Rickettsia aeschlimannii Infection in a Man, Greece

To the Editor: In Greece, 6 spotted fever group (SFG) Rickettsia species have been detected in ticks: Rickettsia conorii, R. massiliae, R. aeschlimannii, R. sibirica mongolitimonae, R. slovaca, and R. rhipicephali (1). SFG species present characteristic clinical signs, including high fever, headache, and maculopapular rash; an inoculation es-char at the tick bite site is characteristic of some, but not all, SFG rickettsioses. Symptoms during the early stages of illness are nonspecific, and diagnosis is a challenge for physicians who are not familiar with rickettsial diseases. So far, 2 SFG Rickettsia species have been implicated in human disease in Greece: Mediterranean spotted fever caused by R. conorii (2), and lymphagitis-associated rickettsiosis (LAR) caused by R. sibirica mongolitimonae (3). We report a rickettsiosis case in a man on the island of Crete, Greece caused by a third Rickettsia species belonging to the SFG, R. aeschlimannii. During June 2010, a 70-year-old man residing in an agricultural area of eastern Crete was admitted to the emergency unit of General Hospital of Agios Nikolaos for evaluation of a reddish, painless papule on the anterior surface of his left arm. The pap-ule was 2 cm in diameter, and was surrounded by a less reddened infiltrated area 8 cm in diameter (Figure). The area was without tenderness or pruritus. At the center of the papule, which was cyanotic, the presence of a tick was recorded, and the tick was removed carefully in its entirety. The patient was afebrile and reported no other symptoms. The papule had developed within few hours, although 5 days previously, the patient had noticed a dark colored nodule on his left arm but paid no attention to it. The patient reported that rabbits were bred and goats and sheep grazed at close proximity to his residence. Serum and whole blood samples were drawn, and a local skin biopsy was performed from the center of the skin lesion. Laboratory tests revealed a high level of C-reactive protein, microscopic hematuria, and a leukocyte count of 6.01 × 10 9 cells/L. Hepatic enzymes alanine transaminase and as-partate aminotransferase were within normal ranges. The patient was treated with doxycycline, 100 mg twice daily for 7 days; he did not develop further symptoms, and the skin lesion healed without ulceration. All samples were sent to the Laboratory of Clinical Bacteriology, Para-sitology, Zoonoses and Geographic Medicine at the University of Crete for further testing. The tick was identified as …