Flea-borne Rickettsiosis Research Articles

Duplex Reverse-Transcription Real-Time Polymerase Chain Reaction Assay Targeting 23S rRNA Single Nucleotide Polymorphisms for the Detection of Flea-Borne Rickettsioses.

Flea-borne spotted fever and flea-borne (murine) typhus are rickettsioses caused by Rickettsia felis and Rickettsia typhi, respectively, and typically present as undifferentiated febrile illnesses. The relative contribution of these agents to flea-borne rickettsioses in California is unclear. We have developed a duplex reverse transcription real-time polymerase chain reaction (RT-rtPCR) assay targeting R. felis- and R. typhi-specific 23S ribosomal RNA single nucleotide polymorphisms to better understand the respective roles of these agents in causing flea-borne rickettsioses in California. This assay was compared with an established duplex R. felis- and R. typhi-ompB rt-PCR assay and was shown to have 1,000-fold and 10-fold greater analytical sensitivity for the detection of R. felis and R. typhi, respectively. Retrospective testing of clinical specimens with both assays established R. typhi as the major etiologic agent of flea-borne rickettsioses in California.

Flea-Borne Rickettsioses and Scrub Typhus in Patients with Suspected Arbovirus Infection in Bangkok, Thailand.

Background: In urban Thailand, arboviral infections dominate diagnoses of acute undifferentiated fevers (AUFs) owing to their well-defined epidemiology and characteristic clinical presentations. However, rickettsial diseases, also endemic in this setting, remain under-recognized owing to challenges in early detection. Objective: This study aimed to identify potential rickettsial infections among patients with AUF in Bangkok and vicinity utilizing leftover nucleic acid extracted from serum samples from patients initially suspected of but negative for arbovirus infections. Materials and Methods: A total of 609 nucleic acid samples were screened for rickettsial bacteria using real-time PCR, targeting the 17-kDa common antigen gene of Rickettsia spp. and the 47-kDa gene of Orientia tsutsugamushi. Results: Nine samples were positive for Rickettsia spp. and two were positive for O. tsutsugamushi. DNA sequence and phylogenetic analyses based on partial 17-kDa antigen and citrate synthase (gltA) genes identified the Rickettsia-positive samples as R. typhi in eight cases and R. felis in one case. Analysis of the 56-kDa type-specific antigen gene identified the two O. tsutsugamushi isolates as Gilliam-related genotypes. Although rickettsial diseases typically present with mild symptoms, two patients with R. typhi infection (murine typhus) developed respiratory distress syndrome, highlighting the potential for rare but serious complications. Conclusion: This study underscores the critical importance of differential diagnosis and prompt, effective intervention to prevent complications in suspected cases.

Cat Flea Coinfection with Rickettsia felis and Rickettsia typhi.

Purpose: Flea-borne rickettsioses, collectively referred to as a term for etiological agents Rickettsia felis, Rickettsia typhi, and RFLOs (R. felis-like organisms), has become a public health concern around the world, specifically in the United States. Due to a shared arthropod vector (the cat flea) and clinical signs, discriminating between Rickettsia species has proven difficult. While the effects of microbial coinfections in the vector can result in antagonistic or synergistic interrelationships, subsequently altering potential human exposure and disease, the impact of bacterial interactions within flea populations remains poorly defined. Methods: In this study, in vitro and in vivo systems were utilized to assess rickettsial interactions in arthropods. Results: Coinfection of both R. felis and R. typhi within a tick-derived cell line indicated that the two species could infect the same cell, but distinct growth kinetics led to reduced R. felis growth over time, regardless of infection order. Sequential flea coinfections revealed the vector could acquire both Rickettsia spp. and sustain coinfection for up to 2 weeks, but rickettsial loads in coinfected fleas and feces were altered during coinfection. Conclusion: Altered rickettsial loads during coinfection suggest R. felis and R. typhi interactions may enhance the transmission potential of either agent. Thus, this study provides a functional foundation to disentangle transmission events propelled by complex interspecies relationships during vector coinfections.

