
Rickettsia rickettsii, Rickettsia parkeri, and Rickettsia akari are the most common causes of spotted fever group rickettsioses indigenous to the United States. Infected patients characteristically present with a maculopapular rash, often accompanied by an inoculation eschar. Skin biopsy specimens are often obtained from these lesions for diagnostic evaluation. However, a species-specific diagnosis is achieved infrequently from pathologic specimens because immunohistochemical stains do not differentiate among the causative agents of spotted fever group rickettsiae, and existing polymerase chain reaction (PCR) assays generally target large gene segments that may be difficult or impossible to obtain from formalin-fixed tissues.
This work describes the development and evaluation of a multiplex real-time PCR assay for the detection of these 3 Rickettsia species from formalin-fixed, paraffin-embedded (FFPE) skin biopsy specimens.
The multiplex PCR assay was specific at discriminating each species from FFPE controls of unrelated bacterial, viral, protozoan, and fungal pathogens that cause skin lesions, as well as other closely related spotted fever group Rickettsia species.
This multiplex real-time PCR demonstrates greater sensitivity than nested PCR assays in FFPE tissues and provides an effective method to specifically identify cases of Rocky Mountain spotted fever, rickettsialpox, and R. parkeri rickettsiosis by using skin biopsy specimens.
Rickettsia; real-time PCR; skin biopsies
We evaluated culture-negative, community-acquired endocarditis by using indirect immunofluorescent assays and molecular analyses for Bartonella spp. and Coxiella burnetii and found a prevalence of 19.6% and 7.8%, respectively. Our findings reinforce the need to study these organisms in patients with culture-negative, community-acquired endocarditis, especially B. henselae in cat owners.
endocarditis; Bartonella; Coxiella burnettii; Brazil; zoonoses; bacteria
A 65-year-old female with a history of multiple tick bites presented with fever and pancytopenia. Intracytoplasmic rickettsial morulae were detected on peripheral smear and bone marrow biopsy specimens, and PCR amplified Ehrlichia ewingii DNA from both specimens. To our knowledge, this is the first report of E. ewingii infection of human bone marrow.
Rickettsia parkeri Luckman (Rickettsiales: Rickettsiaceae), a member of the spotted fever group of Rickettsia, is the tick-borne causative agent of a newly recognized, eschar-associated rickettsiosis. Because of its relatively recent designation as a pathogen, few studies have examined the pathogenesis of transmission of R. parkeri to the vertebrate host. To further elucidate the role of tick feeding in rickettsial infection of vertebrates, nymphal Amblyomma maculatum Koch (Acari: Ixodidae) were fed on C3H/HeJ mice intradermally inoculated with R. parkeri (Portsmouth strain). The ticks were allowed to feed to repletion, at which time samples were taken for histopathology, immunohistochemistry (IHC), quantitative polymerase chain reaction (qPCR) for rickettsial quantification, and reverse transcriptase polymerase chain reaction(RT-PCR)for expression of Itgax, Mcp1, and Il1β. The group of mice that received intradermal inoculation of R. parkeri with tick feeding displayed significant increases in rickettsial load and IHC staining, but not in cytokine expression, when compared with the group of mice that received intradermal inoculation of R. parkeri without tick feeding. Tick feeding alone was associated with histopathologic changes in the skin, but these changes, and particularly vascular pathology, were more pronounced in the skin of mice inoculated previously with R. parkeri and followed by tick feeding. The marked differences in IHC staining and qPCR for the R. parkeri with tick feeding group strongly suggest an important role for tick feeding in the early establishment of rickettsial infection in the skin.
Rickettsia; Amblyomma; tick-borne; C3H/HeJ
Tick-borne rickettsioses are caused by obligate intracellular bacteria belonging to the spotted fever group of the genus Rickettsia. These zoonoses are among the oldest known vector-borne diseases. However, in the past 25 years, the scope and importance of the recognized tick-associated rickettsial pathogens have increased dramatically, making this complex of diseases an ideal paradigm for the understanding of emerging and reemerging infections. Several species of tick-borne rickettsiae that were considered nonpathogenic for decades are now associated with human infections, and novel Rickettsia species of undetermined pathogenicity continue to be detected in or isolated from ticks around the world. This remarkable expansion of information has been driven largely by the use of molecular techniques that have facilitated the identification of novel and previously recognized rickettsiae in ticks. New approaches, such as swabbing of eschars to obtain material to be tested by PCR, have emerged in recent years and have played a role in describing emerging tick-borne rickettsioses. Here, we present the current knowledge on tick-borne rickettsiae and rickettsioses using a geographic approach toward the epidemiology of these diseases.
