b. miyamotoi はあなたのそばにいる

B. miyamotoiはあなたのそばにいる

かもしれない

忽那賢志

2013/11/23-24 DEKABEN_ID annual meeting @京都

Am. J. Trop. Med. Hyg., 89(3), 2013, pp. 460–461doi:10.4269/ajtmh.13-0187Copyright © 2013 by The American Society of Tropical Medicine and Hygiene

Case Report: The First Case of Imported Relapsing Fever in Japan

Satoshi Kutsuna,* Hiroki Kawabata, Kei Kasahara, Ai Takano, and Keiichi MikasaNational Center for Global Health and Medicine, Disease Control and Prevention Center, Shinjuku-ku, Tokyo, Japan;

National Institute of Infectious Diseases, Bacteriology, Shinjuku-ku, Tokyo, Japan; Nara Medical University, Center for Infectious Diseases,Nara City, Nara, Japan; Yamaguchi University, Joint Faculty of Veterinary Medicine, Yamaguchi-City, Yamaguchi, Japan

Abstract. Tick-borne relapsing fever (TBRF) is endemic in discrete areas throughout the world; however, a domesticor imported case of relapsing fever has not been reported in Japan. Here, we report the first imported case. A previouslyhealthy 20-year-old woman presented to our hospital on October 8, 2010, because of recurrent fever and lower leg pain.Before consultation, she had experienced four febrile episodes at 10–12-day intervals after returning from her stay inUzbekistan from 1 to 8 September. Giemsa stain of peripheral blood showed Borrelia spirochetes. The spirochete wasidentified as Borrelia persica by sequencing of the amplicons of flaB using polymerase chain reaction and phylogeneticanalysis. The patient was diagnosed with TBRF, and she completed a 10-day course of minocycline 100 mg twice daily.After treatment, her periodic fever subsided. Physicians should be aware of TBRF in patients with recurrent fever whohave returned from TBRF-endemic countries, including areas of the former USSR.

Relapsing fever caused by spirochetes of the genus Borreliais an acute febrile illness characterized by recurrent episodesof fever. These Borrelia spirochetes are transmitted to humansvia the bite of an infected Ornithodoros tick (tick-bornerelapsing fever; TBRF) or by contact with the body fluid ofan infected human body louse (louse-borne relapsing fever).The TBRF is endemic in discrete areas throughout theworld. Each Borrelia species that causes relapsing fever isdifferent according to areas. The TBRF is caused by Borreliacrocidurae or Borrelia duttonii in Africa, whereas Borreliahermsii or Borrelia turicatae in the North American continent.In central Asia, Borrelia persica or Borrelia latyschewii is thecausative pathogen1; a domestic or imported case of relapsingfever has not been reported in Japan. Here, we report the firstimported case.A previously healthy 20-year-old woman presented to our

hospital on October 8, 2010, because of recurrent fever andlower leg pain. Before consultation, she had experienced fourfebrile episodes at 10–12-day intervals. She had visited Rishton,a town in Fergana Province, Uzbekistan, from 1 to 8 Septem-ber while working as a Japanese language volunteer. Shestayed in a house with a thatched roof with a local family inRishton and meals were mainly taken at home. She recalledbeing bitten by a tick on her right thigh. Four days afterreturning from Uzbekistan, she visited her primary care doc-tor because of high fever and lower leg pain. She was diag-nosed with common cold, and was prescribed cefcapenepivoxil (CFPN-PI). After taking CFPN-PI, her fever promptlyresolved, and she discontinued treatment with CFPN-PI.However, she experienced two further episodes of recurrenthigh fever and lower leg pain, at 12 and 22 days, respectively,after the first febrile episode. She took CFPN-PI during eachepisode, and her fever rapidly abated. During the fourthfebrile episode, occurring 11 days after the third episode, shepresented to our hospital for further evaluation.On examination, her temperature was 39.8°C, her blood

pressure was 112/70 mm of Hg, and her pulse rate was 90/min.Her physical examination revealed normal findings except foreschar on her right inner thigh. Laboratory tests revealed

lymphopenia (1,110 mg/mL), elevated levels of C-reactive pro-tein (195 mg/L) and alanine aminotransferase (69 IU/mL).Leukocytes were 7,290 mg/mL (73% of neutrophil and 15.2%of lymphocyte). Count of red blood cells and platelets werenormal. Abdominal ultrasonography revealed mild spleno-megaly. Blood culture was negative (BACTEC plus aerobicmedium and anaerobic medium, Becton, Dickinson and Com-pany, Franklin Lakes, NJ), and Giemsa stain of peripheralblood collected during the febrile phase showed helical bacte-ria suggestive of Borrelia spirochetes (Figure 1). BorrelialDNA was also detected in blood cultures and serum speci-mens obtained during the fourth febrile phase using Borrelia-specific flagellin gene (flaB)-based polymerase chain reaction(PCR).2 The sequence was deposited in GenBank as acces-sion no. AB781030. The spirochete was identified as B. persicaby sequencing of the amplicons of flaB using PCR and phylo-genetic analysis (sequence similarity was 99.6% to B. persicastrain T [accession no. JF708953], whereas 86% to Borreliahispanica, 84–85% to B. duttonii and B. crocidurae, 84% toBorrelia recurrentis strains). The post-treatment serum sam-ple was negative in this PCR assay. The Borrelia was inocu-lated into culture bottles containing Barbour-Stoenner-Kellymedium with 10% rabbit serum (homemade); however, theydid not propagate. The patient was diagnosed with relapsingfever, and she completed a 10-day course of minocycline(100 mg twice daily). Jarisch-Herxheimer syndrome did notoccur. After treatment, her periodic fever subsided.The TBRF is characterized by periodic fever with non-

specific symptoms such as headache, myalgia, arthralgia, andnausea. These symptoms last several days, followed by aninterval without fever, followed by another episode of fever.If left untreated, patients usually experience 1 to 4 episodes offever before the illness spontaneously resolves. The definitivediagnosis of TBRF is primarily based on the detection ofBorrelia spirochetes in smears of peripheral blood collectedduring the febrile period. The PCR techniques (e.g., glpQ-based PCR) along with sequence analysis can often identifythe infectious Borrelia species3; although the preferred treat-ment is doxycycline 100 mg twice daily for 10 days, we pre-scribed minocycline as an alternative treatment in this case.De Pierpont and others all reported that minocycline was aseffective as doxycycline in areas with limited resources.4

Borrelia persica is frequently detected in Israel, Iran,and Jordan. However, the tick Ornithodoros tholozani, the

*Address correspondence to Satoshi Kutsuna, 1-21-1-Toyama,Shinjuku-ku, 1-21-1-Toyama, Shinjuku-ku, Tokyo, Japan 162-8655.E-mail: [email protected]

460

回帰性といえば輸入感染症

Am J Trop Med Hyg. 2013 Sep;89(3):460-1.

だと思っていませんか？

いきなりですが

症例呈示

症例： 80歳女性• 主訴：4ヶ月前からボーっとしてきた

• 現病歴：4ヶ月前から家族と交流をしなくなり、よろよろ歩きで、だんだんベッドから出なくなってきた。難聴も出現し、食欲低下により13.6kg減少した。

• 既往歴：悪性リンパ腫（濾胞型、StageIIA）　　　　2005年2月に診断　　　　2005年6月～9月 R-CHOP

　　　　その後2011年8月までRを6ヶ月毎に投与　　　　高血圧、鬱病

• 旅行歴、ダニ曝露なし

• 遊走性紅斑なし

• USAのニュージャージー州に住んでいる。家禽、猫、イヌ、ネズミ、鹿の曝露はある

• これまでに2回ライム病に罹患歴（2006年11月、2007年6月）があり、遊走性紅斑を呈しDOXY2週間の投与で治療された。

症例： 80歳女性

検査結果• かかりつけ医にて代謝性疾患のワークアップが行われ異常なし

• がんセンターに紹介となり、胸腹部骨盤CTが撮られたが異常なし。頭部造影MRIも撮影されたが急性の変化なし（2012/2/6）。

• 髄膜炎を疑い腰椎穿刺を施行

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preparation of CSF sediment revealed spirochetes,

which w

ere also visualized by means of G

ram’s

staining.The patient w

as admitted to the hospital on

February 23, 2012, for further evaluation. On ex-

amination, she w

as afebrile and vital signs were

stable. Physical examination w

as unremarkable

except for a soft systolic murm

ur. Neurologic ex-

amination revealed that she w

as slow to answ

er questions and follow

comm

ands, was hard of

hearing, and had an unsteady gait. The patient could not give any details of her history or sym

p-tom

s; she did not say that she had a headache or stiff neck.

A follow-up spinal tap, on February 23, again

showed spirochetes on G

iemsa staining (Table 1).

After blood and CSF samples had been obtained

for cultures, ceftriaxone, at a dose of 2 g intrave-nously, w

as administered, at 8:45 p.m

. Approxi-m

ately 9 hours later, at 6 a.m. on February 24,

the patient had a temperature of 38.7°C (101.6°F),

her systolic blood pressure was in the low

90s, and she appeared ill. She had a salutary thera-peutic response to the adm

inistration of fluids and acetam

inophen. The clinical presentation af-ter the patient received ceftriaxone w

as suggestive of a Jarisch–H

erxheimer reaction. Treatm

ent was

then switched to penicillin G

at a daily dose of 24 m

illion U given intravenously, because the

specific pathogen remained unidentified. D

ur-ing the first 5 days of therapy, the patient’s physical condition im

proved dramatically; the

hyponatremia resolved by February 26. H

er men-

tal condition improved progressively over the

first 3 to 5 days, returning to normal at the end

of the 30-day regimen of intravenous penicillin

G therapy.Additional laboratory findings on February 23

included negative results on Venereal Disease Ref-

erence Laboratory testing of CSF and on serum

rapid plasma reagin testing (no prozone phenom

-enon). N

o organisms or spirochetes w

ere observed on a peripheral-blood sm

ear. Serum electrophore-

sis showed a total protein level of 5.6 g per

deciliter, a gamm

a globulin level of 0.5 g per deci-liter, and no m

onoclonal protein; the IgA level was

70 mg per deciliter (norm

al range, 61 to 356), the IgM

level 18 mg per deciliter (norm

al range, 37 to 286), and the IgG

level 445 mg per deciliter

(normal range, 767 to 1590). The sodium

level was

127 mm

ol per liter, the cortisol level was 14.7 µ

g per deciliter (406 nm

ol per liter), and results of

Table 1. Results of Repeated Examinations of Cerebrospinal Fluid.

