Fiebre manchada de montañas rocosas: experiencia en 5 años de vigilancia activa en un hospital pediátrico de segundo nivel en el noreste de México / Rocky mountain spotted fever: five years of active surveillance experience in a second level pediatric hospital in northeastern Mexico

Resumen: Introducción: La fiebre manchada de las montañas rocosas (FMMR) es causada por Rickettsia rickettsii. En Coahuila, la región de la Comarca Lagunera se considera una zona endémica. No se han reportado casos en la zona sur del estado, específicamente en la ciudad de Saltillo. Métodos: Estudio prospectivo, reporte de casos. Se incluyeron los casos de niños atendidos en el Hospital del Niño Dr. Federico Gómez Santos en la ciudad de Saltillo, Coah., del mes de septiembre de 2012 a septiembre 2017 con diagnóstico confirmado clínicamente y por reacción en cadena de la polimerasa (PCR) de FMMR. Se presentan los antecedentes epidemiológicos, las características clínicas y evolución de los pacientes. Resultados: Se confirmaron 14 pacientes. La relación masculino:femenino fue de 1.8:1, la edad promedio de los pacientes fue de 7.6 años (18 meses a 13 años). El 42.8% de los pacientes refirió el contacto con perros y el 57.1% afirmó tener contacto con garrapatas. En todos los casos hubo fiebre y exantema purpúrico; alrededor del 70% manifestaron mialgias y artralgias; el 28% tuvo sangrado del tubo digestivo, y el 11% alteraciones neurológicas graves. El 64.2% de los casos recibió tratamiento adecuado con doxiciclina. Fallecieron 8 pacientes, con una tasa de letalidad de 57.1%. Conclusiones: La zona sur de Coahuila debe considerarse una zona endémica para FMMR. El retraso en el diagnóstico y tratamiento favorecen una mayor letalidad.

Abstract: Background: Rocky Mountain Spotted Fever (RMSF) is caused by Rickettsia rickettsii. In Coahuila, Comarca Lagunera is considered an endemic zone; no cases have been reported in the southern zone of the state, specifically in the city of Saltillo­. Methods: Prospective study, cases report. Children evaluated in the Hospital del Niño Dr. Federico Gómez Santos from September 2012 to September 2017, with clinically and laboratory (by polymerase chain reaction, PCR) confirmed diagnosis of FMMR were included. The epidemiological antecedents, clinical characteristics and patient's evolution are presented. Results: 14 patients were confirmed. The male: female ratio was 1.8: 1, the average age of the patients was 7.6 years (18 months to 13 years). 42.8% reported contact with dogs and 57.1% confirmed contact with ticks. In all cases, there was fever and purpuric rash; around 70% manifested myalgias and arthralgias; 28% presented digestive tract bleeding and 11% had severe neurological alterations. 64.2% of the cases received adequate treatment with doxycycline. Eight patients died with a case fatality rate of 57.1%. Conclusions: The southern zone of Coahuila should be considered an endemic area for FMMR. The delay in diagnosis and treatment favor a greater lethality.

[Fiebre manchada de montañas rocosas: experiencia en 5 años de vigilancia activa en un hospital pediátrico de segundo nivel en el noreste de México]. / Rocky mountain spotted fever: five years of active surveillance experience in a second level pediatric hospital in northeastern Mexico.