Clinical reports of an eschar-associated rickettsiosis in the Paraná River Delta of Argentina prompted an evaluation of Amblyomma triste ticks in this region. When evaluated by PCR, 17 (7.6%) of 223 questing adult A. triste ticks, collected from 2 sites in the lower Paraná River Delta, contained DNA of Rickettsia parkeri.
Rickettsia parkeri; Amblyomma triste; rickettsiosis; Argentina; dispatch
Molecular techniques were used to characterize genetic features of Staphylococcus aureus in 66 fatal cases of pneumonia caused by S. aureus and influenza A or B viruses. Nucleic acids were extracted from formalin-fixed, paraffin-embedded tissues. The majority of cases revealed genetic markers for Panton-Valentine leukocidin, mecA, and spa type t008.
Geographic distribution of Rickettsia parkeri in its US tick vector, Amblyomma maculatum, was evaluated by PCR. R. parkeri was detected in ticks from Florida, Georgia, Kentucky, Mississippi, Oklahoma, and South Carolina, which suggests that A. maculatum may be responsible for additional cases of R. parkeri rickettsiosis throughout much of its US range.
Rickettsia parkeri; Amblyomma maculatum; spotted fever rickettsia; dispatch
We diagnosed invasive meningococcal disease by using immunohistochemical staining of embalmed tissue and PCR of vitreous humor from 2 men in New York City. Because vitreous humor is less subject than other body fluids to putrefaction, it is a good material for postmortem analysis.
Neisseria meningitidis; New York City; polymerase chain reaction; PCR; bacteria; New York
Although it has been >30 years since the eradication of smallpox, the unearthing of well-preserved tissue material in which the virus may reside has called into question the viability of variola virus decades or centuries after its original occurrence. Experimental data to address the long-term stability and viability of the virus are limited. There are several instances of well-preserved corpses and tissues that have been examined for poxvirus viability and viral DNA. These historical specimens cause concern for potential exposures, and each situation should be approached cautiously and independently with the available information. Nevertheless, these specimens provide information on the history of a major disease and vaccination against it.
smallpox; smallpox virus; poxvirus; viruses; variola; orthopoxvirus; vaccinia; viability; signatures; artifacts; historical relics; mummies
Whooping cough results from infection of the respiratory tract with Bordetella pertussis, and the secreted adenylate cyclase toxin (ACT) is essential for the bacterium to establish infection. Despite extensive study of the mechanism of ACT cytotoxicity and its effects over a range of concentrations in vitro, ACT has not been observed or quantified in vivo, and thus the concentration of ACT at the site of infection is unknown. The recently developed baboon model of infection mimics the prolonged cough and transmissibility of pertussis, and we hypothesized that measurement of ACT in nasopharyngeal washes (NPW) from baboons, combined with human and in vitro data, would provide an estimate of the ACT concentration in the airway during infection. NPW contained up to ∼108 CFU/ml B. pertussis and 1 to 5 ng/ml ACT at the peak of infection. Nasal aspirate specimens from two human infants with pertussis contained bacterial concentrations similar to those in the baboons, with 12 to 20 ng/ml ACT. When ∼108 CFU/ml of a laboratory strain of B. pertussis was cultured in vitro, ACT production was detected in 60 min and reached a plateau of ∼60 ng/ml in 6 h. Furthermore, when bacteria were brought into close proximity to target cells by centrifugation, intoxication was increased 4-fold. Collectively, these data suggest that at the bacterium-target cell interface during infection of the respiratory tract, the concentration of ACT can exceed 100 ng/ml, providing a reference point for future studies of ACT and pertussis pathogenesis.
During outbreaks of infectious diseases or in cases of severely ill patients, it is imperative to identify the causative agent. This report describes several events in which virus isolation and identification by electron microscopy were critical to initial recognition of the etiologic agent, which was further analyzed by additional laboratory diagnostic assays. Examples include severe acute respiratory syndrome coronavirus, and Nipah, lymphocytic choriomeningitis, West Nile, Cache Valley, and Heartland viruses. These cases illustrate the importance of the techniques of cell culture and electron microscopy in pathogen identification and recognition of emerging diseases.
