Bartonella quintana transmission from mite to family with high socioeconomic status.

Article Type:

Letter to the editor

Subject:

Verruga peruana (Diagnosis)
Verruga peruana (Care and treatment)
Verruga peruana (Social aspects)
Mites (Health aspects)

Authors:

Melter, Oto
Arvand, Mardjan
Votypka, Jin
Hulinska, Dagmar

Pub Date:

01/01/2012

Publication:

Name: Emerging Infectious Diseases Publisher: U.S. National Center for Infectious Diseases Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. National Center for Infectious Diseases ISSN: 1080-6040

Issue:

Date: Jan, 2012 Source Volume: 18 Source Issue: 1

Topic:

Event Code: 290 Public affairs

Geographic:

Geographic Scope: Czech Republic Geographic Code: 4EXCZ Czech Republic

Accession Number:

277344823

Full Text:

To the Editor: Urban trench fever caused by Bartonella quintana has been reported in persons who abuse alcohol and in homeless persons in large cities worldwide. Symptoms vary from asymptomatic intermittent bacteremia to serious complications (1). Pediculus humanus mites, the known vector of the infection, are not always identified, which raises the possibility that other vectors might also be involved (2). We report on an outbreak of B. quintana infection among a young family of high socioeconomic status and their visiting relatives.

The family resides in a regional city (population 104,000) in northern Czech Republic in an old, renovated apartment located on the top floor, just under the roof. In the summer of 2007, hundreds of ectoparasitic mites migrated from a whole in the roof and settled on the inner side of a permanently open window before infesting family members. Two weeks later (day 1 of symptom onset), a papular rash and pruritic vesicular lesions were noted by the parents on the body and legs of their 2 children, a 1-year-old girl and a 3-year-old boy. On day 3, the girl's body temperature rose to 38.0[degrees]C, and the boy's temperature rose to 39.5[degrees]C. The rash resolved in -10 days in both children. Vesicular lesions on the girl's buccal mucosal membrane resolved in 5 days. Excoriated areas resulting from spontaneous rupture of lesions or scratching were still visible on day 14.

On day 4, a fever (temperature, 38.5[degrees]C) and intense tibialgia, which persisted for 5 days, developed in the 33-year-old father of the infected children. On day 5, a vesicular rash, which resolved in 10 days, developed in the 33-year-old mother. The children's grandfather and both grandmothers also showed symptoms of infection within [approximately equal to] 14 days after having spent [greater than or equal to] 1 days or nights in the infected family's household (Table). In addition, the regional epidemiologist who was involved in the investigation showed development of a severe infection 16 days after exposure to implicated mites that escaped from a collection tube (Table). Recurrent fevers of decreasing intensity, followed by remissions at 1-week intervals, were observed in all patients for up to 3 months.

Seven mites, which were collected by the father on day 6 after symptom onset, were identified as engorged and nonengorged members of the genus Dermanyssus. After treatment with ethanol, the mites were investigated by culture and DNA analysis. DNA fragments specific for Bartonella spp. (i.e., a 185-bp [3] and a 397-bp [4,5] fragment of the 16S rRNA gene) were amplified; the sequence of the 397-bp fragment was 100% similar to the htrA sequence of the B. quintana strain Toulouse (Table). Results were negative for PCRs with primers for 16S rDNA of Anaplasma phagocytophilum (6) and primers for ospA of Borrelia burgdorferi (7). Only Staphylococcus cohnii subsp. urealyticus, as part of human or animal commensal flora, was detected on blood agar plates that were cultured for 30 days in a microaerophilic atmosphere.

Patient samples were analyzed by using the specific 16S rRNA primers; the Bartonella-specific amplicon was found only in a sample that was collected on day 4 from the father. Amplification of the htrA gene fragment of identical size and with identical sequences also confirmed the presence of DNA specific for B. quintana in the father's sample. Hemocultures were not performed at symptom onset, but results for patient serum samples cultured under the same conditions as the homogenized parasites remained negative. Significant titers of IgG against B. quintana and B. henselae or IgG seroconversion in paired serum samples were observed for all patients except the grandfather (Table).