Murine Typhus: A Review of a Reemerging Flea-Borne Rickettsiosis with Potential for Neurologic Manifestations and Sequalae.

Murine typhus is an acute febrile illness caused by Rickettsia typhi, an obligately intracellular Gram-negative coccobacillus. Rats (Rattus species) and their fleas (Xenopsylla cheopis) serve as the reservoir and vector of R. typhi, respectively. Humans become infected when R. typhi-infected flea feces are rubbed into flea bite wounds or onto mucous membranes. The disease is endemic throughout much of the world, especially in tropical and subtropical seaboard regions where rats are common. Murine typhus is reemerging as an important cause of febrile illness in Texas and Southern California, where an alternate transmission cycle likely involves opossums (Didelphis virginiana) and cat fleas (Ctenocephalides felis). Although primarily an undifferentiated febrile illness, a range of neurologic manifestations may occur, especially when treatment is delayed. Serology is the mainstay of diagnostic testing, but confirmation usually requires demonstrating seroconversion or a fourfold increase in antibody titer from acute- and convalescent-phase sera (antibodies are seldom detectable in the first week of illness). Thus, early empiric treatment with doxycycline, the drug of choice, is imperative. The purpose of this review is to highlight murine typhus as an important emerging and reemerging infectious disease, review its neurologic manifestations, and discuss areas in need of further study.

Rickettsia felis DNA recovered from a child who lived in southern Africa 2000 years ago

The Stone Age record of South Africa provides some of the earliest evidence for the biological and cultural origins of Homo sapiens. While there is extensive genomic evidence for the selection of polymorphisms in response to pathogen-pressure in sub-Saharan Africa, e.g., the sickle cell trait which provides protection against malaria, there is inadequate direct human genomic evidence for ancient human-pathogen infection in the region. Here, we analysed shotgun metagenome libraries derived from the sequencing of a Later Stone Age hunter-gatherer child who lived near Ballito Bay, South Africa, c. 2000 years ago. This resulted in the identification of ancient DNA sequence reads homologous to Rickettsia felis, the causative agent of typhus-like flea-borne rickettsioses, and the reconstruction of an ancient R. felis genome.

Molecular Evidence for Flea-Borne Rickettsiosis in Febrile Patients from Madagascar.

Rickettsiae may cause febrile infections in humans in tropical and subtropical regions. From Madagascar, no molecular data on the role of rickettsioses in febrile patients are available. Blood samples from patients presenting with fever in the area of the capital Antananarivo were screened for the presence of rickettsial DNA. EDTA (ethylenediaminetetraacetic acid) blood from 1020 patients presenting with pyrexia > 38.5 °C was analyzed by gltA-specific qPCR. Positive samples were confirmed by ompB-specific qPCR. From confirmed samples, the gltA amplicons were sequenced and subjected to phylogenetic analysis. From five gltA-reactive samples, two were confirmed by ompB-specific qPCR. The gltA sequence in the sample taken from a 38-year-old female showed 100% homology with R. typhi. The other sample taken from a 1.5-year-old infant was 100% homologous to R. felis. Tick-borne rickettsiae were not identified. The overall rate of febrile patients with molecular evidence for a rickettsial infection from the Madagascan study site was 0.2% (2/1020 patients). Flea-borne rickettsiosis is a rare but neglected cause of infection in Madagascar. Accurate diagnosis may prompt adequate antimicrobial treatment.

Manifestations and Management of Flea-Borne Rickettsioses.

