Rickettsia conorii Indian Tick Typhus Strain and R. slovaca in Humans, Sicily

Suggested citation for this article: Torina A, Fernandez de Mera IG, Alongi A, Mangold AJ, Blanda V, Scarlata F, et al. Rickettsia conorii Indian tick typhus strain and R. slovaca in humans, Sicily [letter]. Emerg Infect Dis [serial on the Internet] 2012 Jun [date cited]. http://dx.doi.org/10.3201/eid1806.110966

. Pathogens in the Rickettsia conorii complex are known to cause Mediterranean spotted fever (MSF) (R. conorii Malish strain), Astrakhan fever (R. conorii Astrakhan strain), Israeli spotted fever (R. conorii Israeli spotted fever strain), and Indian tick typhus (R. conorii Indian tick typhus strain) in the Mediterranean basin and Africa, southern Russia, the Middle East, and India and Pakistan, respectively (2). These rickettsioses share some clinical features, such as febrile illness and generalized cutaneous rash, and are transmitted to humans by Rhipicephalus spp. ticks (2).
MSF is endemic to Sicily (Italy); fatal cases occur each year, and the prevalence of R. conorii in dogs is high (3)(4)(5)(6). Recently, R. conorii Malish strain and R. conorii Israeli spotted fever strain were confi rmed in humans in Sicily in whom MSF was diagnosed (4), which suggests that other R. conorii strains might be present and diagnosed as causing MSF. The rickettsiae within the R. conorii complex, which are relevant for the study of bacterial evolution and epidemiology, can be properly identifi ed only by appropriate genetic analyses.
We analyzed 15 blood and 19 inoculation eschar samples collected during 2005-2009 from 31 patients in Palermo Province and 2 in Catania Province, none of whom had recently traveled. None were severely ill, but all 33 had clinical manifestations and laboratory results compatible with MSF: 1-week incubation after tick bite, fever, headache, myalgia, papulonodular rash that started on the upper limbs and spread centripetally with or without tache noire, and detection of antibody titers >180 to R. conorii by indirect immunofl uorescence antibody test (bioMérieux, Marcy L'Etoile, France).
Total DNA was extracted by using the GeneElute Mammalian Genomic DNA Miniprep Kit (Sigma-Aldrich, Milan, Italy) and used to analyze Rickettsia spp. sequences by PCR, cloning, and sequence analysis of the amplicons. At least 3 clones were sequenced for each amplicon. Genes targeted by PCR included ATP synthase α subunit (atpA) (7), heatshock protein 70 (dnaK) (7), outer membrane protein A (ompA) (primers Rr190.70p and 190-701 [8]), outer membrane protein B (ompB) (primers rompBSFGIF and rompBSFG/TGIR [9]), citrate synthase (gltA) (2), and 17-kDa protein (primers TZ15-19 and TZ16-20 [6]). Nucleotide sequence identity to reference strains (2), multilocus analysis by atpA-dnaK-ompA-ompB-gltA-17-kDa and ompA-ompB sequences and in silico PstI-RsaI restriction analysis of ompA sequences (8)  Multilocus sequence analysis (Figure, panel A) and in silico PstI-RsaI restriction analysis of ompA sequences also confi rmed the identity Figure. Multilocus sequence analysis of Rickettsia spp. Evolutionary history was inferred by using the neighbor-joining method for ATP synthase α subunit (atpA)-heat shock protein 70 (dnaK)-outer membrane protein A (ompA)-ompB-citrate synthase (gltA)-17-kDa (A) and ompA-ompB sequences (B). The optimal tree with the sum of branch length = 0.06205323 (A) and 0.11097561 (B) is shown. The percentage of replicate trees in which the associated taxa clustered together in the bootstrap test (1,000 replicates) are shown next to the branches. The tree is drawn to scale, with branch lengths in the same units as those of the evolutionary distances used to infer the phylogenetic relationship. of the Rickettsia spp. we identifi ed. As shown (2), multilocus analysis with ompA-ompB sequences was highly informative about the phylogenetic relationship between Rickettsia spp. and R. conorii strains (Figure, panel B).
In Sicily, R. conorii Malish strain has been characterized in MSF patients (4), and R. slovaca DNA was identifi ed in ixodid ticks (5

Detection of European Strain of Echinococcus multilocularis in North America
To the Editor: In 2009, an alveolar hydatid cyst, the intermediate stage of the cestode Echinococcus multilocularis, was detected in the liver of a dog from Quesnel, British Columbia (BC), Canada (1), 600 km west of the nearest known record of this parasite in central North America (Figure). Alveolar hydatid cysts normally occur in rodent intermediate hosts. However, humans can serve as aberrant intermediate hosts; cysts generally originate in the liver and, in about one third of cases, metastasize throughout the body (2). Detection of the larval stage of this pathogen in an unusual host in a new geographic region required application of multiple molecular epidemi-