REVISIÓN DE LITERATURA

Rickettsioses in Latin America, Caribbean, Spain and Portugal

Rickettsiosis en América Latina, el Caribe, España y Portugal

Marcelo B. Labruna,^1* Ph.D, Salim Mattar V,² Ph.D, Santiago Nava,³ Ph.D, Sergio Bermudez,⁴ M.Sc, Jose M. Venzal,⁵ Ph.D, Gaby Dolz,⁶ Ph.D, Katia Abarca,⁷ M.D, Luis Romero,⁸ M.Sc, Rita de Sousa,⁹ Ph.D, Jose Oteo,¹⁰ M.D, Jorge Zavala-Castro,¹¹ Ph.D.

¹Universidade de São Paulo, Departamento de Medicina Veterinária Preventiva e Saúde Animal, Faculdade de Medicina Veterinhária e Zootecnia, São Paulo, SP, Brazil;
²Universidad de Córdoba, Instituto de Investigaciones Bilogicas del Tropico, Montería, Colombia,
³Instituto Nacional de Tecnología Agropecuaria, Estación Experimental, Agropecuaria Rafaela, Rafaela, Santa Fe, Argentina.
⁴Instituto Conmemorativo Gorgas de Estudios de la Salud, Ciudad de Panamá, Panamá.
⁵Universidad de la República de Uruguay. Facultad de Veterinaria, Departamento de Parasitología Veterinaria, Regional Norte-Salto, Uruguay.
⁶Universidad Nacional de Costa Rica, Facultad Ciencias de la Salud, Escuela de Medicina Veterinaria. Heredia, Costa Rica.
⁷Pontificia Universidad Católica de Chile, Facultad de Medicina, Chile.
⁸Laboratorio Central de Diagnóstico Veterinario, Ministerio de Agricultura y Ganadería (MAG), San Salvador, El Salvador.
⁹Laboratorio de Saude Publica, Lisboa, Portugal.
¹⁰Hospital San Pedro, área de Enfermedades Infecciosas, Logroño (La Rioja), España.
¹¹Universidad Autónoma de Yucatan. Centro de investigaciones regionales Dr. Hideyo Noguchi, Merida Yucatan, Mexico.

^*Corresponding author: labruna@usp.br

Recibido: Enero de 2011; Aceptado: Agosto de 2011

Abstract

Data on genus and infectious by Rickettsia were retrospectively compiled from the critical review literature regarding all countries in Latin America, Caribbean islands, Portugal and Spain. We considered all Rickettsia records reported for human and/or animal hosts, and/or invertebrate hosts considered being the vector. In a few cases, when no direct detection of a given Rickettsia group or species was available for a given country, the serologic method was considered. A total of 13 Rickettsia species have been recorded in Latin America and the Caribbean. The species with the largest number of country confirmed records were Rickettsia felis (9 countries), R. prowazekii (7 countries), R. typhi (6 countries), R. rickettsii (6 countries), R. amblyommii (5 countries), and R. parkeri (4 countries). The Rickettsial records for the Caribbean islands (West Indies) were grouped in only one geographical area. Both R. bellii, R. akari, and Candidatus 'R. andeane' have been recorded in only 2 countries each, whereas R. massiliae, R. rhipicephali, R.monteiroi, and R. africae have each been recorded in a single country (in this case, R. africae has been recorded in nine Caribbean Islands). For El Salvador, Honduras, and Nicaragua, no specific Rickettsia has been reported so far, but there have been serological evidence of human or/and animal infection. The following countries remain without any Rickettsial records: Belize, Venezuela, Guyana, Surinam, and Paraguay. In addition, except for a few islands, many Caribbean islands remain without records. A total of 12 Rickettsia species have been reported in Spain and Portugal: R. conorii, R. helvetica, R. monacensis, R. felis, R. slovaca, R. raoultii, R. sibirica, R. aeschlimannii, R. rioja, R. massiliae, R. typhi, and R. prowazekii. Amongst these Rickettsia species reported in Spain and Portugal, only R. prowazekii, R. typhi, R. felis, and R. massiliae have also been reported in Latin America. This study summarizes the current state of art on the Rickettsial distribution in Latin America, Caribbean, Spain and Portugal. The data obtained allow a better understanding on Rickettsial epidemiology and distribution of vector ecology.