Introducción: La fiebre manchada de las montañas rocosas (FMMR) es causada por Rickettsia rickettsii. En Coahuila, la región de la Comarca Lagunera se considera una zona endémica. No se han reportado casos en la zona sur del estado, específicamente en la ciudad de Saltillo. Métodos: Estudio prospectivo, reporte de casos. Se incluyeron los casos de niños atendidos en el Hospital del Niño Dr. Federico Gómez Santos en la ciudad de Saltillo, Coah., del mes de septiembre de 2012 a septiembre 2017 con diagnóstico confirmado clínicamente y por reacción en cadena de la polimerasa (PCR) de FMMR. Se presentan los antecedentes epidemiológicos, las características clínicas y evolución de los pacientes. Resultados: Se confirmaron 14 pacientes. La relación masculino:femenino fue de 1.8:1, la edad promedio de los pacientes fue de 7.6 años (18 meses a 13 años). El 42.8% de los pacientes refirió el contacto con perros y el 57.1% afirmó tener contacto con garrapatas. En todos los casos hubo fiebre y exantema purpúrico; alrededor del 70% manifestaron mialgias y artralgias; el 28% tuvo sangrado del tubo digestivo, y el 11% alteraciones neurológicas graves. El 64.2% de los casos recibió tratamiento adecuado con doxiciclina. Fallecieron 8 pacientes, con una tasa de letalidad de 57.1%. Conclusiones: La zona sur de Coahuila debe considerarse una zona endémica para FMMR. El retraso en el diagnóstico y tratamiento favorecen una mayor letalidad. Background: Rocky Mountain Spotted Fever (RMSF) is caused by Rickettsia rickettsii. In Coahuila, Comarca Lagunera is considered an endemic zone; no cases have been reported in the southern zone of the state, specifically in the city of ­Saltillo. Methods: Prospective study, cases report. Children evaluated in the Hospital del Niño Dr. Federico Gómez Santos from September 2012 to September 2017, with clinically and laboratory (by polymerase chain reaction, PCR) confirmed diagnosis of FMMR were included. The epidemiological antecedents, clinical characteristics and patient's evolution are presented. Results: 14 patients were confirmed. The male: female ratio was 1.8: 1, the average age of the patients was 7.6 years (18 months to 13 years). 42.8% reported contact with dogs and 57.1% confirmed contact with ticks. In all cases, there was fever and purpuric rash; around 70% manifested myalgias and arthralgias; 28% presented digestive tract bleeding and 11% had severe neurological alterations. 64.2% of the cases received adequate treatment with doxycycline. Eight patients died with a case fatality rate of 57.1%. Conclusions: The southern zone of Coahuila should be considered an endemic area for FMMR. The delay in diagnosis and treatment favor a greater lethality.

Ongoing Cerebral Vasculitis During Treatment of Rocky Mountain Spotted Fever.

BACKGROUND: Rocky Mountain spotted fever is a tickborne infection that produces a systemic small-vessel vasculitis; its prognosis is excellent if appropriate treatment is initiated early. Because the advent of effective antirickettsial therapies predates the widespread use of brain magnetic resonance imaging, there are limited data on the effect of untreated Rocky Mountain spotted fever infection on neuroimaging studies. PATIENT DESCRIPTION: We describe a 7-year-old girl with delayed treatment of Rocky Mountain spotted fever who suffered severe neurological impairment. Serial brain magnetic resonance images revealed a progressive "starry sky appearance," which is proposed to result from the same small vessel vasculitis that causes the characteristic skin rash of this infection. CONCLUSION: Neurological injury can continue to occur despite specific antirickettsial therapy in Rocky Mountain spotted fever. This child's clinical features raise questions about the optimal management of this infection, particularly the utility of immune modulating therapies in cases of delayed treatment and neurological involvement.

Rocky Mountain spotted fever in children.

Rocky Mountain spotted fever is typically undifferentiated from many other infections in the first few days of illness. Treatment should not be delayed pending confirmation of infection when Rocky Mountain spotted fever is suspected. Doxycycline is the drug of choice even for infants and children less than 8 years old.

Dose-response model of Rocky Mountain spotted fever (RMSF) for human.

Rickettsia rickettsii is the causative agent of Rocky Mountain spotted fever (RMSF) and is the prototype bacterium in the spotted fever group of rickettsiae, which is found in North, Central, and South America. The bacterium is gram negative and an obligate intracellular pathogen. The disease is transmitted to humans and vertebrate host through tick bites; however, some cases of aerosol transmission also have been reported. The disease can be difficult to diagnose in the early stages, and without prompt and appropriate treatment, it can be fatal. This article develops dose-response models of different routes of exposure for RMSF in primates and humans. The beta-Poisson model provided the best fit to the dose-response data of aerosol-exposed rhesus monkeys, and intradermally inoculated humans (morbidity as end point of response). The average 50% infectious dose among (ID50) exposed human population, N50, is 23 organisms with 95% confidence limits of 1 to 89 organisms. Similarly, ID10 and ID20 are 2.2 and 5.0, respectively. Moreover, the data of aerosol-exposed rhesus monkeys and intradermally inoculated humans could be pooled. This indicates that the dose-response models fitted to different data sets are not significantly different and can be described by the same relationship.

[Rocky Mountain spotted fever in Brazil]. / A febre maculosa no Brasil.