Oral clarithromycin and doxycycline were administered to the children and adults, respectively, for 10 days. The apartment was repeatedly treated with insecticide, and the hole in the roof was repaired, leading

to eradication of the mites. The few dead and dry mites that were available for additional parasitologic analysis were mounted in Swan mounting medium (information about the medium is available from the authors), but no characteristics allowing differentiation between species of the genus Dermanyssus were recognized during examination by light microscopy. Failed attempts were made to trap pigeons that had lived on the roof of the apartment or in the same city; however, samples from trapped synanthropic pigeons from the north (n = 20) and central (n = 33) part of the country were negative for Bartonella spp. by the culture and amplification methods described above. Recurrent fever reported by adult patients resolved in 3 months, and all patients made a full clinical recovery. Laboratory findings for the patients were followed for 6 months after symptom onset (Table).

The fact that the suspected vector was a hematophagous mite (Dermanyssus sp.), a parasite of synanthropic pigeons and a suspected vector of other bacterial pathogens (8,9), and that the 16S rRNA Bartonella spp. gene was detected in mites (Steatonyssus sp. from the superfamily Dermanyssoidea) (10) remains a challenge for additional study. Pigeons probably played the role of accidental host in this outbreak, but the source of the infection remains unclear.

Acknowledgments

We thank V. Rupes for parasitologic analysis, A. Valkoun for serologic analysis of specific antibodies to Rickettsia and Coxiella spp., D. Kafkova for collection of patient data, and E. Kodytkova for manuscript review.

References

(1.) Drancourt M, Mainardi JL, Brouqui P, Vandenesch F, Carta A, Lehnert F, et al. Bartonella (Rochalimaea) quintana endocarditis in three homeless men. N Engl J Med. 1995;332:419-23. doi:10.1056/NEJM199502163320702

(2.) Comer JA, Paddock CD, Childs JE. Urban zoonoses caused by Bartonella, Coxiella, Ehrlichia, and Rickettsia species. Vector Borne Zoonotic Dis. 2001;1:91-118. doi:10.1089/153036601316977714

(3.) Breitschwerdt EB, Hegarty BC, Hancock SI. Sequential evaluation of dogs naturally infected with Ehrlichia canis, Ehrlichia chaffeensis, Ehrlichia equi, Ehrlichia ewingii, or Bartonella vinsonii. J Clin Micro biol. 1998;36:2645-51.

(4.) Anderson B, Sims K, Regnery R, Robinson L, Schmidt MJ, Goral S, et al. Detection of Rochalimaea henselae DNA in specimens from cat scratch disease patients by PCR. J Clin Microbiol. 1994;32:942-8.

(5.) Arvand M, Schad SG. Isolation of Bartonella henselae DNA from the peripheral blood of a patient with cat scratch disease up to 4 months after the cat scratch injury. J Clin Microbiol. 2006;44:2288-90. doi:10.1128/JCM.00239-06

(6.) Massung RF, Slater KG. Comparison of PCR assays for detection of the agent of human granulocytic ehrlichiosis, Anaplasma phagocytophilum. J Clin Microbiol. 2003;41:717-22. doi:10.1128/JCM.41.2.717-722.2003

(7.) Hulinska D, Votypka J, Plch J, Vlcek E, Valesova M, Bojar M, et al. Molecular and microscopical evidence of Ehrlichia spp. and Borrelia burgdorferi sensu lato in patients, animals and ticks in the Czech Republic. New Microbiol. 2002;25:437-48.

(8.) Valiente Moro C, De Luna CJ, Tod A, Guy JH, Sparagano OAE, Zenner L. The poultry red mite (Dermanyssus gallinae): a potential vector of pathogenic agents. Exp Appl Acarol. 2009;48:93-104. doi:10.1007/s10493-009-9248-0

(9.) Valiente Moro C, Thioulouse J, Chauve C, Normand P, Zenner L. Bacterial taxa associated with the hematophagous mite Dermanyssus gallinae detected by 16S rRNA PCR amplification and TTGE fingerprinting. Res Microbiol. 2009;160:63-70. doi:10.1016/j.resmic.2008.10.006

(10.) Reeves WK, Dowling APG, Dasch GA. Rickettsial agents from parasitic Dermanyssoidea (Acari: Mesostigmata). Exp Appl Acarol. 2006;38:181-8. doi:10.1007/s10493-006-0007-1

Oto Melter, Mardjan Arvand, Jin Votypka, and Dagmar Hulmska

Author affiliations: Charles University, Prague, Czech Republic (O. Melter); Zentrum fur Gesundheitsschutz, Dillenburg, Germany (M. Arvand); and National Institute of Public Health, Prague (J. Votypka, D. Hullnska)

