Septicaemia with Rickettsia helvetica in a patient with acute febrile illness, rash and myasthenia

doi:10.1016/j.jinf.2008.06.005

Journal of Infection

Volume 58, Issue 1, January 2009, Pages 79-82

https://doi.org/10.1016/j.jinf.2008.06.005 Get rights and content

Summary

The spotted fever rickettsia, Rickettsia helvetica, is mostly reported to present a flu-like self-limiting disease. In the present case, however, where the presence of R. helvetica in the blood was verified by PCR together with serologic evidence of infection, the patient presented a different clinical picture with acute febrile illness, rash and long-lasting myasthenia.

Introduction

The spotted fever rickettsia, Rickettsia helvetica, has been described in several European countries as well as Japan, but recently also reported in Thailand and Laos.1, 2 The tick Ixodes ricinus represents a potential vector and natural reservoir of R. helvetica, but in Japan the organism has also been isolated in other ticks.¹ The pathogenic role of R. helvetica is debated and remains a matter of controversy. But R. helvetica has been implicated in acute perimyocarditis, unexplained febrile illness, sarcoidosis and fever following an Ixodes holocyclus bite.1, 3, 4, 5 In Denmark, a serosurvey of 168 Danish patients seropositive for borreliosis, demonstrated that a total of 12.5% (21/168) tick-bitten patients were seropositive for R. helvetica, and four cases of seroconversion were identified.⁶ Recently, eight patients from France, Italy and Thailand were reported, with serological evidence of infection associated with mild fever, myalgia and no cutaneous rash.¹ In another study from Laos, serological analysis identified R. helvetica as the cause of fever in 2.6% of adults admitted to hospital, and in Sweden, a recent study shows that between 3 and 4.4% of patients with symptoms of infectious disease appearing after a tick bite had significant titres of antibodies to Rickettsia spp.2, 7 Most reported patients have presented a flu-like self-limiting mild febrile disease, sometimes with prolonged fever and less frequently with a rash.¹ Relevant studies using culture or PCR to confirm the causative role of R. helvetica in acute febrile illness are lacking, but in the present case, the presence of R. helvetica in the blood was verified by PCR together with serological evidence of infection. All other reported cases of SFG rickettsiosis, possibly caused by R. helvetica, have been diagnosed using serological criteria including MIF, Western blotting and cross-absorption methods, and the causative role of R. helvetica has not previously been verified by isolation or, as in the present case, by PCR during the phase of active illness. The patient studied here also presented a different clinical picture, with fever and muscular symptoms that were found to be more severe and intense than previously described for this agent, together with a rash and a slow and delayed recovery.

Section snippets

Case report

A 57-year-old, healthy and immunocompetent man, living on the eastern coast of Sweden, a tick-endemic area, was admitted to the Department of Infectious Diseases in Falun, Sweden, on May 17, 2003, with septicaemic fever, myalgias, arthralgias, severe headache and photophobia of unknown aetiology. A prominent neck muscle myalgia with subjective neck stiffness was one reason for initial suspicion of meningitis. The fever had begun on May 11 and 1–2 days after onset of illness, a 1–2-mm macular

Discussion

In addition to high fever, the patient had severe headache, subjective neck stiffness, photophobia and a macular rash involving the arms and legs, a clinical picture that differs from previous observations of R. helvetica. Owing to the prominent neck muscle myalgia, meningitis or meningoencephalitis was suspected, but could be ruled out. Notably, in African tick bite fever and Rocky Mountain spotted fever (RMSF), neck myalgia is thought to indicate a central nervous system affection. However,

Conclusion

The present case indicates that R. helvetica may also present a more acute febrile illness with rash and long-lasting muscular symptoms, and it is therefore important that this agent be taken into consideration in cases of FUO or symptoms of infection appearing after a tick bite. PCR may be a tool that makes early diagnosis possible.

Acknowledgement

This study was supported by grants from the Dalarna Research Foundation (project no. 99285) and the Center for Clinical Research Dalarna (project no. 420016).