Murine typhus and flea-borne spotted fever are undifferentiated febrile illnesses caused by Rickettsia typhi and Rickettsia felis, respectively. These organisms are small obligately intracellular bacteria and are transmitted to humans by fleas. Murine typhus is endemic to coastal areas of the tropics and subtropics (especially port cities), where rats are the primary mammalian host and rat fleas (Xenopsylla cheopis) are the vector. In the United States, a cycle of transmission involving opossums and cat fleas (Ctenocephalides felis) are the presumed reservoir and vector, respectively. The incidence and distribution of murine typhus appear to be increasing in endemic areas of the US. Rickettsia felis has also been reported throughout the world and is found within the ubiquitous cat flea. Flea-borne rickettsioses manifest as an undifferentiated febrile illness. Headache, malaise, and myalgia are frequent symptoms that accompany fever. The incidence of rash is variable, so its absence should not dissuade the clinician to consider a rickettsial illness as part of the differential diagnosis. When present, the rash is usually macular or papular. Although not a feature of murine typhus, eschar has been found in 12% of those with flea-borne spotted fever. Confirmatory laboratory diagnosis is usually obtained by serology; the indirect immunofluorescence assay is the serologic test of choice. Antibodies are seldom present during the first few days of illness. Thus, the diagnosis requires acute- and convalescent-phase specimens to document seroconversion or a four-fold increase in antibody titer. Since laboratory diagnosis is usually retrospective, when a flea-borne rickettsiosis is considered, empiric treatment should be initiated. The treatment of choice for both children and adults is doxycycline, which results in a swift and effective response. The following review is aimed to summarize the key clinical, epidemiological, ecological, diagnostic, and treatment aspects of flea-borne rickettsioses.

Seroprevalence and epidemiology of typhus group Rickettsia infection in Texas

Background: Typhus group Rickettsia (TGR) are a subgroup of vector-borne bacterial pathogens in the genus Rickettsia. Flea-borne TGR rickettsiosis in humans is most often caused by R. typhi. Clinical disease characteristically presents as fever, rash, headache, nausea, and vomiting, making it difficult to distinguish clinically from other flu-like syndromes. If left untreated or with delayed treatment, severe and life-threatening disease can develop. TGR is a growing public health concern in Texas, where surveillance data indicates increasing incidence of flea-borne rickettsiosis, from 157 reported cases in 2008 to 738 in 2018. Fleas that transmit TGR take bloodmeals from a variety of mammalian species, including farm, wild, and domestic animals. For this reason, individuals with frequent animal contact or who engage in outdoor activities with abundant wildlife could be at heightened risk of TGR exposure. Greater understanding of the local epidemiology in the southern United States, where the ecology is conducive to TGR endemicity, in needed. Methods and materials: As part of an attempt to understand the epidemiology of zoonotic and vector-borne diseases in Texas, we conducted serologic screening among individuals engaged in hunting and/or ranching across the state of Texas, enrolled from 2015 to 2018. Serum was tested for IgG to TGR using a commercial ELISA kit, tested in parallel for IgG to Spotted Fever Group Rickettsia (SFGR), and confirmed by immunofluorescence assay. Utilizing interview data on demographics, behaviors, and other potential exposures, we defined characteristics associated with TGR seropositivity. Results: Among 631 study participants, ages 6 to 81 (median 48) years and 80% male, 35% had IgG against TGR by ELISA. To characterize the local epidemiology, spatial distribution of TGR seropositivity are demonstrated, with hotspot and overlay analyses. Potential risk factors for TGR exposure are reported as odds ratios with 95% confidence intervals. Conclusion: This new evidence of highly prevalent TGR exposure among a presumed high-risk population from across Texas suggests that TGR infections may be going under-recognized and underreported, with higher incidence than previously thought, at least in some groups. These findings can drive targeted educational campaigns to raise awareness about risk factors and disease prevention, facilitate early clinical recognition, and inform surveillance strategies.

Flea-borne Rickettsia species in fleas, Caldas department, Colombia.

