Rita de Sousa

Mediterranean Spotted Fever in Portugal

Abstract: Mediterranean spotted fever (MSF) is the most important tick‐borne disease in Portugal. It is a notifiable disease and during 1989–2000 the annual incidence rate in Portugal was 9.8/105 inhabitants. Although recognized as a benign acute disease and treated mainly with ambulatory procedures, some cases are severe and fatalities have increased in the last few years. In 1997, MSF mortality became more evident in Beja, a Portuguese southern district, with a case fatality rate of 32.3% in hospitalized patients. Analysis of 55 variables regarding epidemiologic, clinical, laboratory, and therapeutic data of fatal and nonfatal MSF cases were compared to identify risk factors in 105 patients hospitalized in Beja District Hospital, between 1994 and 1998. It was statistically significant that the patients dying in 1997 were younger than those in other years. The risk of dying is statistically significant in those who presented with diabetes, vomiting, dehydration, and uremia. The interval between the onset of symptoms to administration of anti‐rickettsial therapy was the same for all patients. Therapy delay, reported by some authors to be associated with mortality of MSF, was not a risk factor in our study. The patients who died in 1997 died faster than those in other years. The variables studied could not explain the higher mortality rates observed in our study. Although one may speculate that the pathogenic strain of Israeli tick typhus, isolated in 1997, could be responsible for this increase of fatality rate, inherited patient factors might also be strongly associated with mortality.

Rickettsia sibirica isolation from a patient and detection in ticks, Portugal.

First R. sibirica–related strain is detected.

Ticks Parasitizing Wild Birds in Portugal: Detection of Rickettsia aeschlimannii, R. helvetica and R. massiliae

From January 2002 to December 2004, 152 ticks were collected from 40 wild birds recovered in Santo André Natural Reserve and Monsanto Forestal Park, Portugal mainland. Five ticks species were identified from 22 species of birds, and new host record were provided for some species. In addition, 32 (21%) ticks were screened by PCR to detect infections with agents belonging to order Rickettsiales: Anaplasma phagocytophilum, Ehrlichia chaffeensis, and Rickettsia spp. PCR amplicons were obtained in 5 (15.6%) tick samples. Rickettsia DNA exhibiting gltA sequences similar to those of Rickettsia aeschilimannii, R. helvetica and R. massiliae were identified in Hyalomma marginatum, Ixodes ventalloi and in Rhipicephalus turanicus, respectively. This is the first report of rickettsiae infections in ticks collected from wild birds in Portugal. Giving the results presented above wild birds play an important role in the maintenance and dissemination of several tick species and associated rickettsiae.

Host- and Microbe-Related Risk Factors for and Pathophysiology of Fatal Rickettsia conorii Infection in Portuguese Patients

BACKGROUND The pathophysiologic mechanisms that determine the severity of Mediterranean spotted fever (MSF) and the host-related and microbe-related risk factors for a fatal outcome are incompletely understood. METHODS This prospective study used univariate and multivariate analyses to determine the risk factors for a fatal outcome for 140 patients with Rickettsia conorii infection admitted to 13 Portuguese hospitals during 1994-2006 with documented identification of the rickettsial strain causing their infection. RESULTS A total of 71 patients (51%) were infected with the Malish strain of Rickettsia conorii, and 69 (49%) were infected with the Israeli spotted fever (ISF) strain. Patients were admitted to the intensive care unit (40 [29%]), hospitalized as routine inpatients (95[67%]), or managed as outpatients (5[4%]). Death occurred in 29 adults (21%). A fatal outcome was significantly more likely for patients infected with the ISF strain, and alcoholism was a risk factor. The pathophysiology of a fatal outcome involved significantly greater incidence of petechial rash, gastrointestinal symptoms, obtundation and/or confusion, dehydration, tachypnea, hepatomegaly, leukocytosis, coagulopathy, azotemia, hyperbilirubinemia, and elevated levels of hepatic enzymes and creatine kinase. Some, but not all, of these findings were observed more often in ISF strain-infected patients. CONCLUSIONS Although fatalities and similar clinical manifestations occurred among both groups of patients, the ISF strain was more virulent than the Malish strain. Multivariate analysis revealed that acute renal failure and hyperbilirubinemia were most strongly associated with a fatal outcome.

