Human Case of Rickettsia felis Infection, Taiwan

cattle sera (1,3), we cannot exclude the possibility that the S-1-HUN–like kobuvirus can cause viremia (and generalized infection) in swine. S-1-HUN–like virus may typically cause asymptomatic infections in swine. However, epidemiologic and molecular studies are required regarding the importance of this virus as a causative agent of some diseases of domestic pigs and related animals. Sequence analysis of the complete nucleotide and amino acid sequences of coding (L, P1, P2, and P3: 7,467 nt) and noncoding regions and the genetic organization strain indicate that S-1-HUN is a typical kobuvirus. Phylogenetic analysis shows that S-1-HUN strain is genetically included in the genus Kobuvirus but is distinct from Aichi and bovine kobuviruses. Porcine kobuvirus strain S-1-HUN is a candidate for a new, third species of the genus Kobuvirus. of cytopathic small round viruses with BS-C-1 cells from patients with gastroen-teritis. and characterization of a new species of kobuvirus associated with cattle. and molecular characterization of Aichi viruses from fecal specimens collected in Japan, Bangladesh, Thailand, and Viet-nam.lence and genetic diversity of Aichi virus strains in stool samples from community and hospitalized patients. evaluation of a primer pair that detects both Norwalk-and Sapporo-like cali-civiruses by RT-PCR. Evidence of the etiological predominance of norovirus in gastroenteritis outbreaks—emerging new variant and recombinant noroviruses in Hungary. MEGA4: molecular evolutionary genetic analysis (MEGA) software version 4.0. To the Editor: Rickettsia felis, the etiologic agent of fl ea-borne spotted fever, is carried by fl eas worldwide (1). In the past decade, several human cases of R. felis infection have been reported (1–3). Clinical symptoms and biological data for R. felis infections are similar to those for murine typhus and other rickettsial diseases, which makes clinical diagnosis diffi cult (2). Patients with R. felis infections may have common clinical manifestations, such as fever, headache, myalgia, macular rash, and elevated levels of liver enzymes (4,5). Reportable rickettsioses in Taiwan include scrub typhus, epidemic typhus, and murine typhus. Although there are no known human cases of infections caused by spotted fever group (SFG) rickettsiae in Taiwan, novel strains of SFG rickettsiae have been isolated as recently described (6,7). In addition, evidence for R. felis infections in cat and cat fl ea populations has been iden-tifi ed by using immunofl uorescence assay (IFA), PCR, and organism isolation (K.-H.Tsai et al., unpub. data). We report an indigenous human case of R. felis infection in Taiwan. In January 2005, a 27-year-old woman living in …


Human Case of Rickettsia felis Infection, Taiwan
To the Editor: Rickettsia felis, the etiologic agent of fl ea-borne spotted fever, is carried by fl eas worldwide (1). In the past decade, several human cases of R. felis infection have been reported (1)(2)(3). Clinical symptoms and biological data for R. felis infections are similar to those for murine typhus and other rickettsial diseases, which makes clinical diagnosis diffi cult (2). Patients with R. felis infections may have common clinical manifestations, such as fever, headache, myalgia, macular rash, and elevated levels of liver enzymes (4,5).
Reportable rickettsioses in Taiwan include scrub typhus, epidemic typhus, and murine typhus. Although there are no known human cases of infections caused by spotted fever group (SFG) rickettsiae in Taiwan, novel strains of SFG rickettsiae have been isolated as recently described (6,7). In addition, evidence for R. felis infections in cat and cat fl ea populations has been identifi ed by using immunofl uorescence assay (IFA), PCR, and organism isolation (K.-H.Tsai et al., unpub. data). We report an indigenous human case of R. felis infection in Taiwan.
In January 2005, a 27-year-old woman living in Fongshan City, Kaohsiung County, in southern Taiwan was admitted to Kaohsiung Medical University Hospital with a 4-day history of intermittent fever (37.8°C-38.0°C), chills, headache, and fatigue. Associated symptoms were frequent micturition and a burning sensation upon voiding. The patient was admitted with a possible urinary tract infection; urinalysis showed pyuria (leukocyte count 25-50/high-power fi eld), compatible with the clinical diagnosis. During the 6-day hospital stay, the patient received daily intravenous fi rstgeneration cephalosporin (cefazolin); gentamicin was given only on the 1970 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 12, December 2008 The opinions expressed by authors contributing to this journal do not necessarily refl ect the opinions of the Centers for Disease Control and Prevention or the institutions with which the authors are affi liated.
fi rst 3 days. She was discharged with a prescription for oral antimicrobial drugs (cephradine 500 mg every 6 h) to be taken for 7 days. Micturitionassociated symptoms subsided after treatment.
The patient also had headaches and glove-and-stocking numbness in both hands because of fever, but denied any associated rash and arthralgia. Although the patient did not recall any arthropod bites, she had noticed some stray dogs and cats nearby and rodents in the neighborhood surrounding her house. Because of acute polyneuropathy-like symptoms and exposure history, we prescribed oral doxycycline (100 mg every 12 hours) for 5 days as empirical therapy on the second day at the hospital, suspecting a zoonosis such as rickettsioses, Q fever, or leptospirosis. Headache and glove-and-stocking numbness subsided. Her blood sugar level and thyroid function were within normal limits. Chest radiograph, liver function, renal function, and levels of electrolytes were all normal.
Additionally, painful vesicles on the external genitalia appeared on the fourth day postadmission, and valacyclovir was administered for 5 days because of suspected infection with herpes simplex virus. The lesion subsided after valacyclovir treatment and the patient was discharged in good condition.
Patient whole blood specimens were collected on days 4 and 16 after the onset of fever and sent to the Taiwan Centers for Disease Control for laboratory diagnosis of rickettsial infection. For molecular diagnosis, DNA from the acute-phase blood sample (day 4) was analyzed by using the SYBR green-based real-time PCR specifi c for 17-kDa antigen, 60-kDa heatshock protein (groEL) gene, and outer membrane protein B (ompB) gene for typhus group and SFG rickettsiae and primers listed in the Table. Nucleotide sequences of real-time PCR products demonstrated 100% identity with 17-kDa antigen, groEL, and ompB genes of R. felis URRWXCal2. Real-time PCR results were negative for Orientia tsutsugamushi and Coxiella burnetii (8).
For serologic diagnosis, serum samples were tested for rickettsialspecifi c antibodies by IFA using whole cell antigens of R. felis isolated from the cat fl ea. The patient's serum (days 4 and 16) had immunoglobulin (Ig) G, IgA, and IgM titers of 160 and 2,560, respectively. The serum sample collected from R. felis-infected cat served as the positive control. Test results were negative for R. typhi, R. conorii, R. rickettsii, R. japonica, O. tsutsugamushi, and C. burnetii.
Absence of rash, eschar, and unawareness of arthropod bite may be easily overlooked in some patients with rickettsial infections. In this case, suspicion of rickettsial infection was based on exposure history and acute polyneuropathy, which responded quickly to doxycycline treatment. There are limited reports of rickettsioses with polyneuropathy, and none for cases of R. felis infection (9,10). It was hard to tell whether the urinary tract and herpes simplex virus infections were associated with an R. felis infection, but it is quite rare for 3 different infections to occur in a patient at the same time as isolated entities. The fi nding of a human case of infection and the existence of R. felis in cat fl eas highlights the need for further studies on fl ea-borne rickettsioses in Taiwan.