DateOpening Pressure Appearance

White-Cell Count Differential Count

Red-Cell Count Protein Glucose*

Results on Giemsa Staining or Gram’s

Staining

cm of water per mm3 per mm3 mg/dl mg/dl

February 21 — Xanthochromic 65 23% polymorphonuclear leukocytes, 70% lym-phocytes, 6% monocytes, and 1% uncharac-terized cells

6 >300 33 Spirochete

February 23 21 Xanthochromic 40 37% polymorphonuclear leukocytes, 49% lym-phocytes, 1% bands, 9% monocytes, 1% eosinophils, and 3% uncharacterized cells

2 >300 27 (96 in serum) Spirochete

March 29 16 Clear 21 91% lymphocytes and 9% monocytes 2 168 41 (87 in serum) No organism

* To convert the values for glucose to millimoles per liter, multiply by 0.05551.

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ithout permission.

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assachusetts Medical Society. A

ll rights reserved.




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which w


ram’s




amination, she w



as unremarkable


ur. Neurologic ex-


as slow to answ


comm

ands, was hard of


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. Approxi-m









ent was








er men-








-enon). N





deciliter, a gamm









level was

127 mm









Staining








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n engl j med 368;3 nejm.org january 17, 2013 243

to,2 indicated that the spirochete was probably not B. burgdorferi sensu stricto.

PROPAGATIONThe CSF spirochetes did not propagate in Barbour–Stoenner–Kelly medium. Motility was not ob-served after 4 weeks of incubation.

SEROLOGIC FINDINGSEnzyme immunoassay with B. burgdorferi antigen was negative (optical density, <1) for IgM, IgA, and IgG isotypes in serum and CSF specimens ob-tained during the acute phase of disease and after treatment; immunoblot assay of serum specimens showed no bands. No reactivity to B. microti or A. phagocytophilum was observed.

GENETIC ANALYSISReal-time PCR assay with the use of genuswide borrelia primers confirmed that the patient’s ini-tial CSF specimens contained a borrelia species, not a treponema species. However, negative results from the B. burgdorferi–specific PCR assay targeting the OspA gene ruled out Lyme neuroborreliosis. The specific identity of the CSF spirochete was established by the amplification of two separate gene targets with the use of primers specific for the B. miyamotoi genogroup and was confirmed by sequencing and phylogenetic analysis of the 16S rRNA and flagellin genes (Fig. 2) that de-finitively place the borrelia from this patient within the American clade of the B. miyamotoi–like spirochetes. The post-treatment CSF sample was negative on PCR assay.

DISCUSSION

The genus borrelia can generally be divided into two taxonomic groups that correspond to typical disease manifestations — namely, Lyme disease and relapsing fever. The spirochetes causing Lyme disease are assigned to a species complex re-ferred to as B. burgdorferi sensu lato. The prototypic B. burgdorferi sensu stricto is the only member of the species complex known to cause Lyme disease in the United States. All species classified within B. burgdorferi sensu lato are maintained by hard ticks (Ixodidae) of the genus ixodes. In the eastern United States, the main vectors for Lyme disease are I. dammini and I. scapularis; the merit of consid-ering these ticks to be either one species or two different species continues to be debated.14

The relapsing-fever group comprises geneti-cally diverse agents, many of which are known to cause a disease characterized by a high tempera-ture that cyclically remits. The relapsing-fever agents are maintained by soft ticks (Argasidae), with the exception of B. recurrentis, which is an anthroponosis transmitted by the body louse.15

There are also borrelia species that group ge-netically with the classic relapsing-fever spiro-chetes but are maintained by hard ticks. These include B. lonestari, which is transmitted by Am-blyomma americanum16; B. theileri, transmitted by Boophilus microplus17; and B. miyamotoi, transmit-ted by Ixodes ovatus or Haemaphysalis longicornis in Japan.18 Although B. theileri is well known as the cause of bovine borreliosis,19 the zoonotic poten-tial of the hard tick–transmitted borreliae that are genetically related to those causing relapsing fever remains unclear.

Since the discovery of B. miyamotoi in Japan in 1995,18 it has been detected in Lyme disease vec-tors globally.20-23 B. miyamotoi shares the same

A B

C D

Figure 1. Morphologic Features of Spirochetes Detected in Cerebrospinal Fluid.

Panels A and B show the spirochetes as viewed with the use of dark-field microscopy. Panels C and D show the spirochetes as viewed with the use of bright-field microscopy, with Giemsa staining and a pH of 7.0. The bar indicates 2 µm.

The New England Journal of Medicine Downloaded from nejm.org at NATIONAL CTR FOR GLOBAL HEALTH AND MEDICINE on January 19, 2013. For personal use only. No other uses without permission.

Copyright © 2013 Massachusetts Medical Society. All rights reserved.




brief r

epor

t

n en

gl j m

ed 368;3

nejm

.org

jan

uary 17, 2013

241


which w


ram’s




amination, she w



as unremarkable


ur. Neurologic ex-


as slow to answ


comm

ands, was hard of


p-tom








. Approxi-m









ent was








er men-








-enon). N





deciliter, a gamm









level was

127 mm









Staining








The New


Dow

nloaded from nejm

.org at NA

TION

AL CTR FO

R GLO

BAL H

EALTH

AN

D M

EDICIN


ithout permission.

Copyright © 2013 M


ll rights reserved.

brief report






DISCUSSION





A B

C D





？なんかおる

精査のため入院• Vital Sign：発熱なし、その他バイタル異常なし

• 身体所見：軽い収縮期雑音あり。

• 神経学的所見：質問に対する回答や指示に対する反応が緩慢　　　　　　　難聴、歩行時のふらつき　　　　　　　頭痛の訴えや項部硬直なし

• フォローアップの髄液検査でもグラム染色でスピロヘータを認めた

入院後経過• 血液培養、髄液を採取した後にCTRX 2g div 開始

• その9時間後・・・38.9℃の発熱、血圧低下・・・ショック状態！

• 輸液とアセトアミノフェンで対応

• JHRと考えられた

• 治療はPCG 2400万単位/日に変更した

• 治療開始後3～5日で全身状態、意識障害は改善

• 30日間の投与でPCGは終了

微生物検査• 末梢血でスピロヘータを認めず

• 髄液培養陰性

• クリプトコッカス抗原陰性

• 抗酸菌塗抹陰性

• 髄液ではスピロヘータ塗抹陽性

• 血液培養ではCNSが陽性であったがコンタミと考えられた

顕微鏡検査と免疫染色

• 400倍の鏡検で、7-10μmのスピロヘータが観察された。形態学的にB.

burgdorferi sensu latoとは異なっており（特に軸方向運動と細胞のコイリングが違うらしい・・・）、まずB. burgdorferi sensu latoではないと考えられた。

• 免疫染色で Borrelia sp.のフラジェリンモノクローナル抗体であるH9724と反応が見られたため Borrelia sp.であると判明したが、B.

burgdorferiの表面蛋白であるH5332モノクローナル抗体には反応せず、やはりライム病ボレリアではないと考えられた。

brief report






DISCUSSION





A B

C D





遺伝子解析• 全ボレリア属のプライマーを使ったリアルタイムPCRでは、CSFがボレリア遺伝子を含むことが分かり、OpsA遺伝子を標的にしたPCRが陰性であったことからライム病は除外された。

• B. miyamotoiに特異的なプライマーを用いた2つの分割された標的遺伝子の増幅で陽性となり、16s rRNAとフラジェリン遺伝子を用いたシークエンスと系統発生解析によってB. miyamotoiのアメリカ分岐群の菌種であると同定された。

• 治療後のCSFはPCR陰性であった

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

n engl j med 368;3 nejm.org january 17, 2013244

vector as B. burgdorferi sensu lato,24 but its preva-lence in ticks is only 10% of that for B. burgdor-feri, ranging from 0.7% in I. pacificus in Califor-nia22 to 3.5% in I. ricinus in Germany.21

Nonetheless, in certain sites, people are likely to be exposed to B. miyamotoi infection. In 2011, human cases that were attributed to infection with B. miyamotoi were described in Russia,25

mostly in patients presenting with nonspecific prolonged fever. These patients had seroreactiv-ity to B. burgdorferi sensu lato antigen on enzyme immunoassay, and the cause was suggested by amplification of B. miyamotoi DNA from the pa-tients’ blood. A recent report showed that serum samples from 1 to 3% of residents of New En-gland sites where Lyme disease is endemic were reactive in an experimental serologic assay target-ing the B. miyamotoi GlpQ antigen, a finding that suggests that exposure is relatively common.26

In northern New Jersey (and in many other northeastern U.S. sites), there are diverse enzo-otic borreliae other than B. burgdorferi sensu strictothat could be agents of zoonotic infection. The rabbit tick, I. dentatus, harbors B. andersonii, which has not been associated with infection in hu-mans. Much of eastern New Jersey is plagued by the Lone Star tick, A. americanum, infected by B. lonestari,27 a candidate etiologic agent for Masters’ disease, also known as southern tick–associated rash illness (STARI). Finally, wherever I. dammini and I. scapularis are present, B. miyamo-toi may also be found.24 Thus, the spirochetes found in the CSF of our patient could have been any of these organisms, particularly when pre-liminary antigenic and morphologic analysis appeared to rule out B. burgdorferi sensu stricto.

Our case report shows that B. miyamotoi infec-tion is a likely cause of this case of meningoen-cephalitis. The disease that was observed, char-acterized by a progressive cognitive decline, was nonspecific and might have been misdiagnosed, although it was successfully treated as a case of Lyme neuroborreliosis. However, the microscop-ical detection of an extraordinary density of morphologically distinct spirochetes in the CSF of our patient attracted additional scrutiny. It is possible that similar cases elsewhere in the United States have been attributed to Lyme neu-roborreliosis. The patients would have been treated with intravenous antibiotic agents and might have recovered with no sequelae. It is not known whether the two-tiered Lyme serologic-testing protocol6 would discriminate between exposure to B. miyamotoi and exposure to B. burg-dorferi. At any rate, serum from our patient did not react to B. burgdorferi antigens on enzyme immunoassay, unlike samples from the Russian case series. We suspect that our patient’s recent treatment with rituximab may have prevented a detectable antibody response.

