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and peninsulae corresponding topreserved cortex. There was variablepreservation of the cerebrum, totalliquefaction of occipital lobes, andirregular preservation of the outer

layers of some parts of the temporaland frontal lobes. Altogether, the

picture was compatible with severeporencephaly or hydranencephaly.The spine showed no sign of scoliosis,and movement of the limb joints wasnot restricted (i.e., no arthrogryposis).

Samples were removed fromthe remnants of the cerebrum,diencephalon, and organs (thymus,lung, myocardium, jejunum, ileum,mesenteric lymph node, liver,spleen, kidney, and striated muscle),and 3 independent real-time PCR

protocols were conducted to detectgenomes of bovine viral diarrhea/mucosal disease virus, bluetonguevirus serotype 8, and the novel SBV.Initial retrotranscription of the RNAgenomes was followed by quantitative(real-time) PCR. The process wasconducted by using our procedures(2) and, for SBV, by following the

protocol and using recently developedcontrol reagents as described (1). The

SBV genome was detected in onlyCNS samples (quantification cyclevalue 28.8); bovine viral diarrhea/mucosal disease virus and BTV-8genomes were not detected. The newvirus genome load was 1.61 104copies per gram of cerebrum sample.

Taken together, the above datasuggest that, like other Simbu serogroupviruses, the new virus crosses the

placenta, contaminates the bovinefetus, infects the fetus CNS, and causesnecrosis and/or developmental arrest of

the cerebral cortex. Unlike the virusesmentioned above (3,4), and providedthis case is not an exception, the SBVgenome seems to persist in the infectedfetus and is detectable after birth byreal-time reverse transcription PCR,despite gestation length. Althoughreliable reagents for detectingseroconversion are temporarilyunavailable, the persistence of the

new virus in fetal tissue should greatlyfacilitate the epidemiologic monitoringof the emergence and spread of the newvirus.

When calves from experimentally

infected dams are infected with theclosest phylogenetic relative to SBV,Akabane virus, porencephaly developsduring gestational days 6296 (5). Ifthe same is true for the new virus, theabove calf was probably infected duringJune 9July 13, 2011. Therefore, it ishypothesized that infected arthropodswere already circulating in the villageof Hamois-in-Condroz (502456N,587E), which is 240 km southwestof Schmallenberg (51842N, 81718E), 2 months before the emergenceof the clinical syndrome that led to theidentification of the new virus.

Acknowledgments

We thank Michal Sarlet, DeborahKleijnen, and Christian Korthase forenthusiastic and skilled technical support.

Mutien-Marie Garigliany, Bernd

Hoffmann, Marc Dive, Arnaud

Sartelet, Calixte Bayrou,

Dominique Cassart,

Martin Beer,and Daniel Desmecht

Author affiliations: University of Lige,

Lige, Belgium (M.-M. Garigliany, M. Dive,

A. Sartelet, C. Bayrou, D. Cassart, D.

Desmecht); and Friedrich-Loeffler-Institut,

GreifswaldInsel Riems, Germany (B.

Hoffmann, M. Beer)

DOI: http://dx.doi.org/10.3201/eid1806.120104

References

1. Hoffmann B, Scheuch M, Hper D, Jung-

blut R, Holsteg M, Schirrmeier H, et al.Novel orthobunyavirus in cattle, Europe,2011. Emerg Infect Dis. 2012;18:46972.http://dx.doi.org/10.3201/eid1803.111905

2. Garigliany M, De Leeuw I, Kleijnen D,Vandenbussche F, Callens J, Van Loo H, etal. The presence of bluetongue virus sero-type 8 RNA in Belgian cattle since 2008.Transbound Emerg Dis. 2011;58:5039.http://dx.doi.org/10.1111/j.1865-1682.2011.01230.x

3. Porterfield JS, Della-Porta AJ. Bunyaviri-dae: infections and diagnosis. In: KurstakE, Kurstak C, editors. Comparative diag-nosis of viral diseases, Vol. IV. New York:Academic Press; 1981. p. 479508.

4. Inaba Y, Matsumato M. Akabane virus. In:

Dinter Z, Morein B, editors. Virus infec-tions of ruminants. Amsterdam: ElsevierScience Publishers; 1990. p. 467480.

5. Kurogi H, Inaba Y, Takahashi E, Sato K,Satoda K. Congenital abnormalities innewborn calves after inoculation of preg-nant cows with Akabane virus. Infect Im-mun. 1977;17:33843.

Address for correspondence: Daniel Desmecht,

Pathology, Faculty of Veterinary Medicine,

University of Lige, Sart Tilman B43, Lige

4000, Belgium; email: daniel.desmecht@ulg.

ac.be

Zoonotic DiseasePathogens in FishUsed for Pedicure

To the Editor:Doctor fish (Garrarufa) are freshwater cyprinid fish that

naturally inhabit river basins in centralEurasia. They are widely used in thehealth and beauty industries in footspas for ichthyotherapy (Kangal fishtherapy or doctor fish therapy) (Figure;online Technical Appendix Figure 1,wwwnc.cdc.gov/EID/pdfs/11-1782-Techapp.pdf) (1). During thesesessions, patients immerse their feetor their entire bodies in the spas,allowing the fish to feed on dead skinfor cosmetic reasons or for controlof psoriasis, eczema, and other skin

conditions.A survey during the spring of

2011 identified 279 fish spas in theUnited Kingdom, and the numberhas probably increased since then (1).The Fish Health Inspectorate of theCentre for Environment, Fisheries &Aquaculture Science estimates thateach week 15,00020,000 G. rufafish are imported from Indonesia and

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other countries in Asia into the UnitedKingdom through London HeathrowAirport (the main border inspection

post for the import of live fish).However, ichthyotherapy has now

reportedly been banned in several USstates and Canada provinces becauseof sanitary concerns (1). In theUnited Kingdom, a limited numberof infections after fish pedicures have

been reported (1). Unfortunately, littleis known about the types of bacteriaand other potential pathogens thatmight be carried by these fish and the

potential risks that they might pose tocustomers or to ornamental and nativefish.