Although the number of confirmed cases of spotted fever has been declining in Brazil since 2005, the mortality rate (20% to 30%) is still high in comparison to other countries. This high mortality rate is closely related to the difficulty in making the diagnosis and starting the correct treatment. Only two groups of antibiotics have proven clinical effectiveness against spotted fever: chloramphenicol and tetracyclines. Until recently, the use of tetracyclines was restricted to adults because of the associated bone and tooth changes in children. Recently, however, the American Academy of Pediatrics and various researchers have recommended the use of doxycycline in children. In more severe cases, chloramphenicol injections are often preferred in Brazil because of the lack of experience with injectable tetracycline. Since early diagnosis and the adequate drug treatment are key to a good prognosis, health care professionals must be better prepared to recognize and treat spotted fever.

A febre maculosa no Brasil / Rocky Mountain spotted fever in Brazil

Embora no Brasil o número de casos confirmados de febre maculosa esteja em declínio desde 2005, a taxa de mortalidade (20 a 30 por cento) ainda é muito alta quando comparada a outros países. Esse alto índice de mortalidade tem estreita relação com a dificuldade em fazer o diagnóstico e estabelecer a terapia apropriada. Apenas dois grupos de antibióticos têm comprovada eficácia clínica, o cloranfenicol e as tetraciclinas. Até pouco tempo atrás, as tetraciclinas eram reservadas aos pacientes adultos em virtude das alterações dentárias e ósseas em crianças. Recentemente, entretanto, a Academia Americana de Pediatria e diversos autores têm recomendado a utilização da doxiciclina também em crianças. Em casos mais severos, a falta de experiência com uma tetraciclina injetável no Brasil faz com que se opte pelo cloranfenicol injetável. Como o pronto diagnóstico e a escolha adequada do fármaco são fatores determinantes de um prognóstico positivo, todos os profissionais da saúde devem estar melhor preparados para reconhecer e tratar a febre maculosa.

Although the number of confirmed cases of spotted fever has been declining in Brazil since 2005, the mortality rate (20 percent to 30 percent) is still high in comparison to other countries. This high mortality rate is closely related to the difficulty in making the diagnosis and starting the correct treatment. Only two groups of antibiotics have proven clinical effectiveness against spotted fever: chloramphenicol and tetracyclines. Until recently, the use of tetracyclines was restricted to adults because of the associated bone and tooth changes in children. Recently, however, the American Academy of Pediatrics and various researchers have recommended the use of doxycycline in children. In more severe cases, chloramphenicol injections are often preferred in Brazil because of the lack of experience with injectable tetracycline. Since early diagnosis and the adequate drug treatment are key to a good prognosis, health care professionals must be better prepared to recognize and treat spotted fever.

Rickettsia rickettsii infection protects human microvascular endothelial cells against staurosporine-induced apoptosis by a cIAP(2)-independent mechanism.

BACKGROUND: Manipulation of host cell death is an important determinant of the outcome of an infection. Here, we investigate whether Rickettsia rickettsii-infected host endothelial cells resist the effects of staurosporine, a potent inducer of apoptosis, and we explore the mechanisms underlying the anti-apoptotic effect of infection. METHODS: Human microvascular endothelial cells infected with R. rickettsii for 24 or 48 h were challenged with staurosporine. The extent of apoptosis was evaluated with flow cytometry. mRNA and protein expression levels were determined by use of microarray or polymerase chain reaction and immunoblotting, respectively. RESULTS: Staurosporine-induced apoptosis in endothelial cells infected for 24 and 48 h was significantly reduced, compared with simultaneously treated uninfected cells. A microarray of human genes involved in apoptosis and polymerase chain reaction analyses revealed increased steady-state mRNA expression of cIAP2 (a member of the inhibitor-of-apoptosis family of proteins) at 24 h after infection. The levels of cIAP2 protein (+/-SD) in infected cells were 3.5 +/- 1.7 -fold and 2.3 +/- 1.2 -fold higher than that in uninfected control cells at 24 and 48 h after infection. Nucleofection of human-specific cIAP2-targeted siRNA resulted in inhibition of protein expression by > or = 50% but had no effect on infection-induced protection against apoptosis. CONCLUSIONS: R. rickettsii-induced expression of cIAP2 in host endothelial cells is likely not a major contributor to protection against staurosporine-induced cell death.

Spatial clustering by disease severity among reported Rocky Mountain spotted fever cases in the United States, 2001-2005.