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Association of Rickettsia helvetica with chronic perimyocarditis in sudden cardiac death
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Tick-borne rickettsioses around the world: emerging diseases challenging old concepts
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Emerging Infect Dis
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Ticks and tickborne bacterial diseases in humans: an emerging infectious threat
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Presence of Rickettsia helvetica in granulomatous tissue from patients with sarcoidosis
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Serological and molecular evidence of Rickettsia helvetica in Denmark
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Seroprevalence of Rickettsia spp. infection among tick-bitten patients and blood-donors in Sweden
Scand J Infect Dis
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Cited by (62)

Rickettsiosis in Denmark: A nation-wide survey
2023, Ticks and Tick-borne Diseases
Rickettsia helvetica has been reported at varying prevalences in Danish and other European Ixodes ricinus populations. Though apparently widespread and with reported cases of human infection, the significance of the bacteria as a threat to public health remains unclear. We present a nation-wide survey of rickettsia in ticks, roe deer and humans in Denmark.
Ticks were collected by flagging and screened for presence of rickettsial DNA by polymerase chain reaction. Sera from roe deer, hunters, neuroborreliosis patients and blood donors were analyzed for presence of anti-R. helvetica and Rickettsia felis antibodies by immunofluorescence microscopy.
The Rickettsia minimum infection rate in ticks was 4.9 % (367/973 pools positive, 7510 ticks in total), with 3.9 % in nymphs and 9.3 % in adults. Rickettsia helvetica accounted for 4.17 % and Rickettsia monacensis for 0.03 %, 0.6 % comprised non-differentiable rickettsial DNA. The prevalence of antibodies against R. helvetica was 2.8 % (9/319) in roe deer, while no hunters (n = 536) or blood donors (n = 181) were positive. The prevalence of anti-R. helvetica antibodies among Lyme neuroborreliosis patients was 6 % (3/47), where it co-occurred with Anaplasma phagocytophilum.
Based on our study autochthonous rickettsiosis is of limited concern to the public health in Denmark, but our finding of R. monacensis for the first time in Denmark illustrates the dynamic nature of tick-borne pathogens, emphasizing that continuous surveillance is necessary.
Tick-borne diseases under the radar in the North Sea Region
2023, Ticks and Tick-borne Diseases
The impact of tick-borne diseases caused by pathogens such as Anaplasma phagocytophilum, Neoehrlichia mikurensis, Borrelia miyamotoi, Rickettsia helvetica and Babesia species on public health is largely unknown.
Data on the prevalence of these pathogens in Ixodes ricinus ticks from seven countries within the North Sea Region in Europe as well as the types and availability of diagnostic tests and the main clinical features of their corresponding diseases is reported and discussed. Raised awareness is needed to discover cases of these under-recognized types of tick-borne disease, which should provide valuable insights into these diseases and their clinical significance.
Emerging tick-borne spotted fever group rickettsioses in the Balkans
2023, Infection, Genetics and Evolution
Citation Excerpt :
In contrast to the high prevalence of R. helvetica infection in ticks (Andersson et al., 2018; Szekeres et al., 2016) and frequent human exposure in endemic areas (Lindblom et al., 2016; Wolfel et al., 2017), the reports of clinical infection caused by this TBP in Europe are scarce. Rickettsia helvetica was reported as single causative agent in patients with acute febrile illness (Fournier et al., 2000), rash, myasthenia (Nilsson, 2009) and meningitis (Nilsson et al., 2010). Rickettsia helvetica infection in the tick feeding on human is found to be strongly associated with development of facial paralysis (Azagi et al., 2022).
The impact of tick-borne pathogens (TBPs) on human health has increased in the last decades, since the incidence of emerging and re-emerging infectious and zoonotic tick-borne diseases has increased worldwide. Tick-borne rickettsiae of the Spotted Fever group (SFGR) are considered as emerging pathogens that can infect humans and cause a variety of non-specific clinical symptoms. Here, we report nine cases of atypical tick-borne diseases (9/460; 1.95%) that occurred over a period of four months (from 15 April 2021 to 16 August 2021) in Serbia, from which five cases were classified as confirmed SFGR infection, two cases as probable SFGR infection and two cases as suspected SFGR infection. Within cases of confirmed SFGR infection, R. helvetica was detected as the causative agent in two cases. The most common clinical finding was non-expanding persistent circular redness, followed by eschar and enlargement of regional lymph nodes, and pain at lesion site. Rickettsia outer membrane protein B (ompB) and citrate synthase (gltA) gene fragments were amplified from clinical samples and ticks attached to patients and IgG reacting with Rickettsia conorii antigen were detected in sera samples of patients, which are highly suggestive of exposure to SFGR. Surveillance and monitoring of rickettsial diseases in Serbia should continue and extended to new areas due to the increasing trend of clinical infections caused by SFGR in the country.
Prevalence of zoonotic and non-zoonotic Rickettsia in horses: A systematic review and meta-analysis
2023, New Microbes and New Infections
In a broad sense, Rickettsiae are a group of microorganisms that can be transmitted mechanically or biologically to animals and humans. Rickettsioses are associated with hematic manifestations. Its prevalence in humans, dogs and other animals has been widely explored, but not in equine species.
To determine the prevalence of Rickettsia infection in horses.
A systematic review of the literature was carried out in five databases for the proportion of horses infected with Rickettsia, defined by molecular and immunological techniques. A meta-analysis was performed using a random-effects model to calculate the pooled prevalence and 95% confidence intervals (CI). The Cochran's Q test and the I² statistic were used to assess the between-study-heterogeneity.
