Rickettsia felis in Fleas, France

ity with R. sibirica subsp. mongolotimonae when compared with those in the GenBank database. Infections caused by R. sibirica subsp. mongolitimonae have been reported as lymphangitis-associated rickettsiosis (4). Our case-patient had the clinical symptoms reported for this disease: fever, maculopapular rash, eschar, enlarged satellite lymph nodes, and lymphangitis. Seasonal occurrence of this disease in the spring is common and has been reported in 9 of 12 cases, including the case-patient reported here (2–6). A total of 75% of these R. sibirica subsp. mongolitimonae infections occurred in southern France; other cases have been recently reported in Greece (5), Portugal (6), and South Africa (7). However, the vector of R. sibirica subsp. mongolitimonae has not been identifi ed (7). This rickettsia has been isolated from Hyalomma asiaticum ticks in Inner Mongolia, from H. truncatum in Niger (8), and from H. anatolicum excavatum in Greece (5). Hyalomma spp. ticks are suspected of being the vector and are widespread in Africa, southeastern Europe (including France), and Asia. Rickettsiosis caused by R. rickettsii and R. conorii during pregnancy has been reported without risk for vertical transmission (9). First-line antimicrobial drugs used to treat rickettsial disease are cyclines and quinolones, but they are contraindicated during pregnancy. Chloramphenicol is an alternative drug for pregnant women but it is not available in France. Macrolides (azithromycin, clarithromycin, and josamycin) are effective against rickettsial disease and can be used safely during pregnancy. No ocular complications were reported in the 11 previous cases of rickettsiosis caused by R. subsp. mongolitimonae. However, ocular lesions, including optic disk staining, white retinal lesions, retinal hemorrhages, multiple hypofl uorescent choroidal dots, mild vitritis, and retinal vasculitis, have been described in patients with rickettsiosis caused by R. conorii, R. rickettsii, and R. typhi (10). Most of these posterior segment manifestations are usually asymptomatic in patients with acute Mediterranean spotted fever (10) and can be easily overlooked. Retinal vasculitis was reported in 45%–55% of the patients, but retinal artery occlusion secondary to vasculitis has been described in only 2 cases of infection with R. conorii and R. rickettsii (10) without details of clinical symptoms. Because ocular involvement could be asymptomatic and easily overlooked, an ophthalmic evaluation should be conducted when rickettsiosis is suspected.