人感染新斑點(diǎn)熱群立克次體的發(fā)現(xiàn)及自然疫源地調(diào)查研究
發(fā)布時(shí)間：2018-09-09 19:11
【摘要】：一、研究背景蜱傳斑點(diǎn)熱群立克次體病是一類(lèi)人獸共患的自然疫源性疾病。世界各地廣泛存在著這類(lèi)疾病,在歷史上是人類(lèi)發(fā)病和死亡的重要原因之一,當(dāng)今仍嚴(yán)重威脅著人類(lèi)的健康。同時(shí)該類(lèi)疾病也是生化武器的重要來(lái)源之一,國(guó)際反恐已將落基山斑點(diǎn)熱列入生物戰(zhàn)劑目錄中。蜱是該群立克次體的保菌宿主,可經(jīng)卵垂直傳遞和經(jīng)期水平傳播立克次體,保持立克次體種群的延續(xù)性。斑點(diǎn)熱群立克次體在自然界中的感染循環(huán)是在蜱及哺乳動(dòng)物如野生嚙齒動(dòng)物間維持的。人類(lèi)因偶然接觸到感染蜱,被其叮咬從而發(fā)生感染。人被感染蜱叮咬或被其糞便污染皮膚傷口、粘膜后,立克次體侵入機(jī)體進(jìn)入淋巴系統(tǒng)和血液系統(tǒng),在血管內(nèi)皮細(xì)胞開(kāi)始生長(zhǎng)繁殖,通過(guò)血流播散到全身組織和器官,引起一系列功能變化。不同基因型的斑點(diǎn)熱群立克次體臨床癥狀有所不同,但也有相似之處�；颊咭话惚或缍Ｒ�2-14天后發(fā)病,出現(xiàn)發(fā)熱、頭痛、乏力、皮疹、焦痂、局部淋巴結(jié)腫大等癥狀和體征,發(fā)病初期類(lèi)似病毒性感染,常被誤診、漏診。因此,雖然斑點(diǎn)熱群立克次體遍布世界各地,但經(jīng)實(shí)驗(yàn)室確診的蜱傳斑點(diǎn)熱群立克次體病例報(bào)道多來(lái)自于歐美等發(fā)達(dá)國(guó)家和地區(qū)。本研究之前,在我國(guó)大陸共發(fā)現(xiàn)了9種斑點(diǎn)熱群立克次體基因型:Rickettsia sibirica和Rickettsia heilongjiangensis在我國(guó)已有實(shí)驗(yàn)室確診病例報(bào)道,然而僅有27例斑點(diǎn)熱散發(fā)病例報(bào)道,其中8例為Rickettsia sibirica,19例為Rickettsia heilongjiangensis;Ricekettsia mongolotimona雖在我國(guó)內(nèi)蒙古亞?wèn)|璃眼蜱中成功分離,并在法國(guó)馬賽證實(shí)了對(duì)人類(lèi)致病,但在我國(guó)尚無(wú)確診病例報(bào)道;Rickettsia hulinii和Rickettsia sibirica subspecies sibirica BJ-90分別在嗜群血蜱和中華革蜱中發(fā)現(xiàn),R.slovaca和R.raoultii在我國(guó)新疆森林革蜱中發(fā)現(xiàn),Candidatus Rickettsia hebeiii在我國(guó)河北的草原革蜱和長(zhǎng)角血蜱中發(fā)現(xiàn),Rickettsia monacensis在我國(guó)的安徽、河南和湖北的全溝硬蜱中發(fā)現(xiàn),除了Rickettsia raoultii、R.slovaca和Rickettsia monacensis被證實(shí)對(duì)人類(lèi)有致病性外,其他均在世界上尚無(wú)對(duì)人類(lèi)致病的證據(jù)報(bào)道。近十幾年來(lái),根據(jù)蜱和宿主動(dòng)物的調(diào)查發(fā)現(xiàn)了多種新發(fā)立克次體,然而這些立克次體對(duì)人是否致病;如果致病,有何臨床表現(xiàn);如何治療等一系列問(wèn)題一直缺乏系統(tǒng)的研究,因此亟需針對(duì)蜱接觸高危人群開(kāi)展立克次體病監(jiān)測(cè)工作。東北地區(qū)森林覆蓋率高,蜱種和宿主動(dòng)物種類(lèi)豐富,是我國(guó)重要蜱媒傳染病的自然疫源地,我們以往的調(diào)查發(fā)現(xiàn)媒介蜱和宿主動(dòng)物攜帶多種蜱媒病原體,包括嗜吞噬細(xì)胞無(wú)形體、斑點(diǎn)熱群立克次體、伯氏疏螺旋體、查菲埃立克體、巴貝西蟲(chóng)、森林腦炎病毒等,并且此前在東北地區(qū)均報(bào)道過(guò)人感染Rickettsia sibirica和Rickettsia heilongjiangensis,因此是監(jiān)測(cè)斑點(diǎn)熱的重要地域。二、研究目的本研究于2012-2013年在哨點(diǎn)醫(yī)院---黑龍江牡丹江林業(yè)中心醫(yī)院開(kāi)展了斑點(diǎn)熱群立克次體病的監(jiān)測(cè),旨在發(fā)現(xiàn)蜱傳立克次體病確診病例,了解其病原學(xué)特征,臨床致病特點(diǎn)與治療方案。發(fā)現(xiàn)病例后,開(kāi)展斑點(diǎn)熱群立克次體自然疫源地調(diào)查,以摸清我國(guó)東北地區(qū)斑點(diǎn)熱群立克次體的流行病學(xué)特征。三、研究方法以蜱叮咬史或斑點(diǎn)熱樣癥狀作為病例入選標(biāo)準(zhǔn)。采集納入病例的流行病學(xué)信息和臨床病歷信息。采用聚合酶鏈?zhǔn)椒磻?yīng)(PCR)擴(kuò)增病例全血、皮膚焦痂以及病例體表叮咬蜱中的斑點(diǎn)熱群立克次體特異的基因片段并進(jìn)行序列系統(tǒng)進(jìn)化發(fā)育分析;采用間接免疫熒光(IFA)方法檢測(cè)病例急性期和/或恢復(fù)期血清的斑點(diǎn)熱群立克次體的Ig G和Ig M抗體水平;分析確診病例的臨床表現(xiàn)特征和治療方法的合理性;在斑點(diǎn)熱病例居住地采集游離蜱和野生嚙齒動(dòng)物,采用PCR擴(kuò)增斑點(diǎn)熱群立克次體特異的基因片段并進(jìn)行序列系統(tǒng)進(jìn)化發(fā)育分析。四、研究結(jié)果在1801例斑點(diǎn)熱疑似病人中,11例患者的全血或皮膚焦痂斑點(diǎn)熱群立克次體核酸檢測(cè)陽(yáng)性。經(jīng)序列進(jìn)化分析確定5例為新塔拉塞維奇立克次體(Candidatus Rickettsia tarasevichiae),2例為拉歐蒂立克次體(Rickettsia raoultii),1例為西伯利亞立克次體BJ-90亞種(Rickettsia sibirica subspecies sibirica BJ-90),3例為黑龍江立克次體(Rickettsia heilongjiangensis),其中6例病例急性期和恢復(fù)期雙份血清抗體發(fā)生陽(yáng)轉(zhuǎn)或抗體滴度呈四倍升高;5例病例急性期血清Ig G和Ig M抗體陽(yáng)性,血清學(xué)證據(jù)進(jìn)一步支持近期感染了斑點(diǎn)熱群立克次體。該11名患者均有近期蜱咬史。5例感染Candidatus Rickettsia.tarasevichiae臨床癥狀和實(shí)驗(yàn)室檢查出現(xiàn)發(fā)熱(2/5),皮膚焦痂(3/5),淋巴結(jié)炎(2/5),白細(xì)胞計(jì)數(shù)升高(3/5),無(wú)皮疹。