American demographic characteristics are

B Flagellin Gene Target

A 16S Ribosomal RNA Gene Target

Ixodes persulcatus JF951384 (Russia)Apodemus argenteus AY604976 (Japan)

I. persulcatus 025861 (Japan)Human GU797331 (Russia)I. ricinus JF951382 (Russia)I. ricinus JF951383 (Russia)I. ricinus AF529085 (France)

I. dammini (United States)I. scapularis AY024345(United States)

B. lonestari AY166715B. theileri DQ872186

B. hermsii GQ175067B. turicatae AY934605

B. parkeri AF307100B. coriaceae AF210136

B. persica HQ610930B. hispanica GU350707

B. recurrentis AF107358B. duttonii GU350712

B. afzelii FR733687B. valaisiana NR036807

B. andersonii L46701B. garinii HM007279

B. burgdorferi AF467957B. bissettii AJ224141

I. scapularis AY374135 (New York)I. scapularis AY374134 (New York)I. scapularis AY024344 (Connecticut)

CSF (New Jersey)I. dammini (Massachusetts)

I. pacificus DQ025525 (California)I. pacificus DQ025526 (California)

I. ricinus AF529084 (France)I. ricinus FJ874925 (Poland)I. ricinus JF951389 (Russia)I. ricinus JF951388 (Russia)

Human GU797341 (Russia)

Human GU797342 (Russia)B. lonestari AY850064B. lonestari AY166716

I. persulcatus D43777 (Japan)I. persulcatus JF951392 (Russia)

CSF (New Jersey)

NorthAmerica

Borreliamiyamotoi

clade

Europe

Asia

0.005

0.01

Figure 2. Phylogenetic Analysis of DNA Sequences Obtained by Polymerase-Chain-Reaction Amplification of the Patient’s Cerebrospinal Fluid.

The maximum-likelihood algorithm was implemented in the MEGA 5.05 program.13 The branch labels are from GenBank, which includes accessions deposited with data stating that the sequences came from Ixodes dammini and others stating that they came from I. scapularis. Panel A shows the 16S ribosomal RNA gene target, with the use of a 1127-base-pair portion and the Hasegawa–Kishino–Yano with invariant sites (HKY+G+I) plus gamma model. Panel B shows the flagellin gene target, with the use of a 456-base-pair portion and the Tamura 2 parameter (T92) model. The arrow marks the spirochete in the sample from our patient. The scale bars denote the genetic distance in nucleotide substitutions per site.































CSF (New Jersey)

NorthAmerica

Borreliamiyamotoi

clade

Europe

Asia

0.005

0.01

































CSF (New Jersey)

NorthAmerica

Borreliamiyamotoi

clade

Europe

Asia

0.005

0.01





brief report



Meningoencephalitis from Borrelia miyamotoi in an Immunocompromised Patient

Joseph L. Gugliotta, M.D., Heidi K. Goethert, Sc.D., Victor P. Berardi, B.S., and Sam R. Telford III, Sc.D.

From the Department of Internal Medi-cine, Division of Infectious Disease, Hunterdon Medical Center, Flemington, and the Division of Infectious Disease, Allergy and Immunology, Robert Wood Johnson Medical School, New Brunswick — both in New Jersey ( J.L.G.); and the Reference Diagnostic Division, Imugen, Norwood (H.K.G., V.P.B.), and the Divi-sion of Infectious Diseases, Cummings School of Veterinary Medicine, Tufts Uni-versity, North Grafton (H.K.G., S.R.T.) — both in Massachusetts. Address reprint requests to Dr. Telford at the Division of Infectious Diseases, Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Rd., North Grafton, MA 01536, or at [email protected].

N Engl J Med 2013;368:240-5.DOI: 10.1056/NEJMoa1209039Copyright © 2013 Massachusetts Medical Society.

SUMM A R Y

Ixodes ticks serve as vectors for Borrelia burgdorferi, the agent of Lyme disease. Glob-ally, these ticks often concurrently harbor B. miyamotoi, a spirochete that is classified within the relapsing-fever group of spirochetes. Although humans presumably are exposed to B. miyamotoi, there are limited data suggesting disease attributable to it. We report a case of progressive mental deterioration in an older, immunocompro-mised patient, and even though Koch’s postulates were not met, we posit B. miya-motoi as the cause, owing to its direct detection in cerebrospinal fluid (CSF) with the use of microscopy and a polymerase-chain-reaction (PCR) assay. It is likely that B. miyamotoi is an underrecognized cause of disease, especially in sites where Lyme disease is endemic.

C A SE R EPORT

An 80-year-old woman was evaluated because of 4 months of progressive decline in mental status, including increasing confusion, withdrawal from family interac-tions, episodes of not getting out of bed, wobbling gait, and difficulty hearing, accompanied by a decrease in appetite and a 13.6-kg (30-lb) weight loss. Her medi-cal history was notable for non-Hodgkin’s lymphoma (follicular type, stage IIA), diagnosed in February 2005. She was treated with a regimen of cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab from June 2005 through September 2005, and then with rituximab every 6 months until August 2011. The patient also had a history of hypertension and a recent diagnosis of depression. She had no history of travel, no known tick bites or rash, and no recent erythema mi-grans. She lived on a farm in New Jersey, where there was possible exposure to poultry, cats, dogs, and field mice and where deer were frequently observed. She had been treated twice in the past for Lyme disease: once in November 2006 (clinical details were not available other than a negative result on serologic testing for Lyme disease) and once in July 2007, when she presented with erythema migrans and was treated with doxycycline for 2 weeks.

The patient was evaluated by her primary care provider. A metabolic workup was unrevealing, and she was referred to the oncology department. Computed tomography of the chest, abdomen, and pelvis showed no evidence of new disease. Magnetic resonance imaging of the brain, performed with and without the admin-istration of contrast material on February 6, 2012, showed no acute findings. A lumbar puncture was performed on February 21, 2012, to assess the patient for lymphomatous meningitis. Cytologic analysis and flow cytometry showed pleocy-tosis with an increased protein level (Table 1). Giemsa staining of a cytospin



NEJM症例報告の考察

• Ixodes（マダニ）はライム病の原因であるBorrelia burgdoferiのベクターであるが、同時に回帰熱グループのスピロヘータに分類されるB.

miyamotoiもしばしば保有している。おそらく人間はB. miyamotoiに頻繁に曝露しているが、それによって起こる疾患のデータは限られている

• B. miyamotoiはライム病の流行地域では特に見逃されている可能性がある。

1例報告でNEJM...

Case Report

658 www.thelancet.com Vol 382 August 17, 2013

A case of meningoencephalitis by the relapsing fever spirochaete Borrelia miyamotoi in EuropeJoppe W R Hovius, Bob de Wever, Maaike Sohne, Matthijs C Brouwer, Jeroen Coumou, Alex Wagemakers, Anneke Oei, Henrike Knol, Sukanya Narasimhan, Caspar J Hodiamont, Setareh Jahfari, Steven T Pals, Hugo M Horlings, Erol Fikrig, Hein Sprong, Marinus H J van Oers

On April 1 2012, a 70-year-old patient came to our clinic reporting slow cognitive processing, memory defi cits, and a disturbed gait, all of which had gradually developed over several months and progressed during the last few weeks before the patient’s initial visit. He did not report fever, and he had not been outside the country for several years. He had recently been treated with CHOP (cyclo-phosphamide, doxorubicin, vincristine, and predniso-lone), poly chemo therapy, and rituximab (last dose on Aug 2, 2011) for a stage 4 diff use large B cell lymphoma. His medical history also included Pneumocystis jirovecii pneumonia, un explained chronic diarrhoea, a splen-ectomy, extensive tick exposure, and two tick bites in the summer and fall before onset of symptoms. On neuro-logical examination there was a distinct brady phrenia, and on cognitive assess ment, the patient scored 26 of 30 points on the mini mental state examination. Vital signs were normal and body tempera ture was 36·4°C. Cranial MRI showed no abnormalities, but two lumbar punctures showed cerebro spinal fl uid pleocytosis with raised protein values. The cause of this chronic menin-gitis was not identifi ed by wide-ranging micro biological, pathological, and haematological diag nostic testing (appen dix). A C6-immunofl uorescence assay for Borrelia burgdorferi in serum, but not in cerebro spinal fl uid, was weakly positive (index 1·8). However, a B burgdorferi IgG and IgM immuno blot were non-conclusive and nega tive, respec tively. A B burgdorferi sl qPCR in cerebrospinal fl uid was negative. Nonetheless, because of the absence of an alternative diagnosis and the progression of symp-toms, on April 17, 2012, the patient was treated for a possible Lyme neuroborreliosis with once daily 2000 mg ceftriaxone intravenously for 2 weeks. Dur ing several weeks the patient fully recovered. At his last visit to the outpatient clinic in May, 2013, the patient did not have residual symptoms.

Supported by the recent evidence of the presence of B miyamotoi in Ixodes ricinus ticks across Europe,1,2 the relation in time of the patient’s symptoms with the tick bites, and his immunocompromised status, we retro-spectively considered B miyamotoi as the causative agent. We identifi ed motile spirochaetes in stored pre-treatment cerebrospinal fl uid by dark-fi eld microscopy (appendix). Additionally, a 16S rDNA pan-relapsing fever Borrelia quan titative (q)PCR and a qPCR targeting the B miyamotoi fl agellin gene was positive in two separate pre-treatment cerebrospinal fl uid samples and one pre-treatment blood sample (appendix). Notably, 2·2% of 352 I ricinus nymphal ticks from the vicinity of the patient’s recreational house in the dunes of Zandvoort, the

Netherlands, proved to be positive for B miyamotoi by qPCR (appendix). Amplifi cation and sequencing of the glpQ and p66 genes confi rmed B miyamotoi as the causative agent and showed 100% identical sequences in ticks and the patient’s clinical samples (appendix). We were unable to culture the spiro chaetes in modifi ed Barbour-Stoenner-Kelly medium from stored blood and cerebrospinal fl uid samples. Finally, ELISA and Western blot did not show anti-GlpQ antibodies in blood and CSF.

Relapsing fever is caused by various Borrelia species, which are predominantly transmitted by soft ticks. How ever, relapsing fever Borrelia species have also been identifi ed in hard ticks, including B miyamotoi in Ixodes ticks.3 B miyamotoi infection has been associated with systemic complaints, including malaise and fever, in case series.4,5 Recently, in the USA, B miyamotoi was shown to be able to cause meningoencephalitis in an immuno compromised patient.6 Physicians worldwide managing immunocompromised patients from Ixodes tick-endemic areas with a meningo encephalitis should consider B miyamotoi as a potential causative agent and should be aware that regular diagnostic tests for B burgdorferi will most probably overlook this diagnosis. Whether B miyamotoi is also able to cause neurological symptoms in non-immunocompromised patients requires further investigation.AcknowledgementsJWRH, MS, MCB, CJH, STP, and MHJvO took care of the patient. JWRH, BdW, JC, AW, AO, HK, SN, SJ, HMH, EF, and HS contributed to retrospectively establishing the diagnosis. JWRH, BdW, SJ and HS interpreted the PCR and sequencing data. JWRH drafted the manuscript and all authors contributed to writing the manuscript. Written consent to publish was obtained. Finally, we are grateful to Manoj Fonville and Paul Hengeveld for their outstanding technical support.