DOI: http://dx.doi.org/10.3201/eid1801.110186

Address for correspondence: Oto Melter, Department of Medical Microbiology, 2nd Medical Faculty, Charles University, V Uvalu 84, 150 06 Prague 5--Motol, Prague, Czech Republic; email: oto.melter@lfmotol.cuni.cz

Table. Patient and microbiologic data from a study of Bartonella
quintana transmission from mites to a family with high socioeconomic
status, Czech Republic, 2007 *

Day after                    Specimen
symptom         Date of        type
onset          specimen      ([double
([dagger])    collection     dagger])      Case-patient

1                 NA            NA        Daughter, son

3             2007 Jul 5       Serum           Son

                               Serum         Daughter

4             2007 Jul 6       Serum          Father

5             2007 Jul 7       Serum          Mother

6             2007 Jul 11      Mites            NA

28            2007 Aug 2       Serum      Epidemiologist

35            2007 Aug 9       Serum       Grandfather

                               Serum      Grandmother 1

                               Serum      Grandmother 2

41            2007 Aug 15      Serum           Son

                               Serum         Daughter

                               Serum          Father

                               Serum          Mother

                               Serum       Grandfather

                               Serum      Grandmother 1

68            2007 Sep 11      Mites            NA

74            2007 Aug 17      Serum      Epidemiologist

163           2007 Dec 13   Serum, B, H   Epidemiologist

197           2008 Jan 17   Serum, B, H        Son

                            Serum, B, H      Daughter

                            Serum, B, H       Father

                            Serum, B, H       Mother

                            Serum, B, H   Grandmother 1

Day after
symptom
onset
([dagger])                Main symptoms

1                Papular rash, pruritic lesions

3                     Rash, vesicles, fever
                   (temperature 39[degrees]C)

                      Rash, vesicles, fever
                  (temperature 39.5[degrees]C)

4                 Recurrent fever (temperature
              38.5[degrees]C), tibialgia, headache

5                      Vesicles, tibialgia

6                              NA

28                Malaise, arthralgia, headache

35                 Malaise, arthralgia, rash,
                            headache

                        Fatigue, malaise

                        Fatigue, malaise

41                       Recurrent fever

                         Recurrent fever

                  Malaise and intense headache

                  Malaise and intense headache

                  Recurrent fatigue and malaise

                  Recurrent fatigue and malaise

68                             NA

74                Recurrent fever; fatigue and
                        intense headache

163               Poor concentration, headache

197                           None

                              None

                  Poor concentration, headache

                              None

                              None

Day after              Specimen testing
symptom
onset            IgG titer            PCR        Incubation
([dagger])      ([section])      ([paragraph])   period, d

1                    NA               NA             14

3                   Neg             Neg/ND           14

                    Neg             Neg/ND           14

4                   256             Pos/pos          15

5                   512             Neg/ND           16

6                    NA             Pos/pos          NA

28                  256             Neg/ND           16

35                  Neg             Neg/ND           14

                    256             Neg/ND           14

                     64             Neg/ND           14

41                  256             Neg/ND           14

                     64             Neg/ND           14

                    256             Neg/ND           15

                    512             Neg/ND           16

                    Neg             Neg/ND           14

                    256             Neg/ND           14

68                   NA             Pos/pos          NA

74                  512             Neg/ND           16

163                 256             Neg/ND           16

197                 Neg             Neg/ND           14

                    Neg             Neg/ND           14

                    128             Neg/ND           15

                    128             Neg/ND           16

                    Neg             Neg/ND           14

* NA, not applicable; neg, negative; ND, not done; pos, positive; B,
blood with anticoagulant EDTA; H, hemoculture. During August 9-19,
2007, children and adult case-patients received oral clarithromycin
and oral doxycycline, respectively. On August 9 and 19, 2007, the
apartment building in which the case-patients lived was treated with
insecticide.

([dagger]) Days after symptom onset do not correlate with incubation
period in last column.

([dagger]) Specimens were analyzed as follows: serum by serologic
testing, EDTA blood by PCR, hemoculture by culture. Patient serum
samples were negative for Anaplasma phagocytophilum (by
immunofluorescence assay [IFA], IgM, and IgG); Borrelia bugdorferi
(by ELISA and Western blot, IgM, and IgG); Coxiella burnetii,
Rickettsia connorii, and R. prowazekii (IFA, total immunoglobulin).