Intralesional Expression of mRNA of Interferon-γ, Tumor Necrosis Factor-α, Interleukin-10, Nitric Oxide Synthase, Indoleamine-2,3-Dioxygenase, and RANTES Is a Major Immune Effector in Mediterranean Spotted Fever Rickettsiosis

BACKGROUND The mechanisms of immunity to Rickettsia conorii that have been elucidated in mouse models have not been evaluated in human tissues. METHODS In this study, quantitative real-time polymerase chain reaction was used to determine the levels of expression of inflammatory and immune mediators in skin-biopsy samples collected from 23 untreated patients with Mediterranean spotted fever (MSF). RESULTS In all 23 patients, the levels of intralesional expression of mRNA of tumor necrosis factor (TNF)- alpha , interferon (IFN)- gamma , interleukin (IL)-10, RANTES, and indoleamine-2,3-dioxygenase (IDO), an enzyme involved in limiting rickettsial growth by tryptophan degradation, were higher than those in control subjects; 6 of the 23 patients had high levels of inducible nitric oxide synthase (iNOS), a source of microbicidal nitric oxide. Positive correlations between TNF- alpha , IFN- gamma , iNOS, IDO, and mild/moderate MSF suggest that type 1 polarization plays a protective role. Significantly higher levels of intralesional expression of IL-10 mRNA were inversely correlated with levels of intralesional expression of IFN- gamma mRNA and TNF- alpha mRNA. The mRNA-expression level of the chemokine RANTES was significantly higher in patients with severe MSF. CONCLUSION Mild/moderate MSF is associated with a strong and balanced intralesional proinflammatory and anti-inflammatory response, with a dominant type 1 immunity, whereas severe MSF is associated with increased expression of chemokine mRNA. Whether these factors are simply correlates of mild and severe MSF or contribute to antirickettsial immunity and pathogenesis remains to be determined.

Serological and molecular survey of Anaplasma species infection in dogs with suspected tickborne disease in Portugal

Fifty-five dogs with suspected tickborne disease were tested by immunofluorescence assay and PCR for Anaplasma phagocytophilum infection. Thirty (54·5 per cent) of the dogs were seropositive and five of them fulfilled the serological criteria for an active infection, with either seroconversion or a fourfold increase in antibody titres. Fragments of DNA of the expected size were detected by PCR in two seropositive and three seronegative dogs. However, direct amplicon sequencing failed to identify active A phagocytophilum infections, but revealed the presence of Anaplasma platys DNA in the PCR-positive animals.

Molecular detection of hemoprotozoa and Rickettsia species in arthropods collected from wild animals in the Burgos Province, Spain

Limited information on the presence of bacterial and hematozoan infections in parasitic arthropods from Spain is available. In an attempt to address this issue, the prevalence of Theileria, Babesia, Hepatozoon, and Rickettsia species was investigated by polymerase chain reaction plus sequencing. In a survey for zoonotic pathogens in ectoparasites, 42 wild animals (which included rodents, carnivores, Sciuridae, and Cervidae) were captured in Burgos (Spain). A total of 256 arthropods (including 107 ticks, 76 fleas, and 73 mites) were collected from these mammals. Molecular diagnostic results showed that (i) Rickettsia felis was found in fleas (two Ctenocephalides felis), (ii) Hepatozoon sp. infected some fleas (two Ctenophtalmus sp. and a DNA pool of Ceratophyllus sciurorum) and Acari (one Neotrombicula sp.), and (iii) Theileria annae was found in Ixodes ricinus and I. hexagonus (each a single infected specimen). All microorganisms and parasites were genetically identical to pathogens already described in Spain or elsewhere. Infected arthropods were recovered from beech marten, bank vole, squirrel, wood mouse, and red fox. Our findings emphasize the potential risk for transmission of rickettsias to humans (namely, R. felis) in Burgos, since C. felis is capable to seek out humans for feeding. No hemoprotozoa with proven significance as human pathogens were found in the survey. However, finding T. annae in ticks recovered from wild canids suggests possible links of sylvatic and domestic cycles for some Piroplasmida.