References1 Geller J, Nazarova L, Katargina O, Jarvekulg L, Fomenko N,

Golovljova I. Detection and genetic characterization of relapsing fever spirochete Borrelia miyamotoi in Estonian ticks. PLoS One 2012; 7: e51914.

2 Subramanian G, Sekeyova Z, Raoult D, Mediannikov O. Multiple tick-associated bacteria in Ixodes ricinus from Slovakia. Ticks Tick Borne Dis 2012; 3: 406–10.

3 Fukunaga M, Takahashi Y, Tsuruta Y, et al. Genetic and phenotypic analysis of Borrelia miyamotoi sp. nov., isolated from the ixodid tick Ixodes persulcatus, the vector for Lyme disease in Japan. Int J Syst Bacteriol 1995; 45: 804–10.

4 Krause PJ, Narasimhan S, Wormser GP, et al. Human Borrelia miyamotoi infection in the United States. N Engl J Med 2013; 368: 291–93.

5 Platonov AE, Karan LS, Kolyasnikova NM, et al. Humans infected with relapsing fever spirochete Borrelia miyamotoi, Russia. Emerg Infect Dis 2011; 17: 1816–23.

6 Gugliotta JL, Goethert HK, Berardi VP, Telford SR III. Meningoencephalitis from Borrelia miyamotoi in an immunocompromised patient. N Engl J Med 2013; 368: 240–45.

Lancet 2013; 382: 658

Department of Internal Medicine, Division of Infectious

Diseases (J W R Hovius MD), Department of Medical

Microbiology (B de Wever MSc, A Oei, H Knol,

C J Hodiamont MD), Department of Hematology

(M Sohne MD, Prof M H J van Oers MD),

Department of Neurology (M C Brouwer MD), Centre for Experimental and Molecular

Medicine (J Coumou MSc, A Wagemakers MD), and

Department of Pathology (Prof S T Pals MD,

H M Horlings MD), Academic Medical Centre, Amsterdam,

The Netherlands; Department of Internal Medicine, Division

of Infectious Disease, Yale University, School of Medicine,

New Haven, CN, USA (S Narasimhan PhD,

Prof E Fikrig MD); and National Institute for Public Health and

Environment, Bilthoven, The Netherlands (S Jahfari MSc,

H Sprong PhD)

Correspondence to:Joppe W R Hovius MD,

Department of Internal Medicine, Division of Infectious Diseases

and Centre for Experimental and Molecular Medicine, Academic

Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam,

The [email protected]

Ixodes ricinus

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See Online for appendix

Case Report














Lancet 2013; 382: 658















H Sprong PhD)






Ixodes ricinus

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1例報告でlancet...

Lancet症例報告の概要• 70歳の患者が数ヶ月の経過で動作の緩慢、記憶障害、歩行困難を主訴に受診

• DLBCLでR-CHOPの治療を受けていた

• 血清検査では陰性だったがNeuroborreliosisが疑われCTRX 2g/day 2wksで治療された。その後、症状は完全に元に戻った

• 後になってmiyamotoiの可能性が考えられたため、CTRX投与前の髄液を暗視野顕微鏡で観察したところスピロヘータを認め、またmiyamotoi flagellin遺伝子が髄液と血液のqPCRで陽性であった。

• 患者の自宅近くのオランダのZandvoortに生息するIxodes ricinusの2.2%がqPCRでmiyamotoi陽性であった。

Case Report














Lancet 2013; 382: 658















H Sprong PhD)






Ixodes ricinus

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Borrelia miyamotoi Infection Presenting as HumanGranulocytic AnaplasmosisA Case ReportHanumara Ram Chowdri, MD; Joseph L. Gugliotta, MD; Victor P. Berardi; Heidi K. Goethert, ScD; Philip J. Molloy, MD;Sherri L. Sterling, MBA, MLS; and Sam R. Telford III, ScD

Background: The diverse tickborne infections of the northeasternUnited States can present as undifferentiated flu-like illnesses. Inareas endemic for Lyme and other tickborne diseases, patientspresenting with acute febrile illness with myalgia, headache, neu-tropenia, thrombocytopenia, and elevated hepatic aminotransferaselevels are presumptively diagnosed as having human granulocyticanaplasmosis (HGA).

Objective: To assign a cause for illness experienced by 2 casepatients who were initially diagnosed with HGA but did not rapidlydefervesce with doxycycline treatment and had no laboratory evi-dence of Anaplasma phagocytophilum infection.

Design: Case report.

Setting: 2 primary care medical centers in Massachusetts and NewJersey.

Patients: 2 case patients acutely presenting with fever.

Measurements: Identification of the causative agent by polymerasechain reaction and DNA sequencing.

Results: Molecular diagnostic assays detected Borrelia miyamotoiin the peripheral blood of both patients. There was no evidence ofinfection with other tickborne pathogens commonly diagnosed inthe referral areas.

Limitation: One of the case patients may have had concurrentLyme disease.

Conclusion: The presence of B. miyamotoi DNA in the peripheralblood and the patients’ eventual therapeutic response to doxycy-cline are consistent with the hypothesis that their illness was due tothis newly recognized spirochete. Samples from tick-exposed pa-tients acutely presenting with signs of HGA but who have a de-layed response to doxycycline therapy or negative confirmatory testresults for HGA should be analyzed carefully for evidence of B.miyamotoi infection.

Primary Funding Source: National Institutes of Health and theEvelyn Lilly Lutz Foundation.

Ann Intern Med. 2013;159:21-27. www.annals.orgFor author affiliations, see end of text.

Eleven tick-transmitted infections of the northeasternUnited States have been recognized (1). Deer ticks

(Ixodes dammini [2], also known as I. scapularis) are vectorsfor 5 of these: Lyme disease due to Borrelia burgdorferisensu stricto, babesiosis due to Babesia microti, humangranulocytic anaplasmosis (HGA) (also known as humangranulocytic ehrlichiosis, due to Anaplasma phagocytophi-lum), deer tick virus encephalitis, and Borrelia miyamotoimeningoencephalitis. All of the tick-transmitted infectionsmay present solely as an undifferentiated flu-like illness.

Deer tick virus (3, 4) and B. miyamotoi (5, 6) havebeen the basis for recent case reports of human illness. Asphysician awareness and the availability of laboratory con-firmation increase, the spectrum of known presentationscaused by these agents will probably expand.

Human granulocytic anaplasmosis due to A. phagocy-tophilum, a rickettsia-like bacterium, was first identified asa zoonotic infection in 1994 (7) with a case series of 12persons, 2 of whom died. The case patients experienced anacute febrile illness comprising severe myalgia and head-ache, shaking chills, and malaise. Intragranulocytic bacte-rial clusters were noted on Wright–Giemsa-stained buffycoat smears, and the identity of the agent was confirmed bypolymerase chain reaction (PCR) amplification and se-quencing of eubacterial 16S ribosomal DNA as well as byseroconversion to European ruminant-derived Ehrlichiaphagocytophila.

Nearly all of the case patients had leukopenia with leftshift, thrombocytopenia, and elevated serum aspartate ami-notransferase and lactate dehydrogenase levels. Of note,among the 10 who recovered, all defervesced within 24hours of receiving the first doses of oral doxycycline. Thisrapid response to treatment is so well-recognized that itsabsence in patients suspected of having HGA suggests adifferent cause (8).

A recent analysis (9) reported the presence of headachein 82% of 44 case patients with culture- or PCR-confirmedA. phagocytophilum infection; 89% with fever, sweats, andrigors; 84% with fatigue; and 73% with leukopenia andthrombocytopenia. These signs and symptoms are cardinalfeatures of tickborne rickettsial diseases in general (10), and“[a]ny reported fever and one or more of the following:headache, myalgia, anemia, leukopenia, thrombocytopenia,or any hepatic transaminase elevation” constitute formalclinical evidence for the case definition from the NationalNotifiable Diseases Surveillance System (wwwn.cdc.gov/NNDSS/script/casedef.aspx?CondYrID!667&DatePub!1/1/2008). Clinicians in the northeastern United States,

See also:

PrintEditorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Annals of Internal Medicine Original Research

© 2013 American College of Physicians 21

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2例報告でannals...

Annals症例報告の概要• 背景：ライム病やその他のダニ媒介感染症の流行するアメリカ北西部ではflu-like illnessを呈し好中球減少・血小板減少・肝酵素上昇を認める症例はヒト顆粒球アナプラズマ症(HGA)と臨床診断されやすい

• 目的：2例のHGAと臨床診断されたが血清学的な証拠がなくDOXY投与のみで解熱が得られた2症例について

• 結果：急性の発熱を呈した2例の末梢血のPCRでmiyamotoiのDNAが検出された。その他のダニ媒介感染症の病原微生物は検出されなかった（1例はライム病の共感染だった）

• 結論：HGAと臨床診断されてもDOXYのみで治癒する症例ではmiyamotoi感染症を疑い検査を行うべきである



















See also:





miyamotoiって？

INTERNATIONAL JOURNAL OF SYSTEMATIC BACTERIOLOGY, OCt. 1995, p. 804-810 0020-7713/95/$04.00.t 0 Copyright 0 1995, International Union of Microbiological Societies

Vol. 45, No. 4

Genetic and Phenotypic Analysis of Borrelia miyamotoi sp. nov., Isolated from the Ixodid Tick Ixodes persulcatus, the

Vector for Lyme Disease in Japan MASAHITO FUKUNAGA,' * YUKIE TAKAHASH1,l YASUTO TSURUTA,l OSAMU MATSUSHITA,*

DAVID RALPH,3 MICHAEL McCLELLAND,~ AND MINORU NAKA04 Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama, Hiroshima 729-02, '

Department of Microbiology, Kagawa Medical School, Ikenobe, Kita-gun, Kagawa 761-07, and Department of Parasitology, Asahikawa Medical College, Nishikagura, Hokkaido 078,

Japan, and California Institute of Biological Research, La Jolla, California 920373

The ixodid tick Ixodes persulcatus is the most important vector of Lyme disease in Japan. Most spirochete isolates obtained from I. persulcatus ticks have been classified as Borrelia burgdorferi sensu lato because of their genetic, biological, and immunological characteristics. However, we found that a small number of isolates obtained from I. persulcatus contained a smaller 38-kDa endoflagellar protein and single 23s-5s rRNA gene unit. Representative isolate HT31T (T = type strain) had the same 23s rRNA gene physical map as Borrelia turicatae. The DNA base composition of strain HT31T was 28.6 mol% G+C. DNA-DNA hybridization experi- ments revealed that strain HT31T exhibited moderate levels of DNA relatedness (24 to 51%) with Borrelia hemsii, B. turicatae, Borrelia parkeri, and Borrelia coriaceae. However, the levels of DNA reassociation with the previously described Lyme disease borreliae (B. burgdorferi, Borrelia garinii, and Borrelia afielii) were only 8 to 13%. None of the previously described species examined exhibited a high level of DNA relatedness with strain HT31T. In addition, the 16s rRNA gene sequence (length, 1,368 nucleotides) of strain HT31T was determined and aligned with the 16s rRNA sequences of other Borrelia species. Distance matrix analyses were performed, and a phylogenetic tree was constructed. The results showed that isolate HT31T is only distantly related to both previously described Lyme disease borreliae and relapsing fever borreliae. Thus, the spirochetes isolated from I. persulcatus and closely related isolates should be classified as members of a new Borrelia species. We propose the name Borrelia rniyamotoi sp. nov. for this spirochete; strain HT31 is the type strain.

