• 1.

    Jensenius M et al. 2009. Multicenter GeoSentinel analysis of rickettsial diseases in international travelers, 1996–2008. Emerg Infect Dis 15: 17911798.

    • Search Google Scholar
    • Export Citation
  • 2.

    Jensenius M, Fournier PE, Kelly P, Myrvang B, Raoult D, 2003. African tick bite fever. Lancet Infect Dis 3: 557564.

  • 3.

    Kelly P, Lucas H, Beati L, Yowell C, Mahan S, Dame J, 2010. Rickettsia africae in Amblyomma variegatum and domestic ruminants on eight Caribbean islands. J Parasitol 96: 10861088.

    • Search Google Scholar
    • Export Citation
  • 4.

    Parola P et al. 2013. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev 26: 657702.

  • 5.

    Mendelson M, Davis XM, Jensenius M, Keystone JS, von Sonnenburg F, Hale DC, Burchard GD, Field V, Vincent P, Freedman DO; GeoSentinel Surveillance Network, 2010. Health risks in travelers to South Africa: the GeoSentinel experience and implications for the 2010 FIFA world cup. Am J Trop Med Hyg 82: 991995.

    • Search Google Scholar
    • Export Citation
  • 6.

    Jensenius M, Parola P, Raoult D, 2006. Threats to international travellers posed by tick-borne diseases. Travel Med Infect Dis 4: 413.

  • 7.

    Rahman A, Tegnell A, Vene S, Giesecke J, 2003. Rickettsioses in Swedish travellers, 1997–2001. Scand J Infect Dis 35: 247250.

  • 8.

    Roch N, Epaulard O, Pelloux I, Pavese P, Brion JP, Raoult D, Maurin M, 2008. African tick bite fever in elderly patients: 8 cases in French tourists returning from South Africa. Clin Infect Dis 47: e28e35.

    • Search Google Scholar
    • Export Citation
  • 9.

    Bellini C, Monti M, Potin M, Dalle Ave A, Bille J, Greub G, 2005. Cardiac involvement in a patient with clinical and serological evidence of African tick-bite fever. BMC Infect Dis 5: 90.

    • Search Google Scholar
    • Export Citation
  • 10.

    Raoult D et al. 2001. Rickettsia africae, a tick-borne pathogen in travelers to sub-Saharan Africa. N Engl J Med 344: 15041510.

  • 11.

    Jensenius M, Fournier PE, Vene S, Hoel T, Hasle G, Henriksen AZ, Hellum KB, Raoult D, Myrvang B; Norwegian African Tick Bite Fever Study Group, 2003. African tick bite fever in travelers to rural sub-Equatorial Africa. Clin Infect Dis 36: 14111417.

    • Search Google Scholar
    • Export Citation
  • 12.

    McQuiston JH, Paddock CD, Singleton J Jr., Wheeling JT, Zaki SR, Childs JE, 2004. Imported spotted fever rickettsioses in United States travelers returning from Africa: a summary of cases confirmed by laboratory testing at the Centers for Disease Control and Prevention, 1999–2002. Am J Trop Med Hyg 70: 98101.

    • Search Google Scholar
    • Export Citation
  • 13.

    McDonald JC, MacLean JD, McDade JE, 1988. Imported rickettsial disease: clinical and epidemiologic features. Am J Med 85: 799805.

  • 14.

    Neal S, Cieslak P, Hedberg K, Fleming D, 1998. African tick-bite fever among international travelers–Oregon, 1998. MMWR Morb Mortal Wkly Rep 47: 950952.

    • Search Google Scholar
    • Export Citation
  • 15.

    Smoak BL, McClain JB, Brundage JF, Broadhurst L, Kelly DJ, Dasch GA, Miller RN, 1996. An outbreak of spotted fever rickettsiosis in U.S. Army troops deployed to Botswana. Emerg Infect Dis 2: 217221.

    • Search Google Scholar
    • Export Citation
  • 16.

    U.S. Departmenf of Commerce, 2016. 2015 United States Resident Travel Abroad. Available at: http://tinet.ita.doc.gov/outreachpages/download_data_table/2015_US_Travel_Abroad.pdf. Accessed April 4, 2018.

  • 17.

    U.S. Department of Commerce, 2005. 2004 Profile of U.S. Resident Traveler Visiting Overseas Destinations Reported from: Survey of International Air Travelers. Available at: http://tinet.ita.doc.gov/view/f-2004-101-001/index.html. Accessed April 4, 2018.