Viruses; electron microscopy; cell culture; emerging diseases; SARS coronavirus; Nipah virus; lymphocytic choriomeningitis virus; West Nile virus; Cache Valley virus; Heartland virus
Death from Rocky Mountain spotted fever (RMSF) is preventable with prompt,
appropriate treatment. Data from two independent sources were analyzed to
estimate the burden of fatal RMSF and identify risk factors for fatal RMSF in
the United States during 1999–2007. Despite increased reporting of RMSF
cases to the Centers for Disease Control and Prevention, no significant changes
in the estimated number of annual fatal RMSF cases were found. American Indians
were at higher risk of fatal RMSF relative to whites (relative risk [RR]
= 3.9), and children 5–9 years of age (RR = 6.0) and adults
≥ 70 years of age (RR = 3.0) were also at increased risk relative
to other ages. Persons with cases of RMSF with an immunosuppressive condition
were at increased risk of death (RR = 4.4). Delaying treatment of RMSF
was also associated with increased deaths. These results may indicate a gap
between recommendations and practice.
Amblyomma maculatum is the primary vector for Rickettsia parkeri, a spotted fever group rickettsia (SFGR) and human pathogen. Cotton rats and quail are known hosts for larval and nymphal A. maculatum; however, the role of these hosts in the ecology of R. parkeri is unknown.
Cotton rats and quail were inoculated with low or high doses of R. parkeri (strain Portsmouth) grown in Vero cells to evaluate infection by R. parkeri in these two hosts species. Animals were euthanized 2, 4, 7, 10, and 14 days post-injection (dpi) and blood, skin, and spleen samples were collected to analyze by Vero cell culture and polymerase chain reaction (PCR). In a second trial, cotton rats and quail were inoculated with R. parkeri and nymphal A. maculatum ticks were allowed to feed on animals. Animals were euthanized on 14, 20, 28, 31, and 38 dpi and blood and tissues were collected for serology and PCR assays. Fed ticks were tested for R. parkeri by PCR and Vero cell culture.
Rickettsia parkeri was isolated in cell culture and detected by PCR in skin, blood, and spleen tissues of cotton rats in the initial trial 2, 4, and 7 dpi, but not in quail tissues. In the second trial, no ticks tested positive for R. parkeri by PCR or cell culture.
These studies demonstrate that viable R. parkeri rickettsiae can persist in the tissues of cotton rats for at least 7 days following subcutaneous inoculation of these bacteria; however, quail are apparently resistant to infection. Rickettsia parkeri was not detected in nymphal ticks that fed on R. parkeri-inoculated cotton rats or quail, suggesting an alternate route of transmission to naïve ticks.
Rickettsia parkeri; Experimental infection; Cotton rat; Quail
B.pertussis adenylate cyclase toxin (ACT) intoxicates cells by producing intracellular cAMP. B.pertussis outer membrane vesicles (OMV) contain ACT on their surface (OMV-ACT), but the properties of OMV-ACT were previously unknown. We found that B.pertussis in the lung from a fatal pertussis case contains OMV, suggesting an involvement in pathogenesis. OMV-ACT and ACT intoxicate cells with and without the toxin’s receptor CD11b/CD18. Intoxication by ACT is blocked by antitoxin and anti-CD11b antibodies, but not by cytochalasin-D; in contrast, OMV-ACT is unaffected by either antibody and blocked by cytochalasin-D. Thus OMV-ACT can deliver ACT by processes distinct from those of ACT alone.
Bordetella; outer membrane vesicles; adenylate cyclase toxin; cAMP; intoxication; endocytosis
Diagnosis of dengue virus (DENV) infection in fatal cases is challenging because of the frequent unavailability of blood or fresh tissues. For formalin-fixed, paraffin-embedded (FFPE) tissues immunohistochemistry (IHC) can be used; however, it may not be as sensitive and serotyping is not possible. The application of reverse transcription-polymerase chain reaction (RT-PCR) for the detection of DENV in FFPE tissues has been very limited. We evaluated FFPE autopsy tissues of 122 patients with suspected DENV infection by flavivirus and DENV RT-PCR, sequencing, and DENV IHC. The DENV was detected in 61 (50%) cases by RT-PCR or IHC. The RT-PCR and sequencing detected DENV in 60 (49%) cases (DENV-1 in 16, DENV-2 in 27, DENV-3 in 8, and DENV-4 in 6 cases). No serotype could be identified in three cases. The IHC detected DENV antigens in 50 (40%) cases. The RT-PCR using FFPE tissue improves detection of DENV in fatal cases and provides sequence information useful for typing and epidemiologic studies.