We previously demonstrated the usefulness of a restriction fragment length polymorphism (RFLP) ribotyping system based on the 23s-5s rRNA gene repetition in Borrelia burgdorferi sensu lato associated with Lyme disease (14, 32). Many spirochete isolates were examined with our RFLP ribotyping system by using rRNA gene probes. The strains isolated in the United States and Europe were placed into three distinct RFLP groups. The North American isolates clustered in ribotype group I (B. burgdo$eri sensu stricto), and the European isolates were placed in ribotype groups I and I1 (Borrelia garinii) and ribotype group I11 (Borrelia afielii). These groups are completely consistent with the three previously described Lyme disease agent species (2,7,18). Our findings also showed that there are no B. burgdorferi sensu stricto representative strains in Japan and that some Japanese isolates belong to ribotype groups I1 and 111. In addition, most of the Japanese isolates produced RFLP patterns that were quite distinct from those of the North American and European isolates and were tentatively classified as ribotype group IV strains (14). Borrelia japonica is carried by Ixodes ovatus ticks, and it is thought that this microorganism is restricted to Japan. Moreover, some atypical spirochetes have been isolated in United States and Europe (38), and these spirochetes produced unique RFLP ribotype patterns.

Two medically important diseases, relapsing fever and Lyme borreliosis, are caused by Borrelia species (4). Both of these

* Corresponding author. Mailing address: Department of Molecular Microbiology, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Gakuencho 1-1, Fukuyama, Hiroshima 729-02, Japan. Phone: 81 849 36 2111. Fax: 81 849 36 2024. Electronic mail address: [email protected].

diseases are transmitted by hematophagous arthropods, and each pathogen is associated with particular vectors. Soft-bodied argasid ticks and the human body louse are the vectors of relapsing fever borreliae, while the vectors of Lyme disease borreliae are hard-bodied ixodid ticks, especially members of the Ixodes ricinus species complex (6, 17). The Borrelia pathogens differ in their clinical spectra. Periodic fever is the main symptom caused by relapsing fever borreliae (4); these organisms multiply in the bloodstream, and they have a high muta- tion rate in the genes which encode the outer membrane pro- teins and thus escape the host immune response. In contrast, Lyme disease borreliae cause various inflammatory reactions involving the skin, joints, heart, and central nervous system (22, 43); emergence of these borreliae into the bloodstream is rare, suggesting that they have a unique mechanism to escape the host immune response. Thus, the two related pathogens are quite different from one another in their adaptations to their arthropod and vertebrate hosts.

In our experimental survey, we found that a small number of the spirochetes examined contained a 38-kDa flagellin protein similar to that found in relapsing fever borreliae; in contrast, a 41-kDa flagellin protein is found in previously described Lyme disease borreliae. In this paper we describe the genetic and phenotypic characteristics of spirochetes isolated from Ixodes persulcatus ticks and a rodent. We also describe the results of a comparative 16s rRNA gene sequence analysis and a DNA- DNA relatedness analysis in which we identified strain HT3 lT (T = type strain) and related isolates as members of a new Borrelia species. Our results indicated that these spirochete isolates obtained from I. persulcatus actually belong to a new Borrelia species. We propose the name Borrelia miyamotoi for this new species.

804

日本で最初にみつかった！！

B. miyamotoiとは？• 1995年に北海道の根室に生息するIxodes persulcatus （シュルツェマダニ）から初めて分離された回帰熱スピロヘータ

• （たぶん）元旭川医科大学医動物学助教授の宮本健司先生に由来

• Ixodes persulcatus が生息する地域（日本、韓国、中国、モンゴル、モスクワ以東の旧ソビエト連邦）でも潜在的に蔓延している可能性が高いと考えられている

• 今回のNEJM, Lancet, Annalsの報告で、I. ricinus、I. scapularis、I. pacificusが生息する欧州・米国でも蔓延していることがわかった

• ボレリア属は病像から大きく2つに分けられる、すなわちライム病と回帰熱である。

• ライム病を起こすスピロヘータはB. burgdorferi sensu latoと呼ばれる。そのプロトタイプであるB. burgdorferi sensu strictoはアメリカでライム病を起こす唯一の菌種である。

• B. burgdorferi sensu latoに分類されるボレリアはマダニの中のカタダニhard ticksが保有している。アメリカ東部ではライム病のベクターはI.

damminiとI. scapularisである。このうちI. scapularisの方がB. miyamotoiのベクターでもあることが分かっている

B. miyamotoiとは？

• 回帰熱グループの菌種は遺伝子的に分かれており、その大部分が特徴的な周期性発熱を起こす。回帰熱グループのボレリアはヒメダニsoft

ticksが保有するが、B. recurrentisは例外でありシラミに媒介される。

• M. miyamotoiは回帰熱グループに属するがカタダニhard ticksに保有されているという特徴があり、日本ではロシアなどと同様にIxodes

persulcatus （シュルツェマダニ）が保有している

B. miyamotoiとは？

日本でも回帰熱に罹患する？

実はこれ以前に1例、2例報告よりも多いcase seriesがあります

なんとその数・・・

Borrelia miyamotoi is distantly related to B. burgdorferi and transmitted by the same hard-body tick species. We report 46 cases of B. miyamotoi infection in humans and compare the frequency and clinical manifestations of this infection with those caused by B. garinii and B. burgdorferi infection. All 46 patients lived in Russia and had infl uenza-like illness with fever as high as 39.5°C; relapsing febrile illness occurred in 5 (11%) and erythema migrans in 4 (9%). In Russia, the rate of B. miyamotoi infection in Ixodes persulcatus ticks was 1%–16%, similar to rates in I. ricinus ticks in western Europe and I. scapularis ticks in the United States. B. miyamotoi infection may cause relapsing fever and Lyme disease–like symptoms throughout the Holarctic region of the world because of the widespread prevalence of this pathogen in its ixodid tick vectors.

Borrelia miyamotoi, discovered in Japan in 1995, belongs to the relapsing fever group of Borrelia (1). Relapsing

fever borreliae infections are characterized by infl uenza-like illness and >1 relapse episode of bacteremia and fever. B. miyamotoi is more distantly related to B. burgdorferi, a group of spirochetes that includes B. burgdorferi s.l. strains (B. afzelii; B. garinii; and B. burgdorferi s.s., the causative agent of Lyme disease) (2,3). In Eurasia and North America, B. miyamotoi is found in a small percentage of all species of ixodid tick vectors of B. burgdorferi, including Ixodes persulcatus (1,3,4), I. ricinus (5–7), I. scapularis (2,3,8,9), and I. pacifi cus (10). It is transmitted

transovarially and transstadially by ticks and coexists with B. burgdorferi (2,3). Recently, we discovered B. miyamotoi in I. persulcatus and I. ricinus ticks in the European and Asian regions of Russia. In these areas, human ixodid tick-borne infections, including those caused by B. afzelii, B. garinii, and viral tick-borne encephalitis virus (TBEV; genus Flavivirus) are endemic and transmitted by the same tick species.

Despite the presence of B. miyamotoi in vector ticks, to our knowledge, human disease caused by this spirochete has not been defi nitively established. We previously noted presumptive B. miyamotoi infection in residents of central Russia with infl uenza-like illness but were uncertain whether their clinical manifestations were caused by co-infecting B. burgdorferi s.l. species (11–13). To confi rm those fi ndings and develop initial estimates of the prevalence and severity of B. miyamotoi infection, we conducted a comparative cohort study. We used improved antibody assays and PCRs to compare the relative frequency and clinical manifestations of B. miyamotoi infection with those of B. garinii infection in Russia and B. burgdorferi infection in the United States.

Methods

Study DesignWe enrolled patients admitted to Municipal Clinical

Hospital No. 33 in Yekaterinburg City, Russia, from May 19 through August 25, 2009, for suspected tick-borne infection. Yekaterinburg is in the Asian part of Russia, §1,200 miles east of Moscow. Viral tick-borne encephalitis and acute borreliosis are highly endemic to this region. Patients with moderate or severe disease are usually hospitalized.

We compared the clinical characteristics of patients experiencing laboratory-confi rmed B. miyamotoi infection

Humans Infected with Relapsing Fever Spirochete Borrelia

miyamotoi, RussiaAlexander E. Platonov, Ludmila S. Karan, Nadezhda M. Kolyasnikova, Natalya A. Makhneva,

Marina G. Toporkova, Victor V. Maleev, Durland Fish, and Peter J. Krause

RESEARCH

1816 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 10, October 2011

Author affi liations: Central Research Institute of Epidemiology, Moscow, Russia (A.E. Platonov, L.S. Karan, N.M. Kolyasnikova, V.V. Maleev); Municipal Clinical Hospital No. 33, Yekaterinburg, Russia (N.A. Makhneva, M.G. Toporkova); and Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, USA (D. Fish, P.J. Krause)

DOI: http://dx.doi.org/10.3201/eid1710.101474

Humans Infected with Borrelia miyamotoi

with those of patients experiencing B. garinii infections from the same area and with those of patients who experienced B. burgdorferi infection in the northeastern United States. The US data came from a tick-borne diseases study conducted during 1991–2008 (14,15). For each patient at all study sites, we recorded the presence or absence of a standard set of 11 clinical manifestations. All patients signed an informed consent form in accordance with the institutional review boards of the Municipal Clinical Hospital in Yekaterinburg City or the University of Connecticut School of Medicine.