The pooled prevalence of Rickettsia in equines was 37.0% (95% CI: 26.0%-47.0%), with significant heterogeneity among studies (I² = 98.12%). In the subgroup analysis, the prevalence of Rickettsia in horses was found to be 24.0% (95%CI: 10.0%-41.0%) for IFI, 47.0% (95%CI: 30.0%-64.0%) for IFA, 14.0% (95%CI: 11.0%-17.0%) for IFAT and 39.0% (95%CI: 0.0%-95.0%) for PCR.
There was a high prevalence of Rickettsia among horses, with some of the species being zoonotic, with their corresponding implications for humans, which increasingly are in close contact with equines, particularly horses and their ticks, posing a risk for spillover and transmission.
Emerging tick-borne pathogens in the Nordic countries: A clinical and laboratory follow-up study of high-risk tick-bitten individuals
2020, Ticks and Tick-borne Diseases
Citation Excerpt :
Moreover, studies have detected Bartonella henselae DNA in field-collected I. ricinus ticks but, thus far, no convincing clinical cases of cat-scratch disease, following a tick-bite, have been reported and the viability of ticks as vectors for this bacterium remains controversial (Telford and Wormser, 2010). All of the aforementioned microorganisms have been associated with infections in humans (Fehr et al., 2010; Nilsson, 2009; Nilsson et al., 2011, 2010; Uhnoo et al., 1992; von Loewenich et al., 2010). Despite this, with the exception of Bbsl and TBE virus, little is known about their pathogenic potential in a northern European setting and the clinical features of patients seeking medical care due to these infections remain to be fully elucidated.
Despite the presence of several microorganisms, other than Borrelia burgdorferi sensu lato (Bbsl) and TBE virus, in Ixodes ricinus ticks from the Nordic countries, data is lacking on their pathogenic potential in humans. In this study, we wanted to investigate the aetiology and clinical manifestations of tick-transmitted infections in individuals seeking medical care following a tick-bite.
The sampling frame was participants of a large-scale, prospective, multi-centre, follow-up study of tick-bitten volunteers recruited in Sweden, Finland and Norway in the years 2007–2015. Participants who sought medical care during the three-month follow-up period and from whom blood samples were collected during this healthcare visit (n = 92) were tested, using PCR, for exposure to spotted fever group (SFG) Rickettsia spp., Anaplasma phagocytophilum and Babesia spp. Moreover, 86 of these individuals had two serum samples, collected three months apart, tested serologically for six tick-borne microorganisms. The selected organisms – Bbsl, SFG rickettsiae, Anaplasma phagocytophilum, TBE virus, Babesia microti and Bartonella henselae – have all been detected in field-collected ticks from the Nordic countries. Medical records were reviewed and questionnaires were completed to determine clinical manifestations.
We found Lyme borreliosis to be the most common tick-transmitted infection as seen in 46 (54%) of the 86 participants with available medical records. Among the 86 participants with paired sera, serological or molecular evidence of recent exposure to other microorganisms than Bbsl could be demonstrated in eight (9%). Five participants (6%) exhibited serological evidence of recent concomitant exposure to more than one tick-borne microorganism. Clinical presentations were mild with one exception (TBE).
In conclusion, our data suggest a low risk of infection with tick-borne microorganisms, other than Bbsl, in immunocompetent tick-bitten persons from the examined regions, a low occurrence of co-infection and mostly mild or no overt clinical signs of infection in immunocompetent persons exposed to the studied agents.
Rickettsioses in Denmark: A retrospective survey of clinical features and travel history
2018, Ticks and Tick-borne Diseases
Citation Excerpt :
This low number of possible endemic rickettsioses in the hospital cohort is in line with several other studies, reporting asymptomatic seroconversion or mild, self-limiting disease during infection with R. helvetica, likely perceived as too mild for hospital referral by many primary care physicians (Fournier et al., 2004, 2000; Lindblom et al., 2016; Phongmany et al., 2006). Serious infections with R. helvetica have been described by a Swedish research group (Nilsson, 2009; Nilsson et al., 2011, 2010, 1999b). However, such reports are scarce and have, so far, not described cases in other geographical locations, outside of Sweden, where R. helvetica is also endemic in ticks.
Rickettsia spp. can be found across the globe and cause disease of varying clinical severity, ranging from life-threatening infections with widespread vasculitis to milder, more localized presentations. Vector and, to some degree, reservoir are hematophagous arthropods, with most species harboured by ticks. In Denmark, rickettsiae are known as a cause of imported travel-related infections, but are also found endemically in ticks across the country. Data are, however, lacking on the geographical origin and clinical features of diagnosed cases.
In this study, we have examined the travel history and clinical features of two groups of patients; 1) hospital-patients diagnosed with rickettsioses in the years 2010–2015 and 2) patients from primary health care (PHC) centers in Denmark having demonstrated anti-rickettsia antibodies in the years 2012–2015. The patients were identified using the Danish National Patient Registry (DNPR) and through the serological database at the State Serum Institute, where the laboratory diagnosis of rickettsioses is currently centralized. Data were collected for 86 hospital patients and 26 PHC center patients by reviewing hospital medical records and performing telephone interviews with PHC centers.
Of the hospital patients, 91% (78/86) had a history of international travel 14 days prior to symptom start, with most having imported their infection from southern Africa, South Africa in particular (65%), and presenting with a clinical picture most compatible with African tick-bite fever caused by R. africae. Only two patients presented with a CRP > 100 mg/L and no mortalities were reported. At the PHC centers, most patients presented with mild flu-like symptoms and had an unknown (50%) or no history (19%) of international travel, raising the possibility of endemic rickettsioses. In view of our findings, rickettsioses do not appear to constitute a major public health problem in Denmark, with most cases being imported infections and potential endemic cases presenting as mild infections.