  • 18.

    Kato CY, Chung IH, Robinson LK, Austin AL, Dasch GA, Massung RF, 2013. Assessment of real-time PCR assay for detection of Rickettsia spp. and Rickettsia rickettsii in banked clinical samples. J Clin Microbiol 51: 314317.

    • Search Google Scholar
    • Export Citation
  • 19.

    Sumner JW, Durden LA, Goddard J, Stromdahl EY, Clark KL, Reeves WK, Paddock CD, 2007. Gulf Coast ticks (Amblyomma maculatum) and Rickettsia parkeri, United States. Emerg Infect Dis 13: 751753.

    • Search Google Scholar
    • Export Citation
  • 20.

    Paddock CD et al. 2014. Phylogeography of Rickettsia rickettsii genotypes associated with fatal Rocky Mountain spotted fever. Am J Trop Med Hyg 91: 589597.

    • Search Google Scholar
    • Export Citation
  • 21.

    Renvoise A, Rolain JM, Socolovschi C, Raoult D, 2012. Widespread use of real-time PCR for rickettsial diagnosis. FEMS Immunol Med Microbiol 64: 126129.

    • Search Google Scholar
    • Export Citation
  • 22.

    Paddock CD et al. 1999. Hidden mortality attributable to Rocky Mountain spotted fever: immunohistochemical detection of fatal, serologically unconfirmed disease. J Infect Dis 179: 14691476.

    • Search Google Scholar
    • Export Citation
  • 23.

    Paddock CD, Koss T, Eremeeva ME, Dasch GA, Zaki SR, Sumner JW, 2006. Isolation of Rickettsia akari from eschars of patients with rickettsialpox. Am J Trop Med Hyg 75: 732738.

    • Search Google Scholar
    • Export Citation
  • 24.

    UNWTO, 2016. UNTWO Tourism Highlights, 2016 Edition. Madrid, Spain: World Tourism Organization.

  • 25.

    Bohaty BR, Hebert AA, 2015. Images in clinical medicine: African tick-bite fever after a game-hunting expedition. N Engl J Med 372: e14.

  • 26.

    Albizuri Prado F, Sanchez A, Feito M, Mayor A, Rodriguez A, de Lucas R, 2017. Fever and multiple eschars after an African safari: report of three cases. Pediatr Dermatol 34: e179e181.

    • Search Google Scholar
    • Export Citation
  • 27.

    Jelinek T, Loscher T, 2001. Clinical features and epidemiology of tick typhus in travelers. J Travel Med 8: 5759.

  • 28.

    Rolain JM, Jensenius M, Raoult D, 2004. Rickettsial infections—a threat to travellers? Curr Opin Infect Dis 17: 433437.

  • 29.

    Maina AN et al. 2014. High prevalence of Rickettsia africae variants in Amblyomma variegatum ticks from domestic mammals in rural western Kenya: implications for human health. Vector Borne Zoonotic Dis 14: 693702.

    • Search Google Scholar
    • Export Citation
  • 30.

    Socolovschi C, Huynh TP, Davoust B, Gomez J, Raoult D, Parola P, 2009. Transovarial and trans-stadial transmission of Rickettsiae africae in Amblyomma variegatum ticks. Clin Microbiol Infect 15 (Suppl 2): 317318.

    • Search Google Scholar
    • Export Citation
  • 31.

    Keller C et al. 2016. High detection rate of Rickettsia africae in Amblyomma variegatum but low prevalence of anti-rickettsial antibodies in healthy pregnant women in Madagascar. Ticks Tick Borne Dis 7: 6065.

    • Search Google Scholar
    • Export Citation
  • 32.

    Nakao R, Qiu Y, Igarashi M, Magona JW, Zhou L, Ito K, Sugimoto C, 2013. High prevalence of spotted fever group rickettsiae in Amblyomma variegatum from Uganda and their identification using sizes of intergenic spacers. Ticks Tick Borne Dis 4: 506512.

    • Search Google Scholar
    • Export Citation
  • 33.

    Fournier PE, Jensenius M, Laferl H, Vene S, Raoult D, 2002. Kinetics of antibody responses in Rickettsia africae and Rickettsia conorii infections. Clin Diagn Lab Immunol 9: 324328.

    • Search Google Scholar
    • Export Citation
  • 34.