Bartonella spp. and Rickettsia felis in Fleas, Democratic Republic of Congo
To the Editor: Bartonella and Rickettsia species are pathogens of humans and domestic mammals that may be transmitted by fl eas and other arthropods. Rickettsia felis causes fl eaborne spotted fever in humans who come into contact with fl ea-infested domestic and peridomestic animals; worldwide distribution of this pathogen in ectoparasites and mammals makes it an emerging threat to human health (1,2). Likewise, species of the genus Bartonella are associated with an increasing array of human diseases, including trench fever, cat-scratch disease, and endocarditis in immunocompetent patients, and bacillary angiomatosis and peliosis hepatitis in immunocompromised patients (3)(4)(5). Although Bartonella spp. and R. felis appear to be globally distributed, their presence in the Democratic Republic of Congo (DRC) has not been previously documented.
Off-host Pulex irritans, Tunga penetrans, Ctenocephalides felis strongylus, Echidnophaga gallinacea, and Xenopsylla brasiliensis were collected in the Ituri district of northeastern DRC from March through April 2007, during an investigation of a plague outbreak. Our investigation area was limited to 4 villages: Djalusene and Kpandruma, which had confi rmed plague patients, and Wanyale and Zaa, which had several suspect cases (6).
We collected fl eas by using a kerosene lamp hung above a 45-cm diameter tray containing water (7). Captured fl eas were identifi ed using a dissecting microscope and standard morphologic keys, sorted into vials by species and locality, and preserved in 70% ethanol (7). Fleas were separated into 193 pools (2-5 fl eas per pool), triturated for 10 minutes; the resultant fl ea triturate was centrifuged at 3,000 rpm for 10 minutes to collect fl ea tissue. DNA was then obtained by using the DNeasy Blood and Tissue Kit (QIAGEN, Valencia, CA, USA).
Bartonella DNA was detected by PCR amplifying a 379-bp fragment of the citrate synthase gene (gltA) (8). For Rickettsia typhi and R. felis, a real-time multiplex PCR assay targeting a conserved fragment of gltA was used (unpub. data). All assays were run in duplicate, and positive and negative controls were included in all assays. Amplicons were purifi ed with the QIAquick PCR purifi cation kit (QIAGEN) and sequenced in both directions by using a BigDye sequencing kit (Applied Biosystems, Foster City, CA, USA) with the same primers used for PCR amplifi cation. Resultant sequences of Bartonella spp. were aligned with MegAlign by using the Clustal algorithm (DNASTAR, Inc., Madison, WI, USA), and compared with reference sequences obtained from GenBank.
Phylogenetic analysis indicated several Bartonella spp. in fl eas that were closely aligned with pathogenic Bartonella spp., including B. vinsonii, Candidatus B. rochalimaea, and B. clarridgeiae (data not shown). Moreover, Bartonella from 3 pools of P. irritans demonstrated only 1.8% to 2.4% divergence to B. vinsonii subspecies arupensis isolated from a human patient in Wyoming, USA. Likewise, sequences of Bartonella from