Emerg Infect DisEIDEmerging Infectious Diseases1080-60401080-6059Centers for Disease Control and Prevention22257438331008811-018610.3201/eid1801.110186Letters to the EditorLetterBartonella quintana Transmission from Mite to Family with High Socioeconomic StatusB. quintana Transmission and High Socioeconomic StatusMelterOtoArvandMardjanVotýpkaJiříHulínskáDagmarCharles University, Prague, Czech Republic (O. Melter);Zentrum für Gesundheitsschutz, Dillenburg, Germany (M. Arvand);National Institute of Public Health, Prague (J. Votýpka, D. Hulínská)Address for correspondence: Oto Melter, Department of Medical Microbiology, 2nd Medical Faculty, Charles University, V Úvalu 84, 150 06 Prague 5—Motol, Prague, Czech Republic; email: oto.melter@lfmotol.cuni.cz12012181163165Keywords: Bartonellaquintana infectionmitetransmissionDermanyssusCzech Republicsocioeconomic statusvectorbacteriarashurban trench fever

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 lice, 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 hole 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°C, and the boy’s temperature rose to 39.5°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°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 ≈14 days after having spent >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.

Patient and microbiologic data from a study of <italic>Bartonella</italic> <italic>quintana</italic> transmission from mites to a family with high socioeconomic status, Czech Republic, 2007*
Day after symptom onset†Date of specimen collectionSpecimen type‡Case-patientMain symptomsSpecimen testing
Incubation period, d
IgG titer§PCR¶
1NANADaughter, sonPapular rash, pruritic lesionsNANA14
32007 Jul 5SerumSonRash, vesicles, fever (temperature 39°C)NegNeg/ND14
SerumDaughterRash, vesicles, fever (temperature 39.5°C)NegNeg/ND14
42007 Jul 6SerumFatherRecurrent fever (temperature 38.5°C), tibialgia, headache256Pos/pos15
52007 Jul 7SerumMotherVesicles, tibialgia512Neg/ND16
62007 Jul 11MitesNANANAPos/posNA
282007 Aug 2SerumEpidemiologistMalaise, arthralgia, headache256Neg/ND16
352007 Aug 9SerumGrandfatherMalaise, arthralgia, rash, headacheNegNeg/ND14
SerumGrandmother 1Fatigue, malaise256Neg/ND14
SerumGrandmother 2Fatigue, malaise64Neg/ND14
412007 Aug 15SerumSonRecurrent fever256Neg/ND14
SerumDaughterRecurrent fever64Neg/ND14
SerumFatherMalaise and intense headache256Neg/ND15
SerumMotherMalaise and intense headache512Neg/ND16
SerumGrandfatherRecurrent fatigue and malaiseNegNeg/ND14
SerumGrandmother 1Recurrent fatigue and malaise256Neg/ND14
682007 Sep 11MitesNANANAPos/posNA
742007 Aug 17SerumEpidemiologistRecurrent fever; fatigue and intense headache512Neg/ND16
1632007 Dec 13Serum, B, HEpidemiologistPoor concentration, headache256Neg/ND16
1972008 Jan 17Serum, B, HSonNoneNegNeg/ND14
Serum, B, HDaughterNoneNegNeg/ND14
Serum, B, HFatherPoor concentration, headache128Neg/ND15
Serum, B, HMotherNone128Neg/ND16
Serum, B, HGrandmother 1NoneNegNeg/ND14

*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.
†Days after symptom onset do not correlate with incubation period in last column.
‡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).
§Determined by IFA.
¶Detected by 16S rRNA and by htrA amplification.

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.

Suggested citation for this article: Melter O, Arvand M, Votýpka J, Hulínská D. Bartonella quintana transmission from mite to family with high socio-economic status [letter]. Emerg Infect Dis [serial on the Internet]. 2012 Jan [date cited]. http://dx.doi.org/10.3201/eid1801.110186

Acknowledgments

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

ReferencesDrancourt M, Mainardi JL, Brouqui P, Vandenesch F, Carta A, Lehnert F, Bartonella (Rochalimaea) quintana endocarditis in three homeless men. N Engl J Med. 1995;332:41923 10.1056/NEJM1995021633207027529894Comer JA, Paddock CD, Childs JE Urban zoonoses caused by Bartonella, Coxiella, Ehrlichia, and Rickettsia species. Vector Borne Zoonotic Dis. 2001;1:91118 10.1089/15303660131697771412653141Breitschwerdt 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 Microbiol. 1998;36:2645519705408Anderson B, Sims K, Regnery R, Robinson L, Schmidt MJ, Goral S, Detection of Rochalimaea henselae DNA in specimens from cat scratch disease patients by PCR. J Clin Microbiol. 1994;32:94288027347Arvand M, Schäd 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;44:228890 10.1128/JCM.00239-0616757642Massung RF, Slater KG Comparison of PCR assays for detection of the agent of human granulocytic ehrlichiosis, Anaplasma phagocytophilum. J Clin Microbiol. 2003;41:71722 10.1128/JCM.41.2.717-722.200312574272Hulinska D, Votypka J, Plch J, Vlcek E, Valešová M, Bojar M, Molecular and microscopical evidence of Ehrlichia spp. and Borrelia burgdorferi sensu lato in patients, animals and ticks in the Czech Republic. New Microbiol. 2002;25:4374812437223Valiente 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;48:93104 10.1007/s10493-009-9248-019205905Valiente 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;160:6370 10.1016/j.resmic.2008.10.00619027065Reeves WK, Dowling APG, Dasch GA Rickettsial agents from parasitic Dermanyssoidea (Acari: Mesostigmata). Exp Appl Acarol. 2006;38:1818 10.1007/s10493-006-0007-116596351