Key words: Acari, epidemiology, rocky mountain spotted fever, vector control. (Source: DeCS).

Resumen

Reportes del genero Rickettsia y sus asociadas infecciones fueron compilados en una revisión crítica retrospectiva de la literatura científica de los países de Latinoamérica, el Caribe, Portugal y España. Se consideraron todos los reportes para huéspedes humanos y/o animales y también para huéspedes invertebrados los cuales fueron considerados como vectores asociados con Rickettsia. En algunos casos, cuando no existió detección directa a un determinado grupo de Rickettsias o especies no disponible en un país, se tuvo en cuenta la detección indirecta por serología. Un total de 13 especies de Rickettsia han sido reportadas en Latinoamérica y el Caribe. Las especies más encontradas en los países fueron: Rickettsia felis (9 países), R. prowazekii (7 países), R. typhi (6 países), R. rickettsii (6 países), R. amblyommii (5 países) y R. parkeri (4 países). Los datos de las islas del Caribe (antillas menores o Indias occidentales), fueron agrupados en una sola área geográfica como un solo país. Ambas R. bellii, R. akari y Candidatus 'R. andeane' fueron reportadas en solo 2 países, mientras que R. massiliae, R. rhipicephali, R.monteiroi, y R. africae fueron informadas en un solo país. En este caso R. africae fue reportada en 9 islas de las Antillas menores. Para El Salvador, Honduras y Nicaragua, hasta ahora no se han reportado especies de Rickettsia, pero si evidencia serológica de infección humana y/o animal. Sin reportes de infección por Rickettsia permanecen: Belice, Venezuela, Guayana, Surinam y Paraguay. Además, a excepción de algunas islas del Caribe, muchas de ellas permanecen sin reportes. Un total de 12 especies de Rickettsia han sido documentadas en España y Portugal: R. conorii, R. helvetica, R. monacensis, R. felis, R. slovaca, R. raoultii, R. sibirica, R. aeschlimannii, R. rioja, R. massiliae, R. typhi y R. prowazekii. Entre estas, solamente R. prowazekii, R. typhi, R. felis y R. massiliae han sido documentados en Latinoamérica, España y Portugal. Los datos de este estudio permiten entender mejor la epidemiología de las Rickettsias en Latinoamérica, Caribe, España y Portugal, y la distribución de los vectores.

Palabras clave: ácaros, control de vectores, epidemiología, fiebre maculosa de las montañas rocosas, garrapatas. (Fuente: DeCS).

Introduction

The genus Rickettsia includes bacteria of the order Rickettsiales in the alpha subdivision of the class Proteobacteria. They are Gram-negative coccobacilli in obligate association with eukaryote cells. A number of species have been identified in various terrestrial arthropods, and more recently in leeches and amoeba (1,2). Traditionally, pathogenic Rickettsiae were classified into two groups: the typhus group (TG), composed of Rickettsia prowazekii and Rickettsia typhi, vectored by lice (Pediculus humanus) and fleas, respectively; and the spotted fever group (SFG), composed of more than 20 species mostly vectored by ticks (3). Other Rickettsiae have shown antigenic and genetic particularities that preclude their inclusion in either the TG or SFG, such as Rickettsia bellii and Rickettsia canadensis, reported in ticks from the American continent (4,5). With the discovery of a variety of new Rickettsiae in different orders of terrestrial arthropods, mostly free-living, and also with genetic analysis of Rickettsial plasmids as R. felis, the genus Rickettsia has been re-classified into different groups, including the SFG, TG, transitional group (TRG), bellii group (BG), canadensis group (CG), and several other basal groups (6,7).

