Israeli Spotted Fever Rickettsia (Rickettsia conorii Complex) Associated with Human Disease in Portugal
To the Editor: Mediterranean spotted fever is endemic in Portugal, where it is a reportable disease with approximately 1,000 new cases per year (1). Rickettsia conorii has been thought to be the only pathogenic rickettsia of the spotted fever group in Portugal (2), as well as in the Western Mediterranean area. Another rickettsia in this group, the Israeli spotted fever rickettsia, which belongs to the R. conorii complex (3-5), was isolated in 1974 from ticks and humans; however, its distribution appeared to be restricted to Israel (6). We report three cases of rickettsiosis in Portugal caused by Israeli spotted fever rickettsia.
Case 1. A 71-year-old woman was hospitalized with a history of fever (39ºC) for 6 days, headache, and icterus. The influenzalike syndrome was treated with an antipyretic. In the next 4 days, the patient had myalgias, malaise, and mental confusion. Ten hours after being transferred to an intensive care unit, she died with septic shock and multiorgan failure, despite intravenous administration of doxycycline and other antibiotics.
Case 2. A 79-year-old woman, who was previously healthy except for high blood pressure, was hospitalized with a 4-day history of gastrointestinal disorders, nausea, and vomiting, which were attributed to food poisoning; high fever (40ºC) developed, and 3 days later a cutaneous rash, which spread to the palms and soles. The diagnosis of Mediterranean spotted fever was made by indirect immunofluorescent assay against R. conorii (immunoglobulin [Ig] M 1:40; IgG 1:512). The patient was treated with doxycycline and was discharged from the hospital 20 days after admission.
Case 3. A 65-year-old woman was hospitalized with a 6-day history of fever (39ºC), headache, vomiting, and epigastric pain, which had been treated with penicillin. Rash and icterus developed, and the patient died of shock and multiorgan failure 9 hours after hospitalization, despite treatment with a mixture of antibiotics, which contained doxycycline.
Rickettsiae of the spotted fever group were isolated by the shell vial technique from the blood of the three patients. Sequences of polymerase chain reaction-amplified fragments of 16SrRNA (1440 bp), citrate synthase (382 bp), and rompA (590 bp) genes of the isolates show 100% similarity with the homologous sequence of Israeli spotted fever rickettsia (4,7,8).
All three patients lived in semirural areas, along the River Tejo (Setubal District). None had left Portugal during the previous year. Although none had a tache noire, contact with ticks cannot be excluded. The absence of tache noire is typical in Israeli spotted fever (6). These findings indicate that the geographic distribution of Israeli spotted fever is wider than had been thought and includes the Iberian Peninsula. Because initial signs and symptoms of the disease are particularly uncharacteristic and appropriate treatment may be delayed, this rickettsia can cause life-threatening disease.
Fatima Bacellar,* Lorenza Beati,† Ana França,‡ José Poças,§ Russell Regnery,† and Armindo Filipe*
*Centro de Estudos de Vectores e Doenças Infecciosas, Instituto Nacional de Saúde Dr. Ricardo Jorge, Aguas de Moura, Portugal; †Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ‡Hospital Garcia da Orta, Almada, Portugal; and §Hospital São Bernardo, Setubal, Portugal
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