Rickettsioses are zoonotic diseases caused by pathogenic bacteria of the genus Rickettsia and transmitted to man by means of arthropod vectors such as ticks, fleas, mites and lice. Historically, Caldas Department has reported a significant number of cases of murine typhus to the Colombian national health surveillance system, and consequent studies of flea-borne rickettsiosis identified the circulation of Rickettsia typhi and Rickettsia felis in multiple municipalities. Our aim was to genotype species of Rickettsia detected in fleas collected from domestic and wild mammals in Caldas. Flea samples were taken by convenience sampling from dogs, cats and wild mammals (rodents and marsupials) in 26 municipalities. Specimens were classified by current taxonomic keys and pooled for DNA extraction and molecular screening for Rickettsia spp. by PCR amplification of gltA, htrA and sca5 genes. Positive samples were genotyped by enzyme digestion (htrA) and sequencing. A total of 1388 flea samples were collected. Rickettsia DNA was amplified in 818 (gltA), 883 (htrA) and 424 (sca5) flea pools. Alignment analysis with available Rickettsia DNA sequences showed greater similarity with R. asembonensis (gltA) and with R. felis (sca5 and htrA). Restriction pattern was compatible with R. felis. R. typhi was not identified. The present study confirms the presence and high prevalence of R. asembonensis and R. felis in fleas from domestic and wild animals in different municipalities from Caldas Department.

Emergence of murine typhus in La Réunion, France, 2012–2017

ObjectiveMurine typhus (MT) is an acute zoonosis caused by Rickettsia typhi, a flea-borne rickettsiosis. The first autochthonous case was reported in 2012. Once autochthonous transmission of Rickettsia typhi was proven, we performed a prospective study to describe and raise awareness of this often-misdiagnosed disease among physicians. Patients and methodsWe performed a prospective observational study of MT cases in La Réunion from 2012 to 2017. MT cases were defined as clinically compatible illnesses with a specific positive serology and/or PCR. ResultsSixty-one confirmed cases were collected. The main clinical features were prolonged fever (90%), asthenia (87%), and headaches (79%). The main biological abnormalities were elevated liver enzymes (84%) and thrombopenia (75%). Renal function was normal in 90% of cases; it was an important feature because leptospirosis is a frequent cause of acute renal failure. A seasonal factor was observed with 79% of cases reported in the warm season and most of them in the west and south of the island (i.e., the dry areas). ConclusionMT is an emerging disease in La Réunion, and local conditions could lead to an endemic situation. Cases of acute undifferentiated fever with headaches should guide to the diagnosis of MT especially in the warm season and dry areas. Leptospirosis is an alternative diagnosis, which differs from MT by its epidemiological characteristics and by the associated frequent renal dysfunction.

Tick- and flea-borne rickettsioses in Tizi-Ouzou, Algeria: Implications for travel medicine.

In Algeria, Mediterranean spotted fever (MSF), caused by Rickettsia conorii conorii and transmitted by Rhipicephalus sanguineus, is endemic. However, the documentation of cases is rare due to a lack of laboratory facilities. Our aim was to screen for rickettsioses in patients with fever, rash and a possible inoculation eschar. Between 2013 and 2015, patients with a fever and a rash presenting at hospitals in the Tizi-Ouzou region were prospectively included in our study. Sera were screened using Indirect Immunofluorescence Assay (IFA) and qPCR was performed on swab samples from eschars. One hundred and sixty-six patients were included. For 57 patients, MSF due to R. conorii conorii was diagnosed by serology and qPCR on a swab eschar sample. Three patients were diagnosed with murine typhus, a flea borne rickettsiosis. In addition, two patients had a positive serology in IgM for R. felis. For nine patients, serology for rickettsiosis was positive, but the specific rickettsia involved could not be determined. Nine patients had a severe disease with neurological involvement or multi-organ failure. Clinicians should routinely screen for rickettsioses in patients and travellers presenting with a rash upon return from Algeria. Doxycycline treatment must be given promptly because the prognosis can be severe.

Rickettsial Infections among Cats and Cat Fleas in Riverside County, California.