其余6例患者均出現(xiàn)了皮疹。1例感染Rickettsia sibirica subspecies sibiricaBJ-90的患者和2例Candidatus Rickettsia tarasevichiae患者臨床表現(xiàn)危重,肝臟轉(zhuǎn)氨酶水平升高,腎功能衰竭,其中1例Candidatus Rickettsia tarasevichiae患者因呼吸衰竭死亡。同時(shí)在1例感染Rickettsia raoultii的患者體表取下的飽血森林革蜱經(jīng)PCR擴(kuò)增顯示攜帶有Rickettsia raoultii。在確診病例居住地附近開(kāi)展的斑點(diǎn)熱立克次體自然疫源地調(diào)查發(fā)現(xiàn),游離蜱中Candidatus Rickettsia tarasevichiae感染率為8.7%(46/528),Rickettsia raoultii感染率為0.6%(3/528),Rickettsia heilongjiangensis感染率為1.3%(7/528),其中46只(46/453)全溝硬蜱攜帶Candidatus Rickettsia tarasevichiae,3只森林革蜱(3/75)攜帶Rickettsia raoultii,1只全溝硬蜱(1/453)和6只森林革蜱(6/75)攜帶Rickettsia heilongjiangensis;嚙齒動(dòng)物中Candidatus Rickettsia tarasevichiae感染率為0.9%(5/531),Rickettsia heilongjiangensis感染率為0.2%(1/531),其中3只黑線姬鼠(3/236)、1只倉(cāng)鼠(1/20)、1只褐家鼠(1/58)感染Candidatus Rickettsia tarasevichiae,1只紅背鼠平(1/16)感染Rickettsia heilongjiangensis。五、研究結(jié)論本研究發(fā)現(xiàn)我國(guó)東北地區(qū)存在4種斑點(diǎn)熱群立克次體同時(shí)流行。世界首次報(bào)道了人感染Candidatus Rickettsia tarasevichiae和Rickettsia sibirica subspecies sibirica BJ-90立克次體病,歐洲以外地區(qū)首次報(bào)道了人感染Rickettsia raoultii立克次體病。這四種斑點(diǎn)熱臨床表現(xiàn)不同,輕則出現(xiàn)流感樣癥狀,重則發(fā)生多器官功能障礙,甚至死亡。多西環(huán)素治療有效,但常因出現(xiàn)非典型斑點(diǎn)熱癥狀而發(fā)生誤診、漏診或遲診。同時(shí)病例居住地蜱和嚙齒動(dòng)物的調(diào)查證實(shí)了東北地區(qū)是上述病原體的自然疫源地。六、意義與創(chuàng)新性由于經(jīng)常性的誤診忽視了斑點(diǎn)熱群立克次體病,我們的研究進(jìn)一步證實(shí)斑點(diǎn)熱群立克次體病遠(yuǎn)比我們想象的要普遍存在,需要引起臨床醫(yī)生及公共衛(wèi)生工作人員的高度重視。我們?cè)谑澜缁驓W洲以外地區(qū)首次報(bào)道的3種新發(fā)立克次體病,豐富了人們對(duì)立克次體病的認(rèn)識(shí),為進(jìn)一步研究致病性立克次體提供了重要依據(jù)。
[Abstract]:1. Background Tick-borne spotted fever group rickettsiasis is a natural zoonotic disease. It is widespread in the world. It is one of the most important causes of human disease and death in history. It is still a serious threat to human health. Rocky Mountain spotted fever has been listed as a biological warfare agent in the anti-terrorism list. Ticks are the preservative hosts of this group of rickettsia, which can be transmitted vertically and horizontally through eggs to maintain the continuity of the Rickettsia population. The infection cycle of spotted fever group rickettsia in nature is maintained between ticks and mammals such as wild rodents. After being bitten by an infected tick or contaminated by its feces, Rickettsia invades the body's lymphatic and blood systems, and begins to grow and reproduce in vascular endothelial cells, which spread through the bloodstream to tissues and organs throughout the body, causing a series of functional changes. The clinical symptoms of different genotypes of spotted fever group Rickettsia are different, but there are similarities. Patients usually develop fever, headache, fatigue, rash, eschar, local lymph node enlargement and other symptoms and signs 2-14 days after being bitten by ticks. Early onset of the disease is similar to viral infection, often misdiagnosed, missed diagnosis. Rickettsia sibirica and Rickettsia heilongjiangensis have been found in the mainland of China before this study. However, only 27 sporadic cases of spotted fever have been reported, including 8 cases of Rickettsia sibirica, 19 cases of Rickettsia heilongjiangensis, Ricekettsia mongolotimona, which has been successfully isolated from Euphorbia