([section]) Determined by IFA.

([paragraph]) Detected by 16S rRNA and by htrA amplification.

Gale Copyright:

Bartonella quintana transmission from mite to family with high socioeconomic status.

Article Type:	Letter to the editor
Subject:	Verruga peruana (Diagnosis) Verruga peruana (Care and treatment) Verruga peruana (Social aspects) Mites (Health aspects)
Authors:	Melter, Oto Arvand, Mardjan Votypka, Jin Hulinska, Dagmar
Pub Date:	01/01/2012
Publication:	Name: Emerging Infectious Diseases Publisher: U.S. National Center for Infectious Diseases Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. National Center for Infectious Diseases ISSN: 1080-6040
Issue:	Date: Jan, 2012 Source Volume: 18 Source Issue: 1
Topic:	Event Code: 290 Public affairs
Geographic:	Geographic Scope: Czech Republic Geographic Code: 4EXCZ Czech Republic

Accession Number:	277344823
Full Text:	To the Editor: Urban trench fever caused by Bartonella quintana has been reported in persons who abuse alcohol and in homeless persons in large cities worldwide. Symptoms vary from asymptomatic intermittent bacteremia to serious complications (1). Pediculus humanus mites, the known vector of the infection, are not always identified, which raises the possibility that other vectors might also be involved (2). We report on an outbreak of B. quintana infection among a young family of high socioeconomic status and their visiting relatives. The family resides in a regional city (population 104,000) in northern Czech Republic in an old, renovated apartment located on the top floor, just under the roof. In the summer of 2007, hundreds of ectoparasitic mites migrated from a whole in the roof and settled on the inner side of a permanently open window before infesting family members. Two weeks later (day 1 of symptom onset), a papular rash and pruritic vesicular lesions were noted by the parents on the body and legs of their 2 children, a 1-year-old girl and a 3-year-old boy. On day 3, the girl's body temperature rose to 38.0[degrees]C, and the boy's temperature rose to 39.5[degrees]C. The rash resolved in -10 days in both children. Vesicular lesions on the girl's buccal mucosal membrane resolved in 5 days. Excoriated areas resulting from spontaneous rupture of lesions or scratching were still visible on day 14. On day 4, a fever (temperature, 38.5[degrees]C) and intense tibialgia, which persisted for 5 days, developed in the 33-year-old father of the infected children. On day 5, a vesicular rash, which resolved in 10 days, developed in the 33-year-old mother. The children's grandfather and both grandmothers also showed symptoms of infection within [approximately equal to] 14 days after having spent [greater than or equal to] 1 days or nights in the infected family's household (Table). In addition, the regional epidemiologist who was involved in the investigation showed development of a severe infection 16 days after exposure to implicated mites that escaped from a collection tube (Table). Recurrent fevers of decreasing intensity, followed by remissions at 1-week intervals, were observed in all patients for up to 3 months. Seven mites, which were collected by the father on day 6 after symptom onset, were identified as engorged and nonengorged members of the genus Dermanyssus. After treatment with ethanol, the mites were investigated by culture and DNA analysis. DNA fragments specific for Bartonella spp. (i.e., a 185-bp [3] and a 397-bp [4,5] fragment of the 16S rRNA gene) were amplified; the sequence of the 397-bp fragment was 100% similar to the htrA sequence of the B. quintana strain Toulouse (Table). Results were negative for PCRs with primers for 16S rDNA of Anaplasma phagocytophilum (6) and primers for ospA of Borrelia burgdorferi (7). Only Staphylococcus cohnii subsp. urealyticus, as part of human or animal commensal flora, was detected on blood agar plates that were cultured for 30 days in a microaerophilic atmosphere. Patient samples were analyzed by using the specific 16S rRNA primers; the Bartonella-specific