The Gulf Coast tick, Amblyomma maculatum, is a vector of Rickettsia parkeri, a recently identified human pathogen that causes a disease with clinical symptoms that resemble a mild form of Rocky Mountain spotted fever. Because the prevalence of R. parkeri infection in geographically distinct populations of A. maculatum is not fully understood, A. maculatum specimens collected as part of a tick and pathogen surveillance system in Fairfax County, Virginia, were screened to determine pathogen infection rates. Overall, R. parkeri was found in 41.4% of the A. maculatum that were screened. Additionally, the novel spotted fever group Rickettsia sp., tentatively named “Candidatus Rickettsia andeanae,” was observed for the first time in Virginia.
Amblyomma maculatum; Rickettsia andeanae; Rickettsia parkeri; Virginia
A 67 year-old Caucasian male from Arizona presented with indolent symptoms of intestinal obstruction and hydronephrosis, found at surgery to be caused by a mass involving the terminal ileum and cecum, extending into the posterior abdominal wall and obstructing the right ureter. Histopathology was diagnostic of basidiobolomycosis. PCR of tissue and sequencing identified the fungus as, Basidiobolus ranarum. During one year of posaconazole treatment, the residual mass shrank, hydronephrosis was relieved and peripheral eosinophilia resolved.
Rickettsia parkeri, a member of the spotted fever group Rickettsia, is the causative agent of American boutonneuse fever in humans. Despite the increased recognition of human cases, limited information is available regarding the infection of invertebrate and vertebrate hosts for this emerging tick-borne disease. Toward the development of a viable transmission model and to further characterize the pathology associated with R. parkeri infection, inbred mouse strains (A/J, BALB/c, C3H/HeJ, and C3H/HeN) were intravenously and intradermally inoculated with 105 low-passage-number R. parkeri (Portsmouth strain), and infection, gross pathology, and histopathology were scored. Additionally, a quantitative real-time PCR (qPCR) was performed to estimate rickettsial load in heart, lung, spleen, and liver tissues of infected mice at 19 days postinoculation. Of the A/J, BALB/c, and C3H/HeN mice, none displayed universal pathology consistent with sustained infection. Compared to age-matched control mice, the intravenously inoculated C3H/HeJ mice exhibited marked facial edema and marked splenomegaly upon gross examination, while the intradermally inoculated mice developed characteristic eschar-like lesions. The C3H/HeJ mice also exhibited the greatest concentrations of rickettsial DNA from heart, lung, liver, and spleen samples when examined by qPCR. The similarity of the pathology of human disease and sustained infection suggests that the C3H/HeJ strain of mice is a promising candidate for subsequent experiments to examine the tick transmission, dissemination, and pathology of R. parkeri rickettsiosis.
Marburg virus (family Filoviridae) causes sporadic outbreaks of severe hemorrhagic disease in sub-Saharan Africa. Bats have been implicated as likely natural reservoir hosts based most recently on an investigation of cases among miners infected in 2007 at the Kitaka mine, Uganda, which contained a large population of Marburg virus-infected Rousettus aegyptiacus fruit bats. Described here is an ecologic investigation of Python Cave, Uganda, where an American and a Dutch tourist acquired Marburg virus infection in December 2007 and July 2008. More than 40,000 R. aegyptiacus were found in the cave and were the sole bat species present. Between August 2008 and November 2009, 1,622 bats were captured and tested for Marburg virus. Q-RT-PCR analysis of bat liver/spleen tissues indicated ∼2.5% of the bats were actively infected, seven of which yielded Marburg virus isolates. Moreover, Q-RT-PCR-positive lung, kidney, colon and reproductive tissues were found, consistent with potential for oral, urine, fecal or sexual transmission. The combined data for R. aegyptiacus tested from Python Cave and Kitaka mine indicate low level horizontal transmission throughout the year. However, Q-RT-PCR data show distinct pulses of virus infection in older juvenile bats (∼six months of age) that temporarily coincide with the peak twice-yearly birthing seasons. Retrospective analysis of historical human infections suspected to have been the result of discrete spillover events directly from nature found 83% (54/65) events occurred during these seasonal pulses in virus circulation, perhaps demonstrating periods of increased risk of human infection. The discovery of two tags at Python Cave from bats marked at Kitaka mine, together with the close genetic linkages evident between viruses detected in geographically distant locations, are consistent with R. aegyptiacus bats existing as a large meta-population with associated virus circulation over broad geographic ranges. These findings provide a basis for developing Marburg hemorrhagic fever risk reduction strategies.