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Journal of Infection

Summary

Introduction

Section snippets

Case report

Discussion

Conclusion

Acknowledgement

References (15)

Association of Rickettsia helvetica with chronic perimyocarditis in sudden cardiac death

Lancet

Tick-borne rickettsioses around the world: emerging diseases challenging old concepts

Clin Microbiol Rev

Rickettsial infections and fever, Vientiane, Laos

Emerging Infect Dis

Ticks and tickborne bacterial diseases in humans: an emerging infectious threat

Clin Infect Dis

Presence of Rickettsia helvetica in granulomatous tissue from patients with sarcoidosis

J Infect Dis

Serological and molecular evidence of Rickettsia helvetica in Denmark

Scand J Infect Dis

Seroprevalence of Rickettsia spp. infection among tick-bitten patients and blood-donors in Sweden

Scand J Infect Dis

Cited by (62)

Rickettsiosis in Denmark: A nation-wide survey

Tick-borne diseases under the radar in the North Sea Region

Emerging tick-borne spotted fever group rickettsioses in the Balkans

Prevalence of zoonotic and non-zoonotic Rickettsia in horses: A systematic review and meta-analysis

Emerging tick-borne pathogens in the Nordic countries: A clinical and laboratory follow-up study of high-risk tick-bitten individuals

Rickettsioses in Denmark: A retrospective survey of clinical features and travel history

Case reportSepticaemia with Rickettsia helvetica in a patient with acute febrile illness, rash and myasthenia

Summary

Introduction

Section snippets

Case report

Discussion

Conclusion

Acknowledgement

Lancet

Tick-borne rickettsioses around the world: emerging diseases challenging old concepts

Clin Microbiol Rev

Rickettsial infections and fever, Vientiane, Laos

Emerging Infect Dis

Ticks and tickborne bacterial diseases in humans: an emerging infectious threat

Clin Infect Dis

Presence of Rickettsia helvetica in granulomatous tissue from patients with sarcoidosis

J Infect Dis

Serological and molecular evidence of Rickettsia helvetica in Denmark

Scand J Infect Dis

Seroprevalence of Rickettsia spp. infection among tick-bitten patients and blood-donors in Sweden

Scand J Infect Dis

Case report
Septicaemia with Rickettsia helvetica in a patient with acute febrile illness, rash and myasthenia