Wohlfahrtiimonas chitiniclastica Bacteremia in Homeless Woman

sequences clustered within the Europe/ Turkey clade. The genetic distance between the 2 strains was 1.15%, but the 2 sequences were identical at the amino acid level. Sequences from the present study showed 96.4%–98.8% similarity with respective CCHFV sequences from Bulgaria from a former study (BUL10/02 and BUL1/03) (3) but differed from the Kosovo 9553/2001 strain by 0.8%–2.0% and from the Greek 66/08 strain by 1.2%–2.4%. Two additional suspected CCHF cases occurred in the same area, on March 30 and April 9 (7). Both persons were negative for CCHFV infection. All 119 ticks of various species (Hyalomma marginatum, Dermacentor marginatus, Rhipicephalus bursa, Ixodes ricinus) collected from the area and tested by reverse transcription–nested PCR were negative for CCHFV. This cluster of CCHF cases has several important highlights. First, it occurred in a region that was considered to have low CCHF endemicity; however, the area is only a few kilometers from Greece, where a human fatal case was observed in June 2008 (8). The index case was observed earlier in the year than in previous years, and clinical manifestations of the cases were unusual (absence of craniopharyngeal syndrome and bleeding from gastrointestinal tract that are typical for CCHF patients from Bulgaria); in the fatal case, autopsy of the patient showed hemorrhages only in the lungs. Two cases were attributable to tick exposure, whereas the other 2 were most likely secondary cases attributable to contact with the index case-patient (in this regard, CCHFV sequences of the secondary cases were almost identical). Finally, the longer incubation period of the wife of the index case-patient might be associated with administration of hyperimmune gamma globulin against CCHFV. In conclusion, CCHF emerged in southwestern Bulgaria near the border with Greece. Person-to-person transmission emphasizes the need for rapid diagnosis of CCHF, especially in cases with atypical clinical manifestations.