Rickettsia rickettsii Transmission by a Lone Star Tick, North Carolina

Only indirect or circumstantial evidence has been published to support transmission of Rickettsia rickettsii by Amblyomma americanum (lone star) ticks in North America. This study provides molecular evidence that A. americanum ticks can function, although most likely infrequently, as vectors of Rocky Mountain spotted fever for humans.


The Study
A 61-year-old man visited his physician in May 2010 and reported a history of fevers, myalgias, and headache. He had been free of symptoms until 3 days earlier, when he experienced nausea and dizziness. The following morning, he had chills and, later the same day, a fever of 38.4°C. Mild headache and myalgias accompanied his fever. His symptoms became progressively more severe during the next 2 days, and fever reached 39.4°C.
The patient resided on a farm in central North Carolina and had occasional exposure to ticks. Seven days before the onset of illness, he had removed an embedded tick from his right axilla. He estimated that the tick had been attached for 2-3 days. Clinical examination showed an eschar-like lesion at the site of the tick bite that appeared erythematous with a necrotic center (Figure). The patient's neutrophil count (2,553 cells/μL) was within low reference limits, accompanied by 5% band neutrophils, and mild thrombocytopenia (148,000 platelets/μL).
A tick-borne rickettsiosis or ehrlichiosis was suspected, and on the 4th day of illness, the patient was prescribed doxycycline, 100 mg 2×/d for 7 days. A maculopapular rash appeared the next morning, which predominantly involved the extremities but not the palms or soles. Fever resolved within 36 hours after beginning therapy, and the rash began to fade. Within 1 week after receiving doxycycline, the patient's symptoms and hematologic abnormalities had resolved (neutrophil count 4,378 cells/μL, no band neutrophils, and platelet count of 320,000/μL).
The patient provided the tick, which he had preserved in alcohol. The tick was identifi ed by using Herms's taxonomic key to Ixodes spp. ticks as a male lone star tick (A. americanum). Amplifi cation of the mitochondrial 16S rRNA gene confi rmed the tick species as A. americanum (417/418 bp, 99.8% homology with GenBank sequence L34313) (6).
Acute-phase serum was collected and stored until the convalescent-phase sample was obtained. Subsequently, seroconversion to R. rickettsii antigens was documented (reciprocal acute-phase titer 64, convalescent-phase titer 512 after 4 weeks). The patient did not seroconvert to Ehrlichia sp. antigens.
Rickettsia and Ehrlichia spp. PCRs were performed immediately. A previously described Rickettsia sp. PCR (primers 107F and 299R) was used to target a 209-212-bp fragment of a variable region of the outer membrane protein (omp) A gene, with species identifi cation determined by DNA sequencing (7). Amplicons were obtained from the patient's blood and from the tick. After direct sequencing and comparative alignment with GenBank sequences, identical R. rickettsii ompA sequences were obtained from the patient's blood and the tick (Table). PCR using 17-kDa primers (17k-5s and 17k-3) were used to further support infection with R. rickettsii (8). An amplicon with 100% homology (502/502 bp) with R. rickettsii 17-kDa surface antigen precursor (omp) gene, GenBank sequence AY281069, was obtained from the tick, and a 17-kDa amplicon was obtained from the patient's blood, but the DNA concentration was too low for sequence analysis. When the ompA and 17-kDa sequences from the tick and the ompA sequences from the patient's blood were compared with those from R. amblyommii, R. parkeri, and R. rickettsii, sequences matched R. rickettsii (Table). A PCR result for Ehrlichia spp. DNA was negative for samples taken from the tick and the patient.
According to CDC criteria, RMSF developed in this patient after he was bitten by an A. americanum tick. Evidence to support a diagnosis of RMSF included 1) amplifi cation of R. rickettsii DNA from the patient's blood sample at the onset of illness; 2) development of a prototypical rickettsial illness, including fever, rash, and thrombocytopenia 8 days after the tick was removed; 3) amplifi cation of R. rickettsii from the alcohol-stored tick removed by the patient; 4) documentation of seroconversion to R. rickettsii antigens; and 5) a rapid and appropriate clinical response after treatment with doxycycline. The patient was not aware of any other recently attached ticks. Therefore, infection by an A. americanum tick caused by preexisting rickettsemia in the patient seems unlikely.

Conclusions
On the basis of historical (4) and recent PCR data, transmission of R. rickettsii by A. americanum ticks is most likely an infrequent event in North America (9). However, in Central and South America, A. cajennense and A. imitator are suspected vectors of R. rickettsii (5). For clinical and surveillance purposes, it is essential to recognize that at least 3 tick genera, Dermacentor, Rhipicephalus, and Amblyomma, may be capable of transmitting RMSF in the eastern and south-central United States.
During the past decade, CDC has reported a progressive rise in cases of RMSF, particularly in the eastern United States (www.cdc.gov/ticks/diseases/rocky_mountain_ spotted_fever/statistics.html). During the same period, there has been a concurrent expansion in the geographic range of A. americanum ticks in conjunction with reports suggesting an increased frequency of attachment of this tick species to animals and humans (10,11). Although R. ambylommii is frequently amplifi ed from A. americanum ticks, no current evidence supports a pathogenic role for this Rickettsia sp. in animals or humans (11). In contrast, A. americanum ticks can transmit R. parkeri, which is a recently documented human pathogen, most often transmitted by the Gulf Coast tick (A. maculatum) (12,13). Eschars have occurred frequently in the limited number of R. parkeri cases published, whereas eschars, such as the one seen in this case, are uncommonly described in association with RMSF (14). Using the 180-bp ompA gene variable region we sequenced in this study, we differentiated R. rickettsii from R. parkeri and R. ambylommii by 9 and 21 bp, respectively. Substantial efforts to amplify R. parkeri by using multiple primer sets (data not shown) from the tick and the patient's blood were not successful.
Taken in the context of other recent studies, this report supports the hypothesis that lone star ticks can transmit