amplicon was found only in a sample that was collected on day 4 from the father. Amplification of the htrA gene fragment of identical size and with identical sequences also confirmed the presence of DNA specific for B. quintana in the father's sample. Hemocultures were not performed at symptom onset, but results for patient serum samples cultured under the same conditions as the homogenized parasites remained negative. Significant titers of IgG against B. quintana and B. henselae or IgG seroconversion in paired serum samples were observed for all patients except the grandfather (Table). Oral clarithromycin and doxycycline were administered to the children and adults, respectively, for 10 days. The apartment was repeatedly treated with insecticide, and the hole in the roof was repaired, leading to eradication of the mites. The few dead and dry mites that were available for additional parasitologic analysis were mounted in Swan mounting medium (information about the medium is available from the authors), but no characteristics allowing differentiation between species of the genus Dermanyssus were recognized during examination by light microscopy. Failed attempts were made to trap pigeons that had lived on the roof of the apartment or in the same city; however, samples from trapped synanthropic pigeons from the north (n = 20) and central (n = 33) part of the country were negative for Bartonella spp. by the culture and amplification methods described above. Recurrent fever reported by adult patients resolved in 3 months, and all patients made a full clinical recovery. Laboratory findings for the patients were followed for 6 months after symptom onset (Table). The fact that the suspected vector was a hematophagous mite (Dermanyssus sp.), a parasite of synanthropic pigeons and a suspected vector of other bacterial pathogens (8,9), and that the 16S rRNA Bartonella spp. gene was detected in mites (Steatonyssus sp. from the superfamily Dermanyssoidea) (10) remains a challenge for additional study. Pigeons probably played the role of accidental host in this outbreak, but the source of the infection remains unclear. Acknowledgments We thank V. Rupes for parasitologic analysis, A. Valkoun for serologic analysis of specific antibodies to Rickettsia and Coxiella spp., D. Kafkova for collection of patient data, and E. Kodytkova for manuscript review. References (1.) Drancourt M, Mainardi JL, Brouqui P, Vandenesch F, Carta A, Lehnert F, et al. Bartonella (Rochalimaea) quintana endocarditis in three homeless men. N Engl J Med. 1995;332:419-23. doi:10.1056/NEJM199502163320702 (2.) Comer JA, Paddock CD, Childs JE. Urban zoonoses caused by Bartonella, Coxiella, Ehrlichia, and Rickettsia species. Vector Borne Zoonotic Dis. 2001;1:91-118. doi:10.1089/153036601316977714 (3.) Breitschwerdt EB, Hegarty BC, Hancock SI. Sequential evaluation of dogs naturally infected with Ehrlichia canis, Ehrlichia chaffeensis, Ehrlichia equi, Ehrlichia ewingii, or Bartonella vinsonii. J Clin Micro biol. 1998;36:2645-51. (4.) Anderson B, Sims K, Regnery R, Robinson L, Schmidt MJ, Goral S, et al. Detection of Rochalimaea henselae DNA in specimens from cat scratch disease patients by PCR. J Clin Microbiol. 1994;32:942-8. (5.) Arvand M, Schad SG. Isolation of Bartonella henselae DNA from the peripheral blood of a patient with cat scratch disease up to 4 months after the cat scratch injury. J Clin Microbiol. 2006;44:2288-90. doi:10.1128/JCM.00239-06 (6.) Massung RF, Slater KG. Comparison of PCR assays for detection of the agent of human granulocytic ehrlichiosis, Anaplasma phagocytophilum. J Clin Microbiol. 2003;41:717-22. doi:10.1128/JCM.41.2.717-722.2003 (7.) Hulinska D, Votypka J, Plch J, Vlcek E, Valesova M, Bojar M, et al. Molecular and microscopical evidence of Ehrlichia spp. and Borrelia burgdorferi sensu lato in patients, animals and ticks in the Czech Republic. New Microbiol. 2002;25:437-48. (8.) Valiente Moro C, De Luna CJ, Tod A, Guy JH, Sparagano OAE, Zenner L. The poultry red mite (Dermanyssus gallinae): a potential vector of pathogenic agents. Exp Appl Acarol. 