Marburg virus, like its close relative Ebola virus, can cause large outbreaks of hemorrhagic fever with case fatalities nearing 90%. For decades the identity of the natural reservoir was unknown. However, in 2007 Marburg viruses were isolated directly from Egyptian fruit bats (Rousettus aegyptiacus) that inhabited a Ugandan gold mine where miners were previously infected. Soon after, two tourists became infected with Marburg virus after visiting nearby Python Cave, a popular attraction in Queen Elizabeth National Park, Uganda. This cave also contained R. aegyptiacus bats (∼40,000 animals). These events prompted a long-term investigation of Python Cave to determine if, 1) R. aegyptiacus in the cave carried infectious Marburg virus genetically similar to that found in the tourists, and 2) what ecological factors might influence virus spillover to humans. In the study, we found that, 1) approximately 2.5% of the bat colony is actively infected at any one time and that virus isolates from bats are genetically similar to those from infected tourists, and 2) specific age groups of bats (juveniles∼six months of age) are particularly likely to be infected at specific times of the year that roughly coincide with historical dates of Marburg virus spillover into humans.
Amblyomma maculatum; co-infection; Mississippi; spotted fever group rickettsiae; Rickettsia parkeri; Candidatus Rickettsia andeanae; bacteria; Gulf Coast ticks; Rickettsia; United States; ticks; vector-borne infections
Lymphocytic choriomeningitis virus (LCMV) is carried by rodents. In very rare instances, it has been transmitted from person-to-person by organ transplantation. In 2011, a total of 14 organ recipients were infected with the virus, of which 11 died in the United States. The 4 most recent patients received organs from the same donor, which resulted in 2 deaths. Only after these 4 organ recipients became sick was it discovered that the donor had been exposed to rodents. Had this exposure been known before transplantation, the organ recipients may have been more closely monitored. Early diagnosis and treatment might have improved their chances of survival. Although organ donor screening reduces the risk for transmission of some viruses, it is not possible to screen for all possible viruses, including LCMV. For patients who get severely ill after receiving a transplant, clinicians should add LCMV infection to their list of possible causes.
Three clusters of organ transplant–associated lymphocytic choriomeningitis virus (LCMV) transmissions have been identified in the United States; 9 of 10 recipients died. In February 2011, we identified a fourth cluster of organ transplant–associated LCMV infections. Diabetic ketoacidosis developed in the organ donor in December 2010; she died with generalized brain edema after a short hospitalization. Both kidneys, liver, and lung were transplanted to 4 recipients; in all 4, severe posttransplant illness developed; 2 recipients died. Through multiple diagnostic methods, we identified LCMV infection in all persons, including in at least 1 sample from the donor and 4 recipients by reverse transcription PCR, and sequences of a 396-bp fragment of the large segment of the virus from all 5 persons were identical. In this cluster, all recipients developed severe illness, but 2 survived. LCMV infection should be considered as a possible cause of severe posttransplant illness.
LCMV; lymphocytic choriomeningitis; organ transplant; transplant-associated infection; organ donation; viruses; zoonoses
Leptospirosis is a zoonosis usually transmitted through contact with water or soil contaminated with urine from infected animals. Severe flooding can put individuals at greater risk for contracting leptospirosis in endemic areas. Rapid testing for the disease and large-scale interventions are necessary to identify and control infection. We describe a leptospirosis outbreak following severe flooding and a mass chemoprophylaxis campaign in Guyana.
From January–March 2005, we collected data on suspected leptospirosis hospitalizations and deaths. Laboratory testing included anti-leptospiral dot enzyme immunoassay (DST), immunohistochemistry (IHC) staining, and microscopic agglutination testing (MAT). DST testing was conducted for 105 (44%) of 236 patients; 52 (50%) tested positive. Four (57%) paired serum samples tested by MAT were confirmed leptospirosis. Of 34 total deaths attributed to leptospirosis, postmortem samples from 10 (83%) of 12 patients were positive by IHC. Of 201 patients interviewed, 89% reported direct contact with flood waters. A 3-week doxycycline chemoprophylaxis campaign reached over 280,000 people.
A confirmed leptospirosis outbreak in Guyana occurred after severe flooding, resulting in a massive chemoprophylaxis campaign to try to limit morbidity and mortality.