Presently, few studies have investigated the role of domestic cats (Felis catus) in the recrudescence of flea-borne rickettsioses in California and the southern United States. In this study, we aimed to investigate the presence of Rickettsia typhi or Rickettisa felis in domestic cats (F. catus) and the fleas (primarily Ctenocephalides felis, the cat flea) associated with these cats in Riverside County, California. Thirty cats and 64 pools of fleas collected from these cats were investigated for rickettsial infections. Three cats and 17 flea pools (from 10 cats) tested positive for rickettsial infections. polymerase chain reaction and DNA sequencing indicated that one of the cats was positive for R. felis infections, whereas two were positive for Candidatus Rickettsia senegalensis infection. In addition, 12 of the flea pools were positive for R. felis, whereas five were positive for Ca. R. senegalensis. By contrast, no cats or their associated fleas tested positive for R. typhi. Finally, eight sera from these cats contained spotted fever group Rickettsia (SFGR) antibodies. The detection of R. felis and SFGR antibodies and the lack of R. typhi and TGR antibodies support R. felis as the main rickettsial species infecting cat fleas. The detection of Ca. R. senegalensis in both fleas and cats also provides additional evidence that cats and their associated fleas are infected with other R. felis-like organisms highlighting the potential risk for human infections with R. felis or R. felis-like organisms.

A 2015 outbreak of flea-borne rickettsiosis in San Gabriel Valley, Los Angeles County, California.

Although flea-borne rickettsiosis is endemic in Los Angeles County, outbreaks are rare. In the spring of 2015 three human cases of flea-borne rickettsiosis among residents of a mobile home community (MHC) prompted an investigation. Fleas were ubiquitous in common areas due to presence of flea-infested opossums and overabundant outdoor cats and dogs. The MHC was summarily abated in June 2015, and within five months, flea control and removal of animals significantly reduced the flea population. Two additional epidemiologically-linked human cases of flea-borne rickettsiosis detected at the MHC were suspected to have occurred before control efforts began. Molecular testing of 106 individual and 85 pooled cat fleas, blood and ear tissue samples from three opossums and thirteen feral cats using PCR amplification and DNA sequencing detected rickettsial DNA in 18.8% of the fleas. Seventeen percent of these cat fleas tested positive for R. felis-specific DNA compared to under two (<2) percent for Candidatus R. senegalensis-specific DNA. In addition, serological testing of 13 cats using a group-specific IgG-ELISA detected antibodies against typhus group rickettsiae and spotted fever group rickettsiae in six (46.2%) and one (7.7%) cat, respectively. These results indicate that cats and their fleas may have played an active role in the epidemiology of the typhus group and/or spotted fever group rickettsial disease(s) in this outbreak.

First Detection of Rickettsia typhi and Rickettsia felis in Fleas Collected From Client-Owned Companion Animals in the Southern Great Plains.

Flea-borne rickettsiosis occurs worldwide and includes a number of pathogens, namely, Rickettsia typhi and Rickettsia felis. Most studies in the United States have occurred in southern Texas and California where flea-borne rickettsiosis is endemic, resulting in a lack of information from other regions of the country. Between March and August 2016, 222 fleas were collected from 52 client-owned dogs and cats in two urban areas in Oklahoma. Fleas were identified using morphological characteristics then pooled and tested by polymerase chain reaction (PCR) using published primers for gltA, ompB, and 17-kDa. The majority (98.6%) of fleas collected were Ctenocephalides felis (Bouché) followed by Pulex irritans (L) (1.4%). Overall, fleas collected from 30.0% (6/20) cats and 43.8% (14/32) dogs were infected with R. felis. Three C. felis-pools collected from three dogs, two in the Enid area (central Oklahoma) and one in the Elk City area (western Oklahoma), were infected with R. typhi as well as R. felis. 'Candidatus R. senegalensis' was detected in one pool of fleas taken from a cat in Oklahoma City. This is the first evidence that flea-borne Rickettsia species occur in fleas obtained from client-owned dogs and cats in the Great Plains region. The impact of these Rickettsia species on public health in the region needs further investigation.

