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.

Update on Tick-Borne Rickettsioses around the World: a Geographic Approach

During most of the 20th century, the epidemiology of tick-borne rickettsioses could be summarized as the occurrence of a single pathogenic rickettsia on each continent. An element of this paradigm suggested that the many other characterized and noncharacterized rickettsiae isolated from ticks were not pathogenic to humans. In this context, it was considered that relatively few tick-borne rickettsiae caused human disease. This concept was modified extensively from 1984 through 2005 by the identification of at least 11 additional rickettsial species or subspecies that cause tick-borne rickettsioses around the world. Of these agents, seven were initially isolated from ticks, often years or decades before a definitive association with human disease was established. We present here the tick-borne rickettsioses described through 2005 and focus on the epidemiological circumstances that have played a role in the emergence of the newly recognized diseases.

Tick-Borne Rickettsioses around the World: Emerging Diseases Challenging Old Concepts

In this article, literature records of argasid and ixodid ticks feeding on humans worldwide are provided in view of increased awareness of risks associated with tick bites. Ticks can cause paralyses, toxicoses, allergic reactions and are vectors of a broad range of viral, rickettsial, bacterial and protozoan pathogens. Approximately 12 argasid species (Argas and Ornithodos) are frequently found attached to humans who intrude into tick-infested caves and burrows. Over 20 ixodid tick species are often found on humans exposed to infested vegetation: four of these are Amblyomma species, 7 Dermacentor spp., 3 Haemaphysalis spp., 2 Hyalomma spp. and 6 Ixodes species. Personal protection methods, such as repellents and acaricide-impregnated clothing are advised to minimize contact with infected ticks. Acaricidal control of ixodid ticks is impractical because of their wide distribution in forested areas, but houses infested with soft ticks can be sprayed with acaricidal formulations. Attached ticks should be removed without delay. The best way is to grasp the tick as close to the skin as possible with fine tweezers and pull firmly and steadily without twisting. Finally, despite the fact that most people who are bitten destroy the offending tick in disgust, it is recommended that they preserve specimens in ethanol for taxonomic identification and detection of pathogens by molecular methods.

Ticks feeding on humans: a review of records on human-biting Ixodoidea with special reference to pathogen transmission.

Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.

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Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States.

Data on genus and infectious by Rickettsia were retrospectively compiled from the critical review literature regarding all countries in Latin America, Caribbean islands, Portugal and Spain. We considered all Rickettsia records reported for human and/or animal hosts, and/or invertebrate hosts considered being the vector. In a few cases, when no direct detection of a given Rickettsia group or species was available for a given country, the serologic method was considered. A total of 13 Rickettsia species have been recorded in Latin America and the Caribbean. The species with the largest number of country confirmed records were Rickettsia felis (9 countries), R. prowazekii (7 countries), R. typhi (6 countries), R. rickettsii (6 countries), R. amblyommii (5 countries), and R. parkeri (4 countries). The rickettsial records for the Caribbean islands (West Indies) were grouped in only one geographical area. Both R. bellii, R. akari, and Candidatus �R. andeane� have been recorded in only 2 countries each, whereas R. massiliae, R. rhipicephali, R.monteiroi, and R. africae have each been recorded in a single country (in this case, R. africae has been recorded in nine Caribbean Islands). For El Salvador, Honduras, and Nicaragua, no specific Rickettsia has been reported so far, but there have been serological evidence of human or/and animal infection. The following countries remain without any rickettsial records: Belize, Venezuela, Guyana, Surinam, and Paraguay. In addition, except for a few islands, many Caribbean islands remain without records. A total of 12 Rickettsia species have been reported in Spain and Portugal: R. conorii, R. helvetica, R. monacensis, R. felis, R. slovaca, R. raoultii, R. sibirica, R. aeschlimannii, R. rioja, R. massiliae, R. typhi, and R. prowazekii. Amongst these Rickettsia species reported in Spain and Portugal, only R. prowazekii, R. typhi, R. felis, and R. massiliae have also been reported in Latin America. This study summarizes the current state of art on the rickettsial distribution in Latin America, Caribbean, Spain and Portugal. The data obtained allow a better understanding on rickettsial epidemiology and distribution of vector ecology.

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Rickettsioses in Latin America, Caribbean, Spain and Portugal

We report three new rickettsiosis human cases in Uruguay. The three clinical cases presented clinical manifestations similar to previous reported cases of Rickettsia parkeri in the United States; that is mild fever (< 40 oC), malaise, headache, rash, inoculation eschar at the tick bite site, regional lymphadenopathy, and no lethality. Serological antibody-absorption tests with purified antigens of R. parkeri and Rickettsia rickettsii, associated with immunofluorescence assay indicated that the patients in two cases were infected by R. parkeri. Epidemiological and clinical evidences, coupled with our serological analysis, suggest that R. parkeri is the etiological agent of human cases of spotted fever in Uruguay, a disease that has been recognized in that country as cutaneous-ganglionar rickettsiosis.

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Serological evidence of Rickettsia parkeri as the etiological agent of rickettsiosis in Uruguay.

Three autochthonous cases of cutaneous-ganglionar rickettsiosis transmitted by dogs ticks (Amblyomma maculatum in one of them) are reported. Two of the three cases were undoubtely produced by Rickettsia conorii according to the results of the specific indirect immunofluorescence technique IEF-IgM anti R. conorii. A third case is included due to the clinical epidemiological similarity, the positive serum reactivity with Proteus O x 19 and the rapid response to tetracycline. Autochthonous rickettsiosis by R. conorii has not been previously registered in the American area what confers special interest to this communication. The search of the disease in the other countries of the region is suggested.

https://www.scielo.br/pdf/rimtsp/v32n5/a01v32n5.pdf

Rickettsiosis cutáneo ganglionar por Rickettsia conorii en el Uruguay

The first two Uruguayan cases of botryomycosis were diagnosed in white adult male patients with cutaneous lesions. Staphylococcus aureus was the etiologic agent in both cases. In one of them, however, Pseudomonas aeruginosa was also identified during relapse. General comments on diagnosis and pathogenesis of the disease are made.

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Ismael A. Conti-Diaz

Papers

Serological evidence of Rickettsia parkeri as the etiological agent of rickettsiosis in Uruguay.

Rickettsiosis cutáneo ganglionar por Rickettsia conorii en el Uruguay

Cutaneous botryomycosis. Report of the two first Uruguayan cases: relato dos dois primeiros casos no Uruguai

Cutaneous-gangliar rickettsiosis due to Rickettsia conorii in Uruguay.