asiatica in Inner Mongolia and confirmed to be pathogenic to humans in Marseilles, France. Ini and Rickettsia sibirica subspecies sibirica BJ-90 were found in Haemaphysalis multilocularis and Dermatophyta sinensis, respectively. R. slovaca and R. raoultii were found in forest ticks in Xinjiang, China. Candidatus Rickettsia hebeiii was found in grassland leathers and Haemaphysalis longicornis in Hebei, China. Rickettsia monacensis was found in Anhui, Henan and Hubei provinces. There is no evidence of human pathogenicity in Ixodes persulcatus except that Rickettsia raoultii, R. slovaca and Rickettsia monacensis have been confirmed to be pathogenic to humans. There is a lack of systematic study on the pathogenesis, clinical manifestations, and treatment of tick-borne infections. Therefore, it is urgent to carry out surveillance of Rickettsia disease in high-risk populations. Vector ticks and host animals were found to carry a variety of tick-borne pathogens, including phagocytosis, spotted fever group rickettsia, Borrelia burgdorferi, chaffei-erik, babesia, and forest encephalitis virus. Human infections with Rickettsia sibirica and Rickettsia heilongjiangensis were previously reported in Northeast China, and were therefore supervised. Objective To investigate the etiology, clinical characteristics and treatment of tick-borne rickettsiasis. The surveillance of spotted fever group rickettsiasis was carried out in the Mudanjiang Forestry Center Hospital of Heilongjiang Province from 2012 to 2013. The epidemiological characteristics of spotted fever group rickettsia in Northeast China were investigated. 3. The history of tick bites or spotted fever-like symptoms were used as the criteria for case selection. Epidemiological and clinical information of the cases were collected and amplified by polymerase chain reaction (PCR). Specific gene fragments of spotted fever group rickettsia in whole blood, skin eschar and tick bites were sequenced and phylogenetic analysis was carried out; serum Ig G and Ig M antibodies against spotted fever group rickettsia in acute and/or convalescent stages were detected by indirect immunofluorescence assay (IFA); and clinical manifestations of confirmed cases were analyzed. Characteristics and rationality of treatment methods; free ticks and wild rodents were collected from the habitats of spotted fever cases, and Rickettsia-specific gene fragments of spotted fever group were amplified by PCR and sequenced for phylogenetic analysis. The nucleic acid test of Rickettsia was positive. Sequence evolution analysis showed that 5 cases were neo-Talasevichiae (Candidatus Rickettsia tarasevichiae), 2 cases were Rickettsia raoultii, 1 case was Rickettsia subspecies sibirica BJ-90, and 3 cases were Rickettsia Heilongjiang Rickettsia BJ-90. Six of the 11 patients had a recent history of tick bites and 5 had a recent history of Ca infection. Ndidatus Rickettsia. tarasevichiae had fever (2/5), skin char (3/5), lymphadenitis (2/5), elevated white blood cell count (3/5) and no rash. The other six patients had rash. One patient was infected with Rickettsia sibirica subspecies sibirica BJ-90 and two patients with Candidatus