Rocky Mountain spotted fever (RMSF) occurs throughout much of the United States, ranging in clinical severity from moderate to fatal infection. Yet, little is known about possible differences among severity levels across geographic locations. To identify significant spatial clusters of severe and non-severe disease, RMSF cases reported to Centers for Disease Control and Prevention (CDC) were geocoded by county and classified by severity level. The statistical software program SaTScan was used to detect significant spatial clusters. Of 4,533 RMSF cases reported, 1,089 hospitalizations (168 with complications) and 23 deaths occurred. Significant clusters of 6 deaths (P = 0.05, RR = 11.4) and 19 hospitalizations with complications (P = 0.02, RR = 3.45) were detected in southwestern Tennessee. Two geographic areas were identified in north-central North Carolina with unusually low rates of severity (P = 0.001, RR = 0.62 and P = 0.001, RR = 0.45, respectively). Of all hospitalizations, 20% were clustered in central Oklahoma (P = 0.02, RR = 1.43). Significant geographic differences in severity were observed, suggesting that biologic and/or anthropogenic factors may be impacting RMSF epidemiology in the United States.

Genomic comparison of virulent Rickettsia rickettsii Sheila Smith and avirulent Rickettsia rickettsii Iowa.

Rickettsia rickettsii is an obligate intracellular pathogen that is the causative agent of Rocky Mountain spotted fever. To identify genes involved in the virulence of R. rickettsii, the genome of an avirulent strain, R. rickettsii Iowa, was sequenced and compared to the genome of the virulent strain R. rickettsii Sheila Smith. R. rickettsii Iowa is avirulent in a guinea pig model of infection and displays altered plaque morphology with decreased lysis of infected host cells. Comparison of the two genomes revealed that R. rickettsii Iowa and R. rickettsii Sheila Smith share a high degree of sequence identity. A whole-genome alignment comparing R. rickettsii Iowa to R. rickettsii Sheila Smith revealed a total of 143 deletions for the two strains. A subsequent single-nucleotide polymorphism (SNP) analysis comparing Iowa to Sheila Smith revealed 492 SNPs for the two genomes. One of the deletions in R. rickettsii Iowa truncates rompA, encoding a major surface antigen (rickettsial outer membrane protein A [rOmpA]) and member of the autotransporter family, 660 bp from the start of translation. Immunoblotting and immunofluorescence confirmed the absence of rOmpA from R. rickettsii Iowa. In addition, R. rickettsii Iowa is defective in the processing of rOmpB, an autotransporter and also a major surface antigen of spotted fever group rickettsiae. Disruption of rompA and the defect in rOmpB processing are most likely factors that contribute to the avirulence of R. rickettsii Iowa. Genomic differences between the two strains do not significantly alter gene expression as analysis of microarrays revealed only four differences in gene expression between R. rickettsii Iowa and R. rickettsii strain R. Although R. rickettsii Iowa does not cause apparent disease, infection of guinea pigs with this strain confers protection against subsequent challenge with the virulent strain R. rickettsii Sheila Smith.

Clinical and laboratory features, hospital course, and outcome of Rocky Mountain spotted fever in children.

OBJECTIVES: To describe the clinical characteristics and course of children with laboratory-diagnosed Rocky Mountain spotted fever (RMSF) and to identify clinical findings independently associated with adverse outcomes of death or discharge with neurologic deficits. STUDY DESIGN: Retrospective chart review of 92 patients at six institutions in the southeastern and southcentral United States from 1990 to 2002. Statistical analyses used descriptive statistics and multiple logistic regression. RESULTS: Children with RMSF presented to study institutions after a median of 6 days of symptoms, which most commonly included fever (98%), rash (97%), nausea and/or vomiting (73%), and headache (61%); no other symptom or sign was present in >50% of children. Only 49% reported antecedent tick bites. Platelet counts were <150,000/mm3 in 59% of children, and serum sodium concentrations were <135 mEq/dL in 52%. Although 86% sought medical care before admission, only 4 patients received anti-rickettsial therapy during this time. Three patients died, and 13 survivors had neurologic deficits at discharge. Coma and need for inotropic support and intravenous fluid boluses were independently associated with adverse outcomes. CONCLUSIONS: Children with RMSF generally present with fever and rash. Delays in diagnosis and initiation of appropriate therapy are unacceptably common. Prognosis is guarded in those with hemodynamic instability or neurologic compromise at initiation of therapy.

Rickettsia as obligate and mycetomic bacteria.