Limited Evidence for Rickettsia felis as a Cause of Zoonotic Flea-Borne Rickettsiosis in Southern California.

Over 90% of human flea-borne rickettsioses cases in California are reported from suburban communities of Los Angeles and Orange counties and are presumed to be associated with either Rickettsia typhi or Rickettsia felis infection. Ctenocephalides felis (Bouché) is considered the principal vector for both rickettsiae, and R. felis has largely replaced R. typhi as the presumptive etiologic agent based on the widespread incidence of R. felis in cat flea populations. However, with no evidence to confirm R. felis as the cause of human illness in southern California, coupled with recent findings that showed R. felis to be widespread in cat fleas statewide, we propose that this hypothesis should be reconsidered. Evidence of only limited numbers of R. typhi-infected cat fleas in the environment may indicate a very rare infection and explain why so few cases of flea-borne rickettsioses are reported each year in southern California relative to the population.

Flea-Borne Rickettsioses and Rickettsiae.

Rickettsia typhi and Rickettsia felis are flea-borne rickettsiae that are distributed throughout the world. This mini-review outlines the ecology and epidemiology of flea-borne rickettsioses; highlights important clinical, diagnostic, and therapeutic considerations; and discusses areas of uncertainty regarding Rickettsia felis and other rickettsiae harbored by fleas.

Rickettsial Infections among Ctenocephalides felis and Host Animals during a Flea-Borne Rickettsioses Outbreak in Orange County, California.

Due to a resurgence of flea-borne rickettsioses in Orange County, California, we investigated the etiologies of rickettsial infections of Ctenocephalides felis, the predominant fleas species obtained from opossums (Didelphis virginiana) and domestic cats (Felis catus), collected from case exposure sites and other areas in Orange County. In addition, we assessed the prevalence of IgG antibodies against spotted fever group (SFGR) and typhus group (TGR) rickettsiae in opossum sera. Of the 597 flea specimens collected from opossums and cats, 37.2% tested positive for Rickettsia. PCR and sequencing of rickettsial genes obtained from C. felis flea DNA preparations revealed the presence of R. typhi (1.3%), R. felis (28.0%) and R. felis-like organisms (7.5%). Sera from opossums contained TGR-specific (40.84%), but not SFGR-specific antibodies. The detection of R. felis and R. typhi in the C. felis fleas in Orange County highlights the potential risk for human infection with either of these pathogens, and underscores the need for further investigations incorporating specimens from humans, animal hosts, and invertebrate vectors in endemic areas. Such studies will be essential for establishing a link in the ongoing flea-borne rickettsioses outbreaks.

Detection of Rickettsia Species in Fleas Collected from Cats in Regions Endemic and Nonendemic for Flea-Borne Rickettsioses in California.

Rickettsia typhi, transmitted by rat fleas, causes most human flea-borne rickettsioses worldwide. Another rickettsia, Rickettsia felis, found in cat fleas, Ctenocephalides felis, has also been implicated as a potential human pathogen. In the continental United States, human cases of flea-borne rickettsioses are reported primarily from the southern regions of Texas and California where the cat flea is considered the principal vector. In California, more than 90% of locally acquired human cases are reported from suburban communities within Los Angeles and Orange counties despite the almost ubiquitous presence of cat fleas and their hosts throughout the state. The objective of this study is to assess the presence and infection rate of Rickettsia species in cat fleas from selected endemic and nonendemic regions of California. Cat fleas were collected from cats in Los Angeles County (endemic region) and Sacramento and Contra Costa counties (nonendemic region). Sequencing of 17 amplicons confirmed the presence of R. felis in both the endemic and non-endemic regions with a calculated maximum likelihood estimation of 131 and 234 per 1000 fleas, respectively. R. typhi was not detected in any flea pools. Two R. felis-like genotypes were also detected in fleas from Los Angeles County; Genotype 1 was detected in 1 flea pool and Genotype 2 was found in 10 flea pools. Genotype 1 was also detected in a single flea pool from Sacramento County. Results from this study show that R. felis is widespread in cat flea populations in both flea-borne rickettsioses endemic and nonendemic regions of California, suggesting that a high prevalence of this bacterium in cat fleas does not predispose to increased risk of human infection. Further studies are needed to elucidate the role of R. felis and the two R. felis-like organisms as etiologic agents of human flea-borne rickettsioses in California.