Rickettsia tarasevichiae. One of the patients died of respiratory failure. Meanwhile, one patient infected with Rickettsia raoultii was found to be carrying Rickettsia raoultii. PCR amplification showed that Rickettsia raoultii was present on the surface of a patient infected with Rickettsia raoultii. Candidatus Rickettsia tarasevichiae infection rate was 8.7% (46/528), Rickettsia raoultii infection rate was 0.6% (3/528) and Rickettsia heilongjiangensis infection rate was 1.3% (7/528) among the free ticks, 46 (46/453) Ixodes carrying Candidatus Rickettsia tarasevichiae, 3 ticks carrying all ditches. Rickettsia raoultii was carried by 3/75 ticks, 1 Ixodes persulcatus (1/453) and 6 ticks (6/75) carried Rickettsia heilongjiangensis, Candidatus Rickettsia tarasevichiae infection rate was 0.9% (5/531) and Rickettsia heilongjiangensis infection rate was 0.2% (1/531) in rodents, including 3 Apodemus AGUS agrarius (3/236) and 1 hamster (1/20). A brown house mouse (1/58) was infected with Candidatus Rickettsia tarasevichiae and a red-backed mouse (1/16) with Rickettsia heilongjiangensis. 5. The study concluded that four species of spotted fever group Rickettsia were prevalent simultaneously in Northeast China. Human infection with Candidatus Rickettsia tarasevichiae and Rickettsia sibirsi was first reported in the world. Rickettsia raoultii Rickettsia is reported for the first time outside Europe. The four types of spotted fever have different clinical manifestations, including flu-like symptoms, multiple organ dysfunction and even death. Doxycycline therapy is effective, but often due to atypical spotted fever symptoms. At the same time, the investigation of ticks and rodents in the habitat confirms that the northeast is the natural focus of the above pathogens. 6. Significance and innovativeness due to frequent misdiagnoses that overlook spotted fever group rickettsiasis, our study further confirms that spotted fever group rickettsiasis is far more common than we thought The three new rickettsiasis reported for the first time in the world or outside Europe have enriched people's understanding of rickettsiasis and provided an important basis for further research on pathogenic rickettsiasis.
【學(xué)位授予單位】：中國(guó)人民解放軍軍事醫(yī)學(xué)科學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R513
[Abstract]:1. Background Tick-borne spotted fever group rickettsiasis is a natural zoonotic disease. It is widespread in the world. It is one of the most important causes of human disease and death in history. It is still a serious threat to human health. Rocky Mountain spotted fever has been listed as a biological warfare agent in the anti-terrorism list. Ticks are the preservative hosts of this group of rickettsia, which can be transmitted vertically and horizontally through eggs to maintain the continuity of the Rickettsia population. The infection cycle of spotted fever group rickettsia in nature is maintained between ticks and mammals such as wild rodents. After being bitten by an infected tick or contaminated by its feces, Rickettsia invades the body's lymphatic and blood systems, and begins to grow and reproduce in vascular endothelial cells, which spread