    Clements ML, Dumler JS, Fiset P, Wisseman CL Jr., Snyder MJ, Levine MM, 1983. Serodiagnosis of Rocky Mountain spotted fever: comparison of IgM and IgG enzyme-linked immunosorbent assays and indirect fluorescent antibody test. J Infect Dis 148: 876880.

    • Search Google Scholar
    • Export Citation
  • 35.

    Biggs HM et al. 2016. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis—United States. MMWR Recomm Rep 65: 144.

    • Search Google Scholar
    • Export Citation
  • 36.

    Socolovschi C, Renvoise A, Brouqui P, Parola P, Raoult D, 2012. The use of eschar swabs for the diagnosis of African tick-bite fever. Ticks Tick Borne Dis 3: 361363.

    • Search Google Scholar
    • Export Citation
  • 37.

    Philip RN, Casper EA, Ormsbee RA, Peacock MG, Burgdorfer W, 1976. Microimmunofluorescence test for the serological study of Rocky Mountain spotted fever and typhus. J Clin Microbiol 3: 5161.

    • Search Google Scholar
    • Export Citation
  • 38.

    Mouffok N, Socolovschi C, Benabdellah A, Renvoise A, Parola P, Raoult D, 2011. Diagnosis of rickettsioses from eschar swab samples, Algeria. Emerg Infect Dis 17: 19681969.

    • Search Google Scholar
    • Export Citation
  • 39.

    Bechah Y, Socolovschi C, Raoult D, 2011. Identification of rickettsial infections by using cutaneous swab specimens and PCR. Emerg Infect Dis 17: 8386.

    • Search Google Scholar
    • Export Citation
  • 40.

    Strand A, Paddock CD, Rinehart AR, Condit ME, Marus JR, Gilliani S, Chung IH, Fowler VG Jr., 2017. African tick bite fever treated successfully with rifampin in a patient with doxycycline intolerance. Clin Infect Dis 65: 15821584.

    • Search Google Scholar
    • Export Citation
 
 
 

 

 

 

 

 

 

Diagnosis of Spotted Fever Group Rickettsioses in U.S. Travelers Returning from Africa, 2007–2016

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  • 1 Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
  • | 2 Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
  • | 3 Epidemiology Elective Program, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia

Spotted fever group rickettsioses (SFGRs), such as African tick bite fever (ATBF), are among the most commonly diagnosed diseases for ill travelers returning from southern Africa. We summarized demographic, clinical, and diagnostic features of imported SFGR cases in U.S. travelers returning from Africa who had laboratory specimens submitted to the Centers for Disease Control and Prevention. Diagnosis of SFGR was performed by indirect immunofluorescence antibody assay, immunohistochemical staining, polymerase chain reaction (PCR), or culture. Cases were defined as probable SFGR, confirmed SFGR, or confirmed ATBF. Clinical and epidemiological categorical variables were described as counts and proportions; continuous variables were described using geometric mean titers, median, and range. One hundred and twenty-seven patients satisfied laboratory criteria for confirmed or probable SFGR. Fever was the most common symptom (N = 88; 69%), followed by ≥ 1 eschars (N = 70; 55%). Paired serums were submitted for 36 patients (28%); 12 patients (33%) had nonreactive initial serum sample but converted to a titer ≥ 64 with the convalescent sample. Twenty-seven patients (21%) had infection with Rickettsia africae based on PCR analysis of eschar swab (N = 8) or biopsy (N = 23). Fifteen patients had eschar biopsy or swab samples and serum sample(s) submitted together; 9 (60%) had PCR-positive eschar results and nonreactive acute serology. Health-care providers should consider SFGR when evaluating patients for a febrile illness with eschar and compatible foreign travel history. Polymerase chain reaction testing of eschar biopsies or swabs provides a confirmed diagnosis in early stages of disease; eschar swabs or biopsies are an underutilized diagnostic technique.

Author Notes

Financial support: This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ addresses: Cara C. Cherry, Cecilia Y. Kato, and Christopher D. Paddock, Rickettsial Zoonoses Branch, Division of Vector-borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: imv5@cdc.gov, hex0@cdc.gov, and cdp9@cdc.gov. Amy M. Denison, Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: crk6@cdc.gov. Katrina Thornton, Penfield Veterinary Hospital, Rochester, NY, E-mail: k.m.thornton424@gmail.com.

Address correspondence to Cara C. Cherry, Rickettsial Zoonoses Branch, Division of Vector-borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop C17, Atlanta, GA 30329. E-mail: ccherry@cdc.gov
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