Orange County Vector Control and the County’s Feral Cat TNR Program: Ne’er the Twain Shall Meet?

In 2006, flea-borne rickettsiosis (flea-borne typhus), a zoonotic disease caused by either Rickettsia typhi or R. felis and transmitted primarily by two flea species, the Oriental rat flea and the cat flea, re-emerged as an important vector-borne disease in Orange County, California. The Orange County Mosquito and Vector Control District (OC Vector Control) has investigated 142 human cases of flea-borne rickettsiosis. Results of these investigations have established a link with Rickettsia-infected cat fleas, opossums, feral cats, and disease transmission to humans; no cases have been associated with rats and their fleas. Since initiation of a Trap-Neuter-Return (TNR) Program by Orange County (OC) Animal Care in 2009, OC Vector Control has been working with OC Animal Care to minimize the potential public health risks associated with the TNR Program. Interagency discussions have led OC Animal Care to prohibit the release of TNR cats at locations with a high risk for zoonotic disease transmission to humans, such as schools, parks, and health care facilities, and also to disclose the release sites to OC Vector Control. OC Animal Care has not agreed to OC Vector Control’s request for a zoonotic disease review of its TNR Program, nor has it provided a procedural manual to verify the verbal agreements reached by the two agencies. In agreement with OC Vector Control’s concerns, an investigation in 2015 by the Orange County Grand Jury of OC Animal Care’s TNR Program recognized the Program’s potential to increase zoonotic disease transmission to the public and other wildlife. We discuss the conflicting views arising from two governmental agencies, which perceive the zoonotic diseases risk associated with a TNR program at significantly different thresholds of concern.

Rickettsioses in Europe

Bacteria of the genera Rickettsia and Orientia (family rickettsiaceae, order rickettsiales) cause rickettsioses worldwide, and are transmitted by lice, fleas, ticks and mites. In Europe, only Rickettsia spp. cause rickettsioses.With improvement of hygiene, the risk of louse-borne rickettsiosis (epidemic typhus) is low in Europe. Nevertheless, recrudescent form of Rickettsia prowazekii infection persists. There could be an epidemic typhus outbreak if a body lice epidemic occurs under unfavorable sanitary conditions.In Europe, endemic typhus or Rickettsia typhi infection, transmitted by rats and fleas, causes febrile illness. At the beginning of this century, flea-borne spotted fever cases caused by Rickettsia felis were diagnosed. Flea-borne rickettsiosis should be suspected after flea bites if fever, with or without rash, is developed.Tick-borne rickettsioses are the main source of rickettsia infections in Europe. Apart from Rickettsia conorii, the Mediterranean Spotted Fever (MSF) agent, other Rickettsia spp. cause MSF-like: Rickettsia helvetica, Rickettsia monacensis, Rickettsia massiliae or Rickettsia aeschlimannii. In the 1990s, two ‘new’ rickettsioses were diagnosed: Lymphangitis Associated Rickettsiosis (LAR) caused by Rickettsia sibirica mongolitimonae, and Tick-Borne Lymphadenopathy/Dermacentor-Borne-Necrosis-Erythema-Lymphadenopathy/Scalp Eschar Neck Lymphadenopathy (TIBOLA/DEBONEL/SENLAT), caused by Rickettsia slovaca, Candidatus Rickettsia rioja and Rickettsia raoultii.Lastly, European reports about mite-borne rickettsiosis are scarce.