through the bloodstream to tissues and organs throughout the body, causing a series of functional changes. The clinical symptoms of different genotypes of spotted fever group Rickettsia are different, but there are similarities. Patients usually develop fever, headache, fatigue, rash, eschar, local lymph node enlargement and other symptoms and signs 2-14 days after being bitten by ticks. Early onset of the disease is similar to viral infection, often misdiagnosed, missed diagnosis. Rickettsia sibirica and Rickettsia heilongjiangensis have been found in the mainland of China before this study. However, only 27 sporadic cases of spotted fever have been reported, including 8 cases of Rickettsia sibirica, 19 cases of Rickettsia heilongjiangensis, Ricekettsia mongolotimona, which has been successfully isolated from Euphorbia asiatica in Inner Mongolia and confirmed to be pathogenic to humans in Marseilles, France. Ini and Rickettsia sibirica subspecies sibirica BJ-90 were found in Haemaphysalis multilocularis and Dermatophyta sinensis, respectively. R. slovaca and R. raoultii were found in forest ticks in Xinjiang, China. Candidatus Rickettsia hebeiii was found in grassland leathers and Haemaphysalis longicornis in Hebei, China. Rickettsia monacensis was found in Anhui, Henan and Hubei provinces. There is no evidence of human pathogenicity in Ixodes persulcatus except that Rickettsia raoultii, R. slovaca and Rickettsia monacensis have been confirmed to be pathogenic to humans. There is a lack of systematic study on the pathogenesis, clinical manifestations, and treatment of tick-borne infections. Therefore, it is urgent to carry out surveillance of Rickettsia disease in high-risk populations. Vector ticks and host animals were found to carry a variety of tick-borne pathogens, including phagocytosis, spotted fever group rickettsia, Borrelia burgdorferi, chaffei-erik, babesia, and forest encephalitis virus. Human infections with Rickettsia sibirica and Rickettsia heilongjiangensis were previously reported in Northeast China, and were therefore supervised. Objective To investigate the etiology, clinical characteristics and treatment of tick-borne rickettsiasis. The surveillance of spotted fever group rickettsiasis was carried out in the Mudanjiang Forestry Center Hospital of Heilongjiang Province from 2012 to 2013. The epidemiological characteristics of spotted fever group rickettsia in Northeast China were investigated. 3. The history of tick bites or spotted fever-like symptoms were used as the criteria for case selection. Epidemiological and clinical information of the cases were collected and amplified by polymerase chain reaction (PCR). Specific gene fragments of spotted fever group rickettsia in whole blood, skin eschar and tick bites were sequenced and phylogenetic analysis was carried out; serum Ig G and Ig M antibodies against spotted fever group rickettsia in acute and/or convalescent stages were detected by indirect immunofluorescence assay (IFA); and clinical manifestations of confirmed cases were analyzed. Characteristics and rationality of treatment methods; free ticks and wild rodents were collected from the habitats of spotted fever