Rickettsiae are well known as intracellular pathogens of animals, humans, and plants and facultative and unorganized symbionts of invertebrates. No close relative of mitochondria has yet been associated with nutritional or developmental dependency of its host cell or organism. We have found a mycetomic Rickettsia that is a strict obligatory symbiont of the parthenogenetic booklouse Liposcelis bostrychophila (Psocoptera). These rickettsiae show an evolutionary transition from a solitary to a primary mycetomic bacterium adapted to the development of its host. These intracellular and intranuclear bacteria reside in specialized cells in several tissues. Their distribution changes markedly with the development of their host. The most advanced phenotype is a paired mycetome in the abdomen, described for the first time for Rickettsia and this host order. The mycetomic rickettsiae of two parthenogenetic book lice species are in the spotted fever group and in the basal limoniae group. While mycetomic bacteria are well known for their metabolic or light-emitting functions, these rickettsiae have an essential role in the early development of the oocyte. Removal of the Rickettsia stops egg production and reproduction in the book louse. In two phylogenetically distant psocopteran species, Rickettsia are shown to be associated with four transitional stages from free bacteria, infected cells, through single mycetocytes to organ-forming mycetomes.

Rocky Mountain spotted fever.

Rocky Mountain spotted fever (RMSF) is an unusual but important dermatological condition to identify without hesitation. The classic triad of headache, fever, and a rash that begins on the extremities and travels proximally to involve the trunk is found in a majority of patients. The cutaneous centripetal pattern is a result of cell to cell migration by the causative organism Rickettsia rickettsii. Such individuals should receive prompt antimicrobial therapy and supportive care to avoid serious and potentially fatal complications.

Tick-borne infections in children: epidemiology, clinical manifestations, and optimal management strategies.

Ticks can transmit bacterial, protozoal, and viral infections to humans. Specific therapy is available for several of these infections. Doxycycline is the antimicrobial treatment of choice for all patients, regardless of age, with Rocky Mountain spotted fever, human monocytic ehrlichiosis, or human granulocytic ehrlichiosis. Chloramphenicol has been used to treat these infections in children but is demonstrably inferior to doxycycline. In patients with Mediterranean spotted fever, doxycycline, chloramphenicol, and newer macrolides all appear to be effective therapies. Therapy of Lyme disease depends on the age of the child and stage of the disease. For early localized disease, amoxicillin (for those aged <8 years) or doxycycline (for those aged >/=8 years) is effective. Doxycycline, penicillin V (phenoxymethylpenicillin) or penicillin G (benzylpenicillin) preparations, and erythromycin are all effective treatments for tick-borne relapsing fever. Hospitalized patients with tularemia should receive gentamicin or streptomycin. Doxycycline and ciprofloxacin have each been investigated for the treatment of tularemia in outpatients; however, these agents do not yet have established roles in the treatment of this disease in children. Combination therapy with clindamycin and quinine is preferred for children with babesiosis; the combination of azithromycin and atovaquone also appears promising. Ribavirin has been recently shown to markedly improve survival in patients with Crimean-Congo hemorrhagic fever. The role of antiviral therapy in the treatment of other tick-borne viral infections, including other hemorrhagic fevers and tick-borne encephalitis, is not yet defined.

NF-kappaB activation suppresses host cell apoptosis during Rickettsia rickettsii infection via regulatory effects on intracellular localization or levels of apoptogenic and anti-apoptotic proteins.

Rickettsia rickettsii, a gram-negative and obligate intracellular bacterium, is the causative agent of Rocky Mountain spotted fever. In human infections, the primary target of R. rickettsii infection is vascular endothelium. Our laboratory has shown that activation of nuclear transcription factor-kappa B (NF-kappaB) during R. rickettsii infection of cultured human endothelial cells protects against apoptosis by preventing the activation of apical caspases-8 and -9, and the effector caspase-3. To understand upstream signaling mechanisms, we have determined the effect of NF-kappaB blockade on the status of different Bcl-2 (B-cell lymphoma 2) proteins in this study. Quantitative analysis following TUNEL and Hoechst staining confirmed that infection of endothelial cells with R. rickettsii for 6 h in the presence of a specific NF-kappaB inhibitor, MG132, resulted in induction of apoptosis. Infection-induced apoptosis of EC was associated with decreased level of Bid and accumulation of Bad, while cytosolic level of Bax remained relatively unchanged. Further, the cellular levels of apoptosis antagonist Bcl-2 were found to be down-regulated and apoptogenic mitochondrial proteins Smac and cytochrome c were released into cytoplasm. These results implicate an important regulatory role for NF-kappaB in controlling the intracellular levels and/or localization of pro- as well as anti-apoptotic proteins of Bcl-2 family, the intricate balance of which is a critical determinant of downstream signaling mechanisms governing cell fate during intracellular infection.