We also determined the frequency of B. garinii, B. afzelii, B. burgdorferi, and B. miyamotoi in I. persulcatus and I. ricinus ticks in Yekaterinburg and several additional regions of Russia (Figure 1). Ticks were collected by drag cloth, visually identifi ed to species level, and analyzed by PCR to identify specifi c Borrelia species.

Case Defi nitionsDiagnosis of B. miyamotoi infection required the report

of a tick bite, presence of clinical manifestations consistent with borreliosis, and laboratory evidence of B. miyamotoi infection. Clinical manifestations included fever, headache, chills, fatigue, vomiting, and myalgia. Confi rmation of active infection consisted of amplifi cation of B. miyamotoi DNA/RNA in blood by species-specifi c PCR and detection of anti-borreliae immunoglobulin (Ig) M in acute- and/or convalescent-phase serum samples.

In Russia, diagnosis of B. garinii infection required report of a tick bite, physician diagnosis of erythema migrans (EM; an expanding, ring-like erythematous rash >5 cm in diameter), or an infl uenza-like illness. Confi rmation of infection consisted of amplifi cation of B. garinii DNA/RNA in blood by specifi c PCR, followed by direct sequencing of 5S-23S ribosomal RNA (rRNA) intergenic spacers, and detection of anti-borreliae IgM in acute- and/or convalescent-phase serum samples.

In the United States, diagnosis of B. burgdorferi infection required a physician’s diagnosis of EM or an infl uenza-like illness. For all cases, confi rmation of infection consisted of a >4-fold increase in anti–B. burgdorferi antibody in acute- and convalescent-phase serum samples. The diagnosis of TBEV infection was based on a viral-like illness, including headache (with or without meningitis or encephalitis), amplifi cation of TBEV RNA in blood by species-specifi c PCR, and/or detection of anti-TBEV IgM in an acute-phase serum sample.

Laboratory Assays

PCRThe PCR we used enabled detection of DNA and

RNA sequences. DNA/RNA was extracted from 2 mL of

whole venous blood with EDTA or from tick suspensions by using an AmpliSens Riboprep Kit (Central Institute of Epidemiology, Moscow, Russia) according to the manufacturer’s instructions. Of the blood samples used for PCR, 81% were obtained at the time of hospital admission and 96% within 2 days of admission. To assay the inhibitory effect of blood and tick extracts on the PCR, all samples were spiked with a universal RNA recombinant control having a known number of RNA copies per milliliter. Reverse transcription of RNA to cDNA was performed by using an Amplisens Reverta-L Kit (Central Institute of Epidemiology). The cDNA samples were assayed for B. miyamotoi and other tick-borne pathogens by using real-time quantitative PCR (qPCR) assays in a Rotor Gene 6000 cycler (Corbett Life Science, Concorde, New South Wales, Australia).

The cDNA samples were divided into 2 aliquots, and different types of real-time qPCR were performed on each. The fi rst used in-house primers and a probe that targeted the 16S rRNA gene of B. miyamotoi. The inclusion of the reverse transcription procedure improved the detection sensitivity because the 16S rRNA that also became detectable is present in higher copy numbers than the 16S rRNA gene. The detection limit of at least 5 u 103 copies/mL was determined by using positive recombinant DNA of the B. miyamotoi 16S rRNA gene fragment with a known number of copies. The B. miyamotoi–specifi c forward and reverse primers at 360 nmol/L were, respectively, Brm1

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 10, October 2011 1817

Figure 1. Percentage of Ixodes persulcatus (I. p.) and I. ricinus (I. r.) ticks infected with Borrelia miyamotoi in Russia. The number of ticks that were tested is given in parenthesis. Star indicates study location of human B. miyamotoi infection.

miyamotoiを保有するダニの比率地域によっては1割以上のダニが保有


in acute- and/or convalescent-phase serum, and 24 had EM alone); 42 had unconfi rmed Borrelia spp. infections with anti-borreliae IgM but lacked EM and were Borrelia spp. negative on PCR; 41 had TBE; 37 had fever of unknown origin after tick bite; and 27 had other diagnoses, including enteroviral infection, mononucleosis, or pyelonephritis. None of the 302 patients had any PCR-based evidence of B. afzelii, A. phagocytophillum, or E. muris infection.

Clinical ManifestationsPatients from Russia with B. miyamotoi and B. garinii

infection and patients from the United States with B. burgdorferi infection were similar in age and sex. Time from tick bite to onset of symptoms was longer and time from symptom onset to hospital admission was shorter for B. miyamotoi patients than for B. garinii patients (Table 2).

More systemic manifestations, including fever and headache, were reported for B. miyamotoi patients than for B. garinii and B. burgdorferi patients (Table 3). Maximum temperatures measured at home and in the hospital were higher for B. miyamotoi patients (39.0°C, interquartile range [IQR] 38.8–39.5°C) than for B. garinii patients (37.6°C, IQR 38.8–39.5°C; p<0.001). Duration of fever was relatively short and did not differ signifi cantly for B. miyamotoi and B. garinii patients (3.4 ± 1.4 and 3.3 ± 2.8 days, respectively). Body temperature began to return to reference range before antimicrobial drug therapy was initiated, as has been described for relapsing fever patients, in all but 1 B. miyamotoi patient. Hospital stay was longer for B. miyamotoi patients (median 20 days, IQR 15–22

days) than for B. garinii patients (median 10 days, IQR 10–13 days; p<0.001).

Although mean peripheral leukocyte and platelet counts were lower for patients with B. miyamotoi than B. garinii infection, they were within the reference range. Proteinuria and transient elevation of serum alanine aminotransferase and aspartate aminotransferase concentrations were found for 3u more B. miyamotoi patients than B. garinii patients (51% and 68% vs. 15% and 20%, respectively, p<0.01), but no nephritis or hepatitis was clinically apparent. We found similar clinical and laboratory results when we omitted from analysis the 4 B. miyamotoi patients with EM who might have been co-infected with B. burgdorferi s.l.

Therapy and Clinical OutcomeAntimicrobial drug therapy for the B. miyamotoi

patients was started §1 week after admission when IgM-based serologic tests results confi rmed the diagnosis (median 7 days, IQR 6–10 days). Therapy consisted of ceftriaxone, 2 g intravenously every 24 hours for 2 weeks (42 patients) or doxycycline 100 mg orally every 12 hours for 2 weeks (2 patients). Two patients received no antimicrobial drug while hospitalized; 1 later received doxycycline at home, and the other was readmitted to the hospital for relapse and received ceftriaxone. Patients with B. garinii infection received doxycycline (71%) or ceftriaxone (29%) immediately after admission because diagnosis of borreliosis, based on presence of EM, was made at the time of admission. B. burgdorferi patients all received doxycycline, 100 mg orally every 12 hours, or


Table 1. Classification of suspected tick-borne infections, Yekaterinburg City, Russia, May–August 2009*

Classification

Total no.

patients

No. patients

with erythema

migrans

Amplifiable DNA/RNA, by PCR Antibody

Borrelia miyamotoi

B. burgdorferi s.l. TBEV

Borrelia IgM

TBEV

IgM

B. miyamotoi infection, confirmed 46 4 46 0 0 46 0

B. miyamotoi infection, unconfirmed 2 0 2 0 0 0 0

B. miyamotoi infection, TBEV co-infection 3 0 3 0 0 2 3

B. garinii infection, confirmed 21 19 0 21 0 21 0

B. burgdorferi s.l. infection 83 83 0 0 0 59 0

Borrelia spp. infection, unconfirmed 42 0 0 0 0 42 0

TBEV infection, confirmed 21 0 0 0 5 0 21

TBEV, B. burgdorferi s.l. co-infection 9 9 0 0 2 ND 9

TBEV, Borrelia spp. co-infection 11 0 0 0 3 11 11

Other inflammatory disease 64 0 0 0 0 0 0

*TBEV, tick-borne encephalitis virus; Ig, immunoglobulin; ND, not determined.

Table 2. Patient characteristics and infection timeline for Borrelia spp. infections, by species*

Borrelia species

No. patients

infected

Infection timeline, median no. days (IQR)

Patient characteristics Tick bite to symptom

onset

Symptom onset to

hospital admission Median age, y (range) Male sex, no. (%)

B. miyamotoi 46 54 (21–77) 24 (52) 15 (12–16) 1 (1–2)

B. garinii 21 58 (18–87) 11 (52) 10 (7–13)† 5 (2–9)†

B. burgdorferi 92 50 (14–79) 49 (53) NA NA

*IQR, interquartile range; NA, not available.

†p<0.001 in comparison with patients with B. miyamotoi infection.


in acute- and/or convalescent-phase serum, and 24 had EM alone); 42 had unconfi rmed Borrelia spp. infections with anti-borreliae IgM but lacked EM and were Borrelia spp. negative on PCR; 41 had TBE; 37 had fever of unknown origin after tick bite; and 27 had other diagnoses, including enteroviral infection, mononucleosis, or pyelonephritis. None of the 302 patients had any PCR-based evidence of B. afzelii, A. phagocytophillum, or E. muris infection.

Clinical ManifestationsPatients from Russia with B. miyamotoi and B. garinii

infection and patients from the United States with B. burgdorferi infection were similar in age and sex. Time from tick bite to onset of symptoms was longer and time from symptom onset to hospital admission was shorter for B. miyamotoi patients than for B. garinii patients (Table 2).

More systemic manifestations, including fever and headache, were reported for B. miyamotoi patients than for B. garinii and B. burgdorferi patients (Table 3). Maximum temperatures measured at home and in the hospital were higher for B. miyamotoi patients (39.0°C, interquartile range [IQR] 38.8–39.5°C) than for B. garinii patients (37.6°C, IQR 38.8–39.5°C; p<0.001). Duration of fever was relatively short and did not differ signifi cantly for B. miyamotoi and B. garinii patients (3.4 ± 1.4 and 3.3 ± 2.8 days, respectively). Body temperature began to return to reference range before antimicrobial drug therapy was initiated, as has been described for relapsing fever patients, in all but 1 B. miyamotoi patient. Hospital stay was longer for B. miyamotoi patients (median 20 days, IQR 15–22

days) than for B. garinii patients (median 10 days, IQR 10–13 days; p<0.001).

