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• W1567469704 abstract "Mediterranean spotted fever (MSF) is caused by Rickettsia conorii conorii transmitted by the brown dog tick Rhipicephalus sanguineus. It is endemic in the Mediterranean area, where most of the cases are encountered during the summer, when the tick vectors are highly active [1Parola P Paddock C Raoult D Tick-borne rickettsioses around the world: emerging diseases challenging old concepts.Clin Microbiol Rev. 2005; 18: 719-756Crossref PubMed Scopus (750) Google Scholar]. In Morocco, MSF has been the sole human tick-borne rickettsiosis known by clinicians, and cases that are clinically recognized are rarely documented [2Charra B Berrada J Hachimi A Judate I Nejmi H Motaouakkil S A fatal case of Mediterranean spotted fever.Med Mal Infect. 2005; 35: 374-375Crossref PubMed Scopus (9) Google Scholar]. Our aim is to describe the clinical and epidemiological characteristics of confirmed cases of MSF in Casablanca and in the surrounding regions of Morocco. Between May and December 2007, we included in this study patients seen at the Infectious Diseases Division of the Ibn Rochd Casablanca Teaching Hospital and at the Pasteur Institute of Morocco, with unexplained fever and/or eruptive fever and/or elevated serum levels of liver transaminases. Clinical and epidemiological data, laboratory results, treatments and outcomes of the patients were collected on a standardized questionnaire. For each patient, the study involved the gathering of an acute-phase serum sample within 2 weeks of the onset of symptoms and, if possible, a convalescent-phase serum sample (i.e. one collected 1–2 weeks later). Punch biopsies were performed on skin lesions, especially on the eschar. Sera were tested in a multiple-antigen immunofluorescence assay using nine SFG rickettsial antigens, including R. conorii conorii strain 7, Rickettsia africae, Rickettsia sibirica mongolitimonae, Rickettsia aeschlimannii, Rickettsia massiliae, Rickettsia helvetica, Rickettsia slovaca, R. conorii israelensis, and Rickettsia felis, and a typhus group antigen, Rickettsia typhi. The rationale for the antigen screening panel was supported by the presence of rickettsial species or subspecies in the Mediterranean area. When cross-reactions were noted between several rickettsial antigens, the standard procedure of the Unité des Rickettsies was followed, including Western blotting and cross-adsorption studies to complement the immunofluorescence assay [3Mouffok N Benabdellah A Richet H et al.Reemergence of rickettsiosis in Oran, Algeria.Ann NY Acad Sci. 2006; 1078: 180-184Crossref PubMed Scopus (22) Google Scholar, 4Jensenius M Fournier PE Vene S Ringertz SH Myrvang B Raoult D Comparison of immunofluorescence, Western blotting, and cross-adsorption assays for diagnosis of African tick bite fever.Clin Diagn Lab Immunol. 2004; 11: 786-788PubMed Google Scholar]. Also, DNA was extracted from skin biopsy specimens using the QIAamp DNA Mini Kit (Qiagen, Hilden, Germany). Standard PCR was performed with primers suitable for hybridization within the conserved region of genes coding for outer membrane protein A (ompA) and citrate synthase (gltA) [3Mouffok N Benabdellah A Richet H et al.Reemergence of rickettsiosis in Oran, Algeria.Ann NY Acad Sci. 2006; 1078: 180-184Crossref PubMed Scopus (22) Google Scholar]. Forty-five patients were included in the study, 65% were men, and 68% of patients were diagnosed between August and September. The average age of the 42 adult patients was 47.3 years, and that of the three children was 5 years. Among the 45 included patients, 77% had been exposed to dogs, 35% had reported tick bites, and 75% had inoculation eschars (25% of them presented with several inoculation eschars); 70% of the patients were treated with doxycycline, 16% with fluoroquinolones, 10% (n = 4) with thiamphenicol, and 2% (n = 1) with josamycine. Three patients were hospitalized in intensive-care units, and one of them died. Among the 45 patients, 28 had significant antibody titres against spotted fever group (SFG) rickettsiae with cross-reactions between several rickettsial antigens. Western blotting and cross-adsorption studies were performed on patients with no eschar biopsies or with negative results on skin biopsy specimens. Antibodies specifically directed against R. conorii conorii were found for nine patients. Twelve (41%) of 29 obtained skin biopsy specimens tested positive by PCR. All sequences obtained from positive PCR products shared 99.5% homology with the corresponding sequence for R. conorii conorii strain Malish ompA (GenBank accession number AE008674) and 99.8% homology with the corresponding sequence for R. conorii conorii strain Malish gltA (GenBank accession number AE008677). Overall, 21 patients of 32 who had antibodies directed against SFG rickettsial antigens and/or positive skin biopsy specimens were definitely confirmed as having MSF due to R. conorii conorii. The clinical data of these confirmed cases are presented in Table 1.TABLE 1Clinical signs of 21 patients confirmed to have Mediterranean spotted fever caused by Rickettsia conorii conorri in Casablanca, Morocco, 2007Findingsn (%)High fever21/21 (100)Myalgia20/21 (95)Arthralgia20/21 (95)Cutaneous rashaIncluding 17 patients with maculopapular rash and four patients with purpuric rash.21/21 (100)Headache21/21 (100)Conjunctivitis1/21 (5)Single eschar15/21 (75)Multiple eschars5/21 (14)Meningism1/21 (5)Liver transaminases >50 UI/L9/15 (60)Platelets <15010 exp 9 = 1 000 000 000/L8/16 (50)Lymphadenodenopathy3/20 (15)Death1/21 (5)a Including 17 patients with maculopapular rash and four patients with purpuric rash. Open table in a new tab This study is the largest series of MSF diagnosed in Morocco with the reference methods allowing definitive confirmation of the rickettsia involved. MSF seems to be the most common rickettsial infection in the country, at least during the summer and in the Casablanca area. It is of interest that 14% of the patients with confirmed MSF presented with multiple eschars. This is thought to be unusual in MSF, for which the typical inoculation eschar at the tick bite site is usually unique, because the brown dog tick is known to have a low propensity to bite people. On the other hand, other SFG tick-borne rickettsioses are characterized by multiple eschars linked with aggressive vectors that readily bite people. However, particular climatic circumstances, including higher temperatures, may have led to an increased proclivity of ticks to bite humans [5Parola P Socolovschi C Jeanjean L Bitam I Fournier PE Sotto A Labauge P Raoult D Warmer weather linked to tick attack and emergence of severe rickettsioses.PLoS Negl Trop Dis. 2008; 2: e338Crossref PubMed Scopus (188) Google Scholar]. None of the emerging pathogens that have been detected in ticks in Morocco were diagnosed in our patients, such as R. massiliae, R. slovaca, Rickettsia raoultii, R. aeschlimannii, Rickettsia monacensis and R. helvetica [6Sarih M Socolovschi C Boudebouch N Hassar M Raoult D Parola P Spotted fever group rickettsiae in ticks, Morocco.Emerg Infect Dis. 2008; 14: 1067-1073Crossref PubMed Scopus (58) Google Scholar]. Clinicians have to be aware of the potential severity of the disease as demonstrated here, with a case–fatality rate of 5% . However, more studies are needed, including elsewhere in Morocco and at different periods of the year." @default.
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• W1567469704 date "2009-12-01" @default.
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• W1567469704 title "Spotted fever group rickettsioses documented in Morocco" @default.
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• W1567469704 doi "https://doi.org/10.1111/j.1469-0691.2008.02276.x" @default.
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