cases, and Rickettsia-specific gene fragments of spotted fever group were amplified by PCR and sequenced for phylogenetic analysis. The nucleic acid test of Rickettsia was positive. Sequence evolution analysis showed that 5 cases were neo-Talasevichiae (Candidatus Rickettsia tarasevichiae), 2 cases were Rickettsia raoultii, 1 case was Rickettsia subspecies sibirica BJ-90, and 3 cases were Rickettsia Heilongjiang Rickettsia BJ-90. Six of the 11 patients had a recent history of tick bites and 5 had a recent history of Ca infection. Ndidatus Rickettsia. tarasevichiae had fever (2/5), skin char (3/5), lymphadenitis (2/5), elevated white blood cell count (3/5) and no rash. The other six patients had rash. One patient was infected with Rickettsia sibirica subspecies sibirica BJ-90 and two patients with Candidatus Rickettsia tarasevichiae. One of the patients died of respiratory failure. Meanwhile, one patient infected with Rickettsia raoultii was found to be carrying Rickettsia raoultii. PCR amplification showed that Rickettsia raoultii was present on the surface of a patient infected with Rickettsia raoultii. Candidatus Rickettsia tarasevichiae infection rate was 8.7% (46/528), Rickettsia raoultii infection rate was 0.6% (3/528) and Rickettsia heilongjiangensis infection rate was 1.3% (7/528) among the free ticks, 46 (46/453) Ixodes carrying Candidatus Rickettsia tarasevichiae, 3 ticks carrying all ditches. Rickettsia raoultii was carried by 3/75 ticks, 1 Ixodes persulcatus (1/453) and 6 ticks (6/75) carried Rickettsia heilongjiangensis, Candidatus Rickettsia tarasevichiae infection rate was 0.9% (5/531) and Rickettsia heilongjiangensis infection rate was 0.2% (1/531) in rodents, including 3 Apodemus AGUS agrarius (3/236) and 1 hamster (1/20). A brown house mouse (1/58) was infected with Candidatus Rickettsia tarasevichiae and a red-backed mouse (1/16) with Rickettsia heilongjiangensis. 5. The study concluded that four species of spotted fever group Rickettsia were prevalent simultaneously in Northeast China. Human infection with Candidatus Rickettsia tarasevichiae and Rickettsia sibirsi was first reported in the world. Rickettsia raoultii Rickettsia is reported for the first time outside Europe. The four types of spotted fever have different clinical manifestations, including flu-like symptoms, multiple organ dysfunction and even death. Doxycycline therapy is effective, but often due to atypical spotted fever symptoms. At the same time, the investigation of ticks and rodents in the habitat confirms that the northeast is the natural focus of the above pathogens. 6. Significance and innovativeness due to frequent misdiagnoses that overlook spotted fever group rickettsiasis, our study further confirms that spotted fever group rickettsiasis is far more common than we thought The three new rickettsiasis reported for the first time in the world or outside Europe have enriched people's understanding of rickettsiasis and provided an important basis for further research on pathogenic rickettsiasis.
【學(xué)位授予單位】：中國(guó)人民解放軍軍事醫(yī)學(xué)科學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R513
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