Although mean peripheral leukocyte and platelet counts were lower for patients with B. miyamotoi than B. garinii infection, they were within the reference range. Proteinuria and transient elevation of serum alanine aminotransferase and aspartate aminotransferase concentrations were found for 3u more B. miyamotoi patients than B. garinii patients (51% and 68% vs. 15% and 20%, respectively, p<0.01), but no nephritis or hepatitis was clinically apparent. We found similar clinical and laboratory results when we omitted from analysis the 4 B. miyamotoi patients with EM who might have been co-infected with B. burgdorferi s.l.

Therapy and Clinical OutcomeAntimicrobial drug therapy for the B. miyamotoi

patients was started §1 week after admission when IgM-based serologic tests results confi rmed the diagnosis (median 7 days, IQR 6–10 days). Therapy consisted of ceftriaxone, 2 g intravenously every 24 hours for 2 weeks (42 patients) or doxycycline 100 mg orally every 12 hours for 2 weeks (2 patients). Two patients received no antimicrobial drug while hospitalized; 1 later received doxycycline at home, and the other was readmitted to the hospital for relapse and received ceftriaxone. Patients with B. garinii infection received doxycycline (71%) or ceftriaxone (29%) immediately after admission because diagnosis of borreliosis, based on presence of EM, was made at the time of admission. B. burgdorferi patients all received doxycycline, 100 mg orally every 12 hours, or


Table 1. Classification of suspected tick-borne infections, Yekaterinburg City, Russia, May–August 2009*

Classification

Total no.

patients

No. patients

with erythema

migrans

Amplifiable DNA/RNA, by PCR Antibody

Borrelia miyamotoi

B. burgdorferi s.l. TBEV

Borrelia IgM

TBEV

IgM

B. miyamotoi infection, confirmed 46 4 46 0 0 46 0

B. miyamotoi infection, unconfirmed 2 0 2 0 0 0 0

B. miyamotoi infection, TBEV co-infection 3 0 3 0 0 2 3

B. garinii infection, confirmed 21 19 0 21 0 21 0

B. burgdorferi s.l. infection 83 83 0 0 0 59 0

Borrelia spp. infection, unconfirmed 42 0 0 0 0 42 0

TBEV infection, confirmed 21 0 0 0 5 0 21

TBEV, B. burgdorferi s.l. co-infection 9 9 0 0 2 ND 9

TBEV, Borrelia spp. co-infection 11 0 0 0 3 11 11

Other inflammatory disease 64 0 0 0 0 0 0

*TBEV, tick-borne encephalitis virus; Ig, immunoglobulin; ND, not determined.

Table 2. Patient characteristics and infection timeline for Borrelia spp. infections, by species*

Borrelia species

No. patients

infected

Infection timeline, median no. days (IQR)

Patient characteristics Tick bite to symptom

onset

Symptom onset to

hospital admission Median age, y (range) Male sex, no. (%)

B. miyamotoi 46 54 (21–77) 24 (52) 15 (12–16) 1 (1–2)

B. garinii 21 58 (18–87) 11 (52) 10 (7–13)† 5 (2–9)†

B. burgdorferi 92 50 (14–79) 49 (53) NA NA

*IQR, interquartile range; NA, not available.

†p<0.001 in comparison with patients with B. miyamotoi infection.

確定例: 末梢血中にmiyamotoi DNA/RNAを検出した症例

患者年齢の中央値は54歳、潜伏期は2週間程度

RESEARCH

amoxicillin, 500 mg orally every 8 hours, for 2–4 weeks. A Jarisch-Herxheimer reaction was noted for 7 (15%) of the 46 B. miyamotoi patients. More such reactions might have been expected if treatment had not been delayed until §1 week after admission. A single course of ceftriaxone or doxycycline appeared to clear B. miyamotoi infection.

Relapsing InfectionOf the 46 B. miyamotoi patients, 5 (11%, 95% con-

fi dence interval 2%–20%) experienced relapse of febrile illness; 1 patient experienced 2 relapses before hospital admission, and 4 experienced 1 relapse after hospitalization but before the start of antimicrobial drug therapy. Thus, antimicrobial drugs might have prevented relapse in those who received this therapy. The mean time between relapses was 9 days (range 2 days to 2 weeks). The maximum fever and duration of illness did not differ signifi cantly for the fi rst and second episodes of illness (Figure 2). No clinical or laboratory fi ndings indicated other infections (including blood-borne, skin, neurologic, respiratory, cardiac, gastrointestinal, and urologic) or medical conditions that could account for these febrile episodes.

B. miyamotoi in TicksDuring 2004–2007, we found B. miyamotoi–infected

I. persulcatus ticks in the regions where the human cases had been noted (11,13), namely, 0.9% of 442 ticks in Yekaterinburg and 6.4% of 394 ticks in Izhevsk. B. miyamotoi–infected I. persulcatus and I. ricinus ticks were found in regions where human cases have not yet been identifi ed (Figure 1). These fi ndings were confi rmed by direct sequencing of PCR DNA amplifi cation products

(GenBank accession nos. GU797336, GU797337, GU797338, GU797346, JF951378–JF951392).

Genetic Characteristics of B. miyamotoiThe nucleotide sequences of 16S rRNA and fl agellin

gene fragments of all B. miyamotoi isolates from humans and I. persulcatus ticks were almost indistinguishable from the corresponding sequences of the prototype Japan HT-31 strain (1) (Figure 3). B. miyamotoi from I. ricinus ticks collected in the European part of Russia were more closely related to European B. miyamotoi strains (5,6).

DiscussionWe provide confi rmatory evidence of B. miyamotoi

infection in humans. Most patients experienced clinical manifestations similar to those caused by B. burgdorferi s.l. and relapsing fever Borrelia infections, a fi nding consistent with the genetic characteristics of this novel spirochete. Febrile relapses occurred in only 1 of 10 B. miyamotoi patients, 2 days to 1 month after the initial illness; however, early treatment may have prevented subsequent relapse for other patients. Although the febrile episodes at home might have been caused by other illnesses, the onset of fever within 2 weeks after a tick bite was consistent with the incubation period of infection with borreliae. Furthermore, no clinical or laboratory fi ndings indicated other infections or medical conditions that could account for the febrile episodes. EM was found in §1 of 10 B. miyamotoi patients, but these patients might have had unrecognized B. burgdorferi s.l. co-infection. A single course of ceftriaxone or doxycycline seemed to clear B. miyamotoi infection. Although effective therapy is available, appropriate diagnosis and therapy are


Table 3. Clinical manifestations in patients with Borrelia spp. infection, Yekaterinburg City, Russia, 2009, and northeastern United States, 1991–2008*

Manifestation

% Patients p value B. miyamotoi,

n = 46B. garinii,

n = 21B. burgdorferi,

n = 92B. miyamotoivs. B. garinii

B. miyamotoi vs. B. burgdorferi

B. garinii vs.B. burgdorferi

Individual EM 9 91 89 <0.001 <0.001 >0.999 Multiple EM 0 14 7 0.03 0.18 0.36 Fever† 98 67 32 0.001 <0.001 0.005 Fatigue 98 86 74 0.09 <0.001 0.4 Headache 89 57 63 0.007 0.001 0.63 Chills 35 10 43 0.04 0.36 0.005 Myalgia 59 52 63 0.8 0.71 0.46 Arthralgia 28 29 62 >0.999 <0.001 0.007 Nausea 30 10 24 0.07 0.420 0.24 Vomiting 7 5 7 >0.999 >0.999 >0.999 Neck stiffness 2 0 38 >0.999 <0.001 <0.001Overall No. symptoms, mean ± SD 4.5 ± 1.4 4.2 ± 2.0 5.0 ± 2.3 0.43 0.13 0.13 No. symptoms (excluding EM and multiple EM), mean ± SD

4.5 ± 1.4 3.1 ± 1.9 4.1 ± 2.3 0.007 0.46 0.09

*EM, erythema migrans. †Maximum axillary temperature >37.2°C for patients in Russia and maximum oral temperature >37.7°C for patients in the United States.

EMを呈した患者が9人・・・ライムとの共感染？

ライムと比較して発熱＋全身症状が多い


complicated by lack of awareness of B. miyamotoi as a human pathogen, the nonspecifi c symptoms of infection, and the absence of standardized and widely available assays. We found no PCR-based evidence of infection caused by B. afzelii, A. phagocytophilum, or E. muris in the patients, although these pathogens have been detected in Ixodes spp. ticks in the same region (16). There is only anecdotal evidence of B. afzelii infection confi rmed by culture or PCR in Russia and none in the Yekaterinburg region. Relapsing fever borreliae other than B. miyamotoi were not found in Yekaterinburg.

B. miyamotoi infection may cause substantial health problems in the regions of Russia where it has been found, given its relatively high incidence and associated severity of disease. On the basis of the number of patients with B. miyamotoi infection in Yekaterinburg Hospital in 2009 and the populations of Yekaterinburg Province (4,395,000), we estimate that the minimal incidence of B. miyamotoi infections is 1 case per 100,000 population. According to offi cial federal notifi cation during the past 10 years, §8,000 cases of human borreliosis occur in Russia annually (12).

B. miyamotoi infection seems to constitute at least 1/4 of all clinical tick-borne borreliosis cases in Yekaterinburg. If other Borrelia spp.–endemic areas have a similar rate of B. miyamotoi infection as Yekaterinburg (and our tick data suggest that this assumption is reasonable), >1,000 B. miyamotoi cases might occur in Russia each year. More studies are necessary to determine if this projection is accurate.

Acute B. miyamotoi infection was more severe than early stage B. burgdorferi infection. The time from symptom onset to hospital admission was shorter, and the number of clinical manifestations was greater for patients with B. miyamotoi infection than with B. garinii infection. Relapsing febrile episodes were only reported for B. miyamotoi patients. Such multiple disease episodes not only have an adverse effect on a patient’s health but also may result in costly medical bills, many days or weeks of lost wages, and medical misdiagnosis (19–22). Co-infection of B. miyamotoi with other ixodid tick–transmitted agents may increase disease severity (15,23). Additional problems that might occur with B. miyamotoi infection are ocular, neurologic, respiratory, cardiac, and pregnancy complications associated with relapsing fever (19–22).