2009;48:93-104. doi:10.1007/s10493-009-9248-0 (9.) Valiente Moro C, Thioulouse J, Chauve C, Normand P, Zenner L. Bacterial taxa associated with the hematophagous mite Dermanyssus gallinae detected by 16S rRNA PCR amplification and TTGE fingerprinting. Res Microbiol. 2009;160:63-70. doi:10.1016/j.resmic.2008.10.006 (10.) Reeves WK, Dowling APG, Dasch GA. Rickettsial agents from parasitic Dermanyssoidea (Acari: Mesostigmata). Exp Appl Acarol. 2006;38:181-8. doi:10.1007/s10493-006-0007-1 Oto Melter, Mardjan Arvand, Jin Votypka, and Dagmar Hulmska Author affiliations: Charles University, Prague, Czech Republic (O. Melter); Zentrum fur Gesundheitsschutz, Dillenburg, Germany (M. Arvand); and National Institute of Public Health, Prague (J. Votypka, D. Hullnska) DOI: http://dx.doi.org/10.3201/eid1801.110186 Address for correspondence: Oto Melter, Department of Medical Microbiology, 2nd Medical Faculty, Charles University, V Uvalu 84, 150 06 Prague 5--Motol, Prague, Czech Republic; email: oto.melter@lfmotol.cuni.cz Table. Patient and microbiologic data from a study of Bartonella quintana transmission from mites to a family with high socioeconomic status, Czech Republic, 2007 * Day after Specimen symptom Date of type onset specimen ([double ([dagger]) collection dagger]) Case-patient 1 NA NA Daughter, son 3 2007 Jul 5 Serum Son Serum Daughter 4 2007 Jul 6 Serum Father 5 2007 Jul 7 Serum Mother 6 2007 Jul 11 Mites NA 28 2007 Aug 2 Serum Epidemiologist 35 2007 Aug 9 Serum Grandfather Serum Grandmother 1 Serum Grandmother 2 41 2007 Aug 15 Serum Son Serum Daughter Serum Father Serum Mother Serum Grandfather Serum Grandmother 1 68 2007 Sep 11 Mites NA 74 2007 Aug 17 Serum Epidemiologist 163 2007 Dec 13 Serum, B, H Epidemiologist 197 2008 Jan 17 Serum, B, H Son Serum, B, H Daughter Serum, B, H Father Serum, B, H Mother Serum, B, H Grandmother 1 Day after symptom onset ([dagger]) Main symptoms 1 Papular rash, pruritic lesions 3 Rash, vesicles, fever (temperature 39[degrees]C) Rash, vesicles, fever (temperature 39.5[degrees]C) 4 Recurrent fever (temperature 38.5[degrees]C), tibialgia, headache 5 Vesicles, tibialgia 6 NA 28 Malaise, arthralgia, headache 35 Malaise, arthralgia, rash, headache Fatigue, malaise Fatigue, malaise 41 Recurrent fever Recurrent fever Malaise and intense headache Malaise and intense headache Recurrent fatigue and malaise Recurrent fatigue and malaise 68 NA 74 Recurrent fever; fatigue and intense headache 163 Poor concentration, headache 197 None None Poor concentration, headache None None Day after Specimen testing symptom onset IgG titer PCR Incubation ([dagger]) ([section]) ([paragraph]) period, d 1 NA NA 14 3 Neg Neg/ND 14 Neg Neg/ND 14 4 256 Pos/pos 15 5 512 Neg/ND 16 6 NA Pos/pos NA 28 256 Neg/ND 16 35 Neg Neg/ND 14 256 Neg/ND 14 64 Neg/ND 14 41 256 Neg/ND 14 64 Neg/ND 14 256 Neg/ND 15 512 Neg/ND 16 Neg Neg/ND 14 256 Neg/ND 14 68 NA Pos/pos NA 74 512 Neg/ND 16 163 256 Neg/ND 16 197 Neg Neg/ND 14 Neg Neg/ND 14 128 Neg/ND 15 128 Neg/ND 16 Neg Neg/ND 14 * NA, not applicable; neg, negative; ND, not done; pos, positive; B, blood with anticoagulant EDTA; H, hemoculture. During August 9-19, 2007, children and adult case-patients received oral clarithromycin and oral doxycycline, respectively. On August 9 and 19, 2007, the apartment building in which the case-patients lived was treated with insecticide. ([dagger]) Days after symptom onset do not correlate with incubation period in last column. ([dagger]) Specimens were analyzed as follows: serum by serologic testing, EDTA blood by PCR, hemoculture by culture. Patient serum samples were negative for Anaplasma phagocytophilum (by immunofluorescence assay [IFA], IgM, and IgG); Borrelia bugdorferi (by ELISA and Western blot, IgM, and IgG); Coxiella burnetii, Rickettsia connorii, and R. prowazekii (IFA, total immunoglobulin). ([section]) Determined by IFA. ([paragraph]) Detected by 16S rRNA and by htrA amplification.
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