During the last decades, there has been an increasing number of new Rickettsia species of unknown pathogenicity, mostly isolated from ticks (8,9). Some of them, previously considered non-pathogenic, were recently shown to be pathogenic to humans, such as the SFG Rickettsia slovaca, Rickettsia aeschlimannii, Rickettsia massiliae, and Rickettsia monacensis in Europe (8,9). In addition, R. parkeri, an 'old' SFG organism first reported in ticks in the 1939 was shown to be pathogenic 65 years later (10). These facts indicate that any novel described Rickettsia from invertebrate hosts, especially ticks, should be regarded as potentially pathogenic for humans.

The aim of this study was to analize and to summarize the Rickettsial reports in Latin America, Caribbean, Portugal and Spain.

Data collection

For the present study, retrospective data on bacteria of the genus Rickettsia were compilled from the available literature regarding all countries in Latin America, and Caribean. Efforts were done to gather all available information for each country. Futhermore, for comparison purposes, we also compiled all Rickettsia species that have been reported in Spain and Portugal, since these two countries were responsible for the main colonization of Latin America. We considered all Rickettsia records reported for human and/or animal hosts, and/or invertebrate hosts (e.g., ticks, lice, fleas), which were considered to be the vector associated with the agent. In a few cases, when no direct detection of a given Rickettsia group TG or SFG or species was available for a given country, the indirect detection through serologic-based methods was considered, when this was the only record available.

Geographic distribution of Rickettsia.

All available records on Rickettsial infection on hosts (humans and animals) and vectors in Latin America and the Caribbean are represented by country, in tables 1-6. Spain and Portugal are presented in table 7.

A total of 13 Rickettsia species have been recorded in Latin America and the Caribbean. The species with the largest number of country confirmed records were Rickettsia felis (9 countries), R. prowazekii (7 countries), R. typhi (6 countries), R. rickettsii (6 countries), R. amblyommii (5 countries), and R. parkeri (4 countries).

Since the Rickettsial records for the Caribbean islands were restricted to West Indies, we grouped these records like that they were represented as a single country (Table 6). R. bellii, R. akari, and Candidatus 'R. andeane' have been recorded in only 2 countries each, whereas R. massiliae, R. rhipicephali, R.monteiroi, and R. africae have each been recorded in a single country in this case, R. africae has been recorded in nine islands from the West Indies.

Eight Rickettsia species have been associated with human diseases in Latin America and Caribbean: R. rickettsii causing rocky mountain spotted fever in Mexico, Costa Rica, Panama, Colombia, Brazil and Argentina; R. prowazekii causing epidemic typhus in Argentina, Bolivia, Chile, Ecuador, Guatemala, Mexico, and Peru; R. typhi causing endemic typhus in Brazil, Colombia, Guatemala, Mexico, Panama, and Puerto Rico; R. felis causing flea spotted fever in Mexico and Brazil; R. parkeri causing spotted fever in Brazil, Uruguay, and Argentina; R. africae causing African tick bite fever in the Caribbean islands; R. akari causing Rickettsial pox in Costa Rica and Mexico; and R. massiliae causing spotted fever in Argentina. This R. massiliae case was reported in a Spanish traveler presumed to have acquired the infection in Argentina, but suffered the disease after her return to Spain (Table 8). The distribution of R. felis-infected fleas included seven countries (Costa Rica, Panama, Caribbean islands, Peru, Argentina, Chile, and Uruguay) where no human cases of infection have been reported so far. A total of five Rickettsia species of unknown pathogenicity has been reported: R. amblyommii (5 countries), R. bellii (2 countries), Candidatus 'R. andeanae' (2 countries), R. monteiroi (1 country), and R. rhipicephali (1 country).

A total of 10 Rickettsia species have been reported in both Spain and Portugal: R. conorii, R. helvetica, R. monacensis, R. felis, R. slovaca, R. raoultii, R. sibirica, R. aeschlimannii, R. typhi, and R. prowazekii. In addition, R. rioja has been reported in Spain, and R. massiliae has been reported to occur in Portugal (Table 7). Amongst these Rickettsia species reported in Portugal and Spain, only R. prowazekii, R. typhi, R. felis, and R. massiliae have also been reported in Latin America.