Our study had several limitations. Attempts to detect B. miyamotoi on blood smear or in culture were not successful, although we confi rmed B. miyamotoi infection with a combination of qPCR, genetic sequencing, clinical, and seroconversion evidence. The comparison of clinical manifestations of Borrelia spp. infection of patients from Russia and the United States was complicated by enrollment at different times and from different locations, although we assessed the same 11 clinical manifestations at each location. The possibility that the clinical description of our B. miyamotoi cases was compromised by unrecognized co-infection with B. burgdorferi s.l. is unlikely. The expected number of cases of co-infection depends on the prevalence of the pathogens in ticks in the region (3,11,24), and this number is even fewer than the 4 B. miyamotoi patients with EM we found. Inclusion or exclusion of these 4 cases had no effect on our comparative analysis with patients who did not have B. miyamotoi infection. We limited our description of B. garinii cases to those that were confi rmed by detection of amplifi able B. garinii DNA/RNA, although such cases may be more severe than those in which such DNA/RNA cannot be detected (25,26). Patients with B. burgdorferi s.l. PCR–negative results experienced fewer symptoms and milder fever than did patients with B. burgdorferi s.l. PCR–positive results. Our analysis of patients with B. miyamotoi and B. garinii infection was limited to those who were hospitalized, although hospital admission policy in these regions of Russia is liberal because of concern about TBE and problems associated with B. burgdorferi infection.


Figure 2. Examples of relapsing fever episodes in 2 patients with Borrelia miyamotoi infection. Arrows indicate the timing of tick bite, hospital admission, PCR testing, anti-borreliae immunoglobulin (Ig) M testing, and initiation of antimicrobial drug therapy.

2例で周期性発熱が観察された

B. miyamotoiのヒト感染例が回帰熱を起こすことを示した初の報告

RESEARCH

The geographic dispersion and extent of B. miyamotoi disease in humans are unclear, but the infection probably

occurs outside of Russia, given the comparative infection

rates of vector ticks in Russia and at several locations in

Europe and the United States (2–8). In the northeastern

United States, §15% of all spirochetes carried by I. scapularis ticks are B. miyamotoi (2). Cases may remain

undiagnosed because of the nonspecifi c nature of the

illness, which might be confused with viral infections or

such tick-borne infections as Lyme disease, babesiosis,

anaplasmosis, or ehrlichiosis, and because of the lack of

laboratory tests for confi rmatory diagnosis (19–22).

B. miyamotoi infection may have negative health

consequences, including relapsing disease that may last for

months and may not respond to inappropriate antimicrobial

drug therapy. The discovery of a Borrelia sp. that is

pathogenic in humans and transmitted by an array of ixodid

ticks greatly expands the potential geographic distribution

of this disease (1–11). Further investigation of possible B. miyamotoi infection in humans is warranted wherever I.

pacifi cus, I. persulcatus, I. ricinus, and I. scapularis ticks

are found.

AcknowledgmentsWe thank Paul Cislo and Diane Mancini for their assistance.

We also thank all specialists who helped collect ticks and clinical

samples.

This project was funded in part by the generous support of

the Russian Ministry of Health and Social Development; special

research programs of Central Research Institute of Epidemiology,

Moscow; the Gordon and Llura Gund Foundation; the G. Harold

and Lyela Y. Mathers Charitable Foundation; and US Department

of Agriculture–Agricultural Research Service Cooperative

Agreement no. 58-0790-5-068.

Prof Platonov is head of the Laboratory for Zoonoses,

Central Research Institute of Epidemiology, Moscow, Russia.

His research interests are focused on, but not limited to, the

epidemiology, diagnosis, and prevention of tick-borne and

mosquito-borne diseases.


Figure 3. Phylogenetic tree of Borrelia spp. detected in persons and ticks, based on fl agellin gene fragment (A) and16S rRNA gene fragment (B). Sequences were aligned and analyzed by using MEGA4.1 software (www.megasoftware.net). Genetic trees were constructed from the partial nucleotide sequences of the fl agellin gene and the 16S rRNA gene by using the Kimura 2-parameter model and the unweighted pair group method with arithmetic mean. Arrow indicates the 16 Borrelia spp. from Yekaterinburg in 2009 that had the same nucleotide sequence. Circles indicate sequences that we listed in GenBank (accession nos. GU797331–GU797346 and JF951378–JF951392). Sequences for B. burgdorferi sensu lato and relapsing fever borreliae are shown for comparison. Scale bars indicate genetic distance.

後ろ向きの血清疫学調査

ライム病流行地域であるロードアイランド州Block 島とPrudence島およびマサチューセッツ州Brimfield 在住者の

健常者584名T h e n e w e ngl a nd j o u r na l o f m e dic i n e


suspected Lyme disease. Group 3 consisted of 14 patients from southern New York who were evaluated at a Lyme disease clinic with a viral-like illness in the late spring or summer; these patients did not have symptoms or signs sugges-tive of an upper respiratory tract infection or gastroenteritis.

The seroprevalence was 1.0% in group 1, 3.2% in group 2, and 21.0% in group 3 (P<0.001

for comparisons among the three groups). In one patient in group 2 and two patients in group 3, the antibody titer was at least four times as high in the convalescent serum samples as in the acute serum samples; these findings suggest that these patients were recently infected with B. miyamotoi (Table 1). All symptomatic patients presented with a viral-like illness and were treated with doxycycline or amoxicillin. Unlike

Table 1. Serologic and Clinical Characteristics of Borrelia miyamotoi Infection in Study Patients.*

Group, Patient No., and Serum Phase† Assay Method Coinfection‡

No. of Symptoms

ELISA Western Blot

IgM IgG

Group 1

Patient 1 Positive at 1:320 dilution Positive Positive None None

Patient 2 Positive at 1:320 dilution Positive Negative None None


Patient 4 Positive at !1:320 dilution§ Not done Positive None None



Group 2

Patient 7 Positive at !1:320 dilution§ Not done Positive None 5

Patient 8 Positive at 1:320 dilution Negative Positive None 9




Patient 12 Positive at 1:1280 dilution Negative Positive Lyme disease 4

Patient 13 Positive at 1:320 dilution Negative Positive Lyme disease Uncertain

Patient 14 Positive at 1:320 dilution Positive Positive Lyme disease Uncertain

Patient 15

Acute Negative at 1:160 dilution Negative Negative Babesiosis 12

Convalescent Positive at 1:1280 dilution Positive Positive

Group 3

Patient 16 Positive at 1:1280 dilution Positive Positive None 5

Patient 17

Acute Negative at 1:80 dilution Positive Negative None 10


Patient 18

Acute Negative at 1:80 dilution Positive Positive Lyme disease 12

Convalescent Positive at 1:320 dilution Negative Positive

* ELISA denotes enzyme-linked immunosorbent assay.† See the text for the definition of the various groups.‡ The diagnosis of Lyme disease was based on a typical erythema migrans skin lesion in Patients 12, 13, 14, and 18.

Patients 8 and 16 had an atypical erythema migrans skin lesion (<5 cm in diameter).§ Tests to determine the presence of antibody in serum dilutions greater than 1:320 were not performed.

The New England Journal of Medicine Downloaded from nejm.org on November 19, 2013. For personal use only. No other uses without permission.


春から秋のマダニ活動期に採血されているが、採血時は健康であった集団

6人/584人がB. miyamotoi IgMまたはIgGが陽性

ニューイングランド州南部の在住者でライム病が疑われた

患者277名








No. of Symptoms

ELISA Western Blot

IgM IgG

Group 1







Group 2









Patient 15



Group 3


Patient 17



Patient 18














No. of Symptoms

ELISA Western Blot

IgM IgG

Group 1







Group 2









Patient 15



Group 3


Patient 17



Patient 18








マダニ活動期である晩春～夏に、ニューヨーク州南部のライム病クリニックを訪れた患者のうち、上気道もしくは腸管性のウイルス感染が否定的で、か

つ何らかのウイルス感染症様症状を伴った

患者14名








No. of Symptoms

ELISA Western Blot

IgM IgG

Group 1







Group 2









Patient 15



Group 3


Patient 17



Patient 18














No. of Symptoms

ELISA Western Blot

IgM IgG

Group 1







Group 2









Patient 15



Group 3


Patient 17



Patient 18








概要• ライム病流行地域では、健常者の1%で

miyamotoi抗体陽性者がいる（知らず知らずのうちに感染している？）

• ライム病が疑われた患者の3.2%でmiyamotoi抗体陽性だった（ライム病との共感染またはmiyamotoi単独感染）

• ライム病流行地域でful-like illnessを呈した患者の21%でmiyamotoi抗体陽性だった（miyamotoi単独感染症？）

miyamotoiはライム病流行地で蔓延している？

ということは日本でも・・・？

そもそもmiyamotoiは北海道で発見されたわけで・・・

そのうち日本でも・・・と思っていたら

PCRをかけまくった感染研の川端寛樹先生

概要• 過去にライム病が疑われた患者血清約800検体を用いた後ろ向き疫学調査を実施し、このうち発症後の有熱期に採血された２検体からB.

miyamotoi DNAを検出した。またこのうちの１検体ではB. miyamotoi

HT31株由来の組換えGlpQ抗原を用いたB.miyamotoi特異的な抗体検査により、回復期ペア血清で抗体上昇が確認された。

• これら２検体は北海道在住の患者より採取されたものであり、いずれもライム病血清診断でも抗体陽性と判定されている。

• これら２症例は国内でのマダニ刺咬により感染したものと考えられている。いずれの症例もミノサイクリンもしくはセフトリアキソン投与により回復している。

日本でも回帰熱に罹患する！！

FIG. 1. Geographical distributions in Japan of the ticks from which the rickettsial isolates studied were isolated. (a) I. persulcatus; (b) I.monospinosus; (c) I. ovatus; (d) H. flava; (e) D. taiwanensis; (f) A. testudinarium. Green dots indicate the distributions of the ticks, and the red dotsindicate the area where the ticks harboring the rickettsiae were collected.

VOL. 40, 2002 IDENTIFICATION OF RICKETTSIAE FROM JAPANESE TICKS 2177

I. persulcatusの分布

J Clin Microbiol. 2002 Jun;40(6):2176-81.

北海道に多いとされているが全国に分布している

miyamotoi診断のための現実的なアプローチ• ライム病疑いの患者では血清を採取してmiyamotoi抗体も同時に依頼（感染研川端寛樹先生）

• I. persucatusの生息する地域でのダニ曝露後にfull-like

illnessを呈した患者で、原因が分からないものに関してはmiyamotoi検査を考慮（特に回帰性発熱を呈する患者では積極的に疑う）

b. miyamotoi はあなたのそばにいる

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