Riquetsioses no Brasil e Portugal: ocorrência, distribuição e diagnóstico

O presente artigo e uma atualizacao sobre a ocorrencia e diagnostico das riquetsioses existentes no Brasil e Portugal, com o objetivo de incentivar e incrementar a vigilância epidemiologica dessas doencas nos dois paises. Realizou-se levantamento bibliografico e foram apresentados dados nao publicados de laboratorios e servicos de epidemiologia. Os resultados descreveram a ocorrencia das riquetsioses no Brasil e Portugal, inclusive aquelas recem-descritas, advindas de riquetsias de potencial patogenico ainda incerto. Os metodos diagnosticos atualmente empregados foram discutidos. Como em outros paises, as riquetsioses parecem assumir crescente importância em saude publica. Relegadas a um plano secundario por muitas decadas, o interesse por essas infeccoes tem aumentado nos dois paises, mas ainda carece de investigacao para esclarecer seu real significado em saude publica.

Coinfections of Rickettsia slovaca and Rickettsia helvetica with Borrelia lusitaniae in ticks collected in a Safari Park, Portugal.

Borrelia and Rickettsia bacteria are the most important tick-borne agents causing disease in Portugal. Identification and characterization of these circulating agents, mainly in recreational areas, is crucial for the development of preventive measures in response to the gradually increasing exposure of humans to tick vectors. A total of 677 questing ticks including Dermacentor marginatus, Rhipicephalus sanguineus, Ixodes ricinus, Hyalomma lusitanicum, H. marginatum, and Haemaphysalis punctata were collected in a Safari Park in Alentejo, Portugal, to investigate the prevalences of infection and characterize Borrelia and Rickettsia species. From a total of 371 ticks tested by PCR for Borrelia burgdorferi sensu lato (s.l.), of which 247 were tested for Rickettsia, an infection prevalence of 18.3% was found for B. lusitaniae and 55.1% for Rickettsia spp. Sequence analysis of positive amplicons identified the presence of B. lusitaniae (18.3%), R. monacensis strain IRS3 (51.7%), and R. helvetica (48.3%) in I. ricinus. R. slovaca (41.5%), R. raoultii (58.5%), and also B. lusitaniae (21%) were identified in D. marginatus ticks. One (5.9%) H. lusitanicum was infected with B. lusitaniae, and R. massiliae was found in one Rhipicephalus sanguineus. Coinfection was found in 7 (20%) I. ricinus and 34 (23.3%) D. marginatus ticks. We report, for the first time, simultaneous infection with R. helvetica and B. lusitaniae and also R. slovaca, the agent of TIBOLA/DEBONEL, with B. lusitaniae. Additionally, 6 isolates of B. lusitaniae were established, and isolates of Rickettsia were also obtained for the detected species using tick macerates cultured in mammalian and mosquito cell lines. This report describes the detection and isolation of tick-borne agents from a Portuguese Safari Park, highlighting the increased likelihood of infection with multiple agents to potential visitors or staff.

The presence of eschars, but not greater severity, in portuguese patients infected with israeli spotted fever

Abstract: In Portugal, Mediterranean spotted fever (MSF) is caused by R. conorii Malish and Israeli spotted fever (ISF) strains. It has been suggested that the ISF strain isolated from patients with MSF causes different clinical manifestations compared to those caused by Malish strain, namely the absence of eschar and greater severity. The aim of this study was to analyze the presence or absence of eschar and of fatality in Portuguese patients infected with either Malish or ISF strain. Of 94 patients with a clinical diagnosis of MSF between 1994 to 2004, 47 were infected with Malish strain and 47 with ISF strain. Eschars were reported in 20 patients (49%) infected with Malish strain, and in 17 (39%) with ISF strain. The presence of eschar is not statistically associated to a greater extent with either R. conorii strain (P= 0.346). A total of 22 patients died, 9 infected with Malish strain and 13 infected with ISF strain, and no statistically significant difference was found (P= 0.330). This study showed that the concepts of absence of the eschar and greater severity in Israeli spotted fever infection should be revised.