Two fatal cases of spotted fever caused by R. conorii have been diagnosed in Brazil, however, patients of these cases were considered to have acquired the infection in Portugal and South Africa, respectively, and then suffered the disease few days after they arrived in Brazil (Table 8). Likewise, one case of R. africae infection was acquired in Africa before the patient returned to Spain.

For El Salvador, Honduras and Nicaragua, although no specific Rickettsia species has been reported so far, there have been serological evidence of human and animal infection by spotted fever and/or typhus group rickettsioses in these countries (Table 4).

According to our compiled data, the following countries remain without any Rickettsial records in Central America and South America: Belize, Venezuela, Guayana, Surinam and Paraguay. In addition, except for the 10 Caribbean islands of this paper, many of them also remain without records. The geographical distribution of the 13 Rickettsia species that have been identified in Latin America and Caribbean are shown in figure 1.

Analysis of data

Until the end of the last century, only three Rickettsia species were known to occur in Latin America and Caribbean: R. rickettsii, R. prowazekii, and R. typhi. With the increasing use of molecular methods since the 1990s, other Rickettsia species were discovered in the continent, such as R. africae in West Indies (147), and R. felis in Mexico (133) and later in Brazil (59). In this new century, there was a bulk in the study of Rickettsia in Latin America, with the discovery of at least 8 other Rickettsia species in the continent during the last 10 years, mostly associated with ticks: R. amblyommii, R. bellii, R. rhipicephali, R. parkeri, R. massiliae, R. akari, R. monteiroi, and Candidatus 'R. andeanae' (73,93,105,137).

Consindering the three species (R. rickettsii, R. prowazekii, and R. typhi) known to occur in the continent since the first half of the last century, only R. rickettsii, the agent of rocky mountain spotted fever, showed an increased expansion on its distribution area during the last decades. In fact, rocky mountain spotted fever is currently considered a re-emerging disease in Mexico, Central and South America (81,93,112,131).

The occurrence of R. typhi in the American continent has been practically neglected. Although this agent has been only scarcely reported in a few Latin American countries recently (49,146,184), most rickettsiologists believe that this Rickettsia is widely distributed in the continent, together with its main hosts, synantropic rats and their flea Xenopsylla cheopis (185). Finally, the scarce number of recent records of R. prowazekii during the last few decades seems to be a result of decreased prevalence of its main vetcor, the body louse Pediculus humanus (185). Thus, almost all records of R. prowazekii in Latin America refer to the last century. More recent reports of human cases seem to have been restricted to highland areas of Peru, where body louse infestations are still a problem (185).

The significant advance in our knowlegment on rickettsiology during the last decade in Latin America and Caribbean was certainly a result of the increased interest of researchers on this subject in the continent. However, this advance should be considered still very incipient, if we compare the modest list of Rickettsia species and Rickettsial diseases of Latin America and Caribbean with the greater lists here reported for the iberian countries, where rickettsiology has had much greater attention from researchers and governmental institutions. Indeed, the list of Rickettsial diseases in Latin America will increase during the next years, not only in the countries with previous records, but also, in many of the American countries where Rickettsia has never been reported. A basal condition for this increase is the urgent need of increased capacity of Latin American laboratories to perform diagnosis of Rickettsia, since the absence of Rickettsial dieases in such countries might be merely a result of absence of investigations.

Acknowledgments

This work was supported by the Programa Iberoamericano de Ciencias y Tecnologia para el Desarrollo (CYTED) to Red Iberoamericana para la Investigación y Control de las Enfermedades Rickettsiales (RIICER). To Janneth Gallegos M.Sc, Escuela Superior Politécnica de Chimborazo. Facultad de Ciencias. Riobamba, Ecuador. To Jorge Miranda M.Sc, University of Córdoba, Colombia for the technical assistance.

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