On April 12, 2011, the FishHeath Inspectorate investigated areport of a disease outbreak among6,000 G. rufa fish from Indonesiathat had been supplied to UK

pedicure spas. Affected fish showedclinical signs of exophthalmia and ofhemorrhage around the gills, mouth,and abdomen. More than 95% of thefish died before the remaining fishwere euthanized. Histopathologicexaminations identified systemic

bacterial infections with small gram-

positive cocci, mostly in the kidneys,spleen, and liver. Bacterial isolatescultured from affected fish wereidentified as Streptococcus agalactiae(group B Streptococcus) accordingto a combination of biochemical testresults (API Strep; bioMrieux, Marcyltoile, France), Lancefield groupingwith serotype B (Oxoid Limited,Basingstoke, UK), and molecular(partial 16S rRNA gene sequencing)testing methods.

Multilocus sequence typing

of a representative isolate (11013;online Technical Appendix Table) (2)indicated that it was a sequence type(ST) 261 S. agalactiae strain (http://

pubmlst.org/sagalactiae). This sameST261 profile was first identifiedin an isolate (ATCC 51487) froma diseased tilapia in Israel (3). Theclinical appearance of the disease andthe diagnostic results suggested that S.

agalactiaewas the causative agent ofthe fish illness and deaths.

To determine whether S.agalactiae and other bacterial

pathogens might be carried more

widely by these fish, from May 5,2011, through June 30, 2011, theFish Health Inspectorate of theCentre for Environment, Fisheries &Aquaculture Science visited HeathrowAirport 5 times to intercept andsample consignments of G. rufafromIndonesia. A taxonomically diverserange of bacteria were identified(online Technical Appendix Table,Figure 2), including a variety ofhuman pathogens capable of causinginvasive soft tissue infections. These

pathogens included Aeromonas spp.(4), potentially pathogenic clinical-type Vibrio vulnificusisolates (onlineTechnical Appendix Figure 2) (5), nonserotype O1 or O139 cholera toxinnegative V. cholerae isolates (onlineTechnical Appendix Figure 2) (6),Mycobacteria (7), and S. agalactiae(3,8). Isolates were resistant to a variety

of antimicrobial drugs, includingtetracyclines, fluoroquinolones, andaminoglycosides (online TechnicalAppendix Table). Other studies havealso reported high levels of multidrug

resistance in bacteria associated withimported ornamental fish (9).

Water is a well-recognizedsource of bacterial skin infectionsin humans. V. vulnificus can causewound infections and primarysepticemia, resulting in high mortalityrates, especially among persons with

predisposing risk conditions (e.g.,liver disease, diabetes, or impairedimmune function) (5). S. agalactiaeisa common cause of skin and soft tissueinfections, especially in older adultsand those with chronic diseases suchas diabetes mellitus (8). Although S.agalactiae ST261 is not consideredto be one of the genotypes typicallyassociated with invasive disease inhumans (3), a fish-adapted straincould eventually take advantage ofthe opportunity afforded by repeatedexposure and thereby also affect

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Figure. Doctor fish surrounding foot during ichthyotherapy.

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humans. Additionally, Mycobacteriaspp. can occasionally cause disease inhumans through contact with fish (M.marinum), and pedicure treatmentshave previously been associated with

M. fortuituminfections (10).Recently, the risks associated

with exposure to G. rufa fish werereported to be low (1). To date, thereare only a limited number of reportsof patients who might have beeninfected by this exposure route (1).However, our study raises someconcerns over the extent that thesefish, or their transport water, mightharbor potential zoonotic disease

pathogens of clinical relevance. Inparticular, patients with underlyingconditions (such as diabetes mellitusor immunosuppression) should

be discouraged from undertakingsuch treatments, especially if theyhave obvious breaks in the skin orabrasions. This risk can probably bereduced by use of certified disease-free fish reared in controlled facilitiesunder high standards of husbandry andwelfare.

The UK Department for Environment

Food and Rural Affairs provided fundingfor this study through projects FA001 andFB002.

David W. Verner-Jeffreys,

Craig Baker-Austin,

Michelle J. Pond,

Georgina S. E. Rimmer,

Rose Kerr, David Stone,

Rachael Griffin, Peter White,

Nicholas Stinton,

Kevin Denham, James Leigh,

Nicola Jones,Matthew Longshaw,

and Stephen W. Feist

Author affiliations: Centre for Environment,

Fisheries & Aquaculture Science Weymouth

Laboratory, Weymouth, UK (D.W. Verner-

Jeffreys, C. Baker-Austin, M.J. Pond,

G.S.E. Rimmer, R. Kerr, D. Stone, R.

Griffin, P. White, N. Stinton, K. Denham,

M. Longshaw, S.W. Feist); University of

Nottingham, Sutton Bonington, UK (J.

Leigh); and Oxford Radcliffe University

Hospitals, Headington, UK (N. Jones)

DOI: http://dx.doi.org/10.3201/eid1806.111782

References

1. Health Protection Agency Fish SpaWorking Group. Guidance on the man-agement of the public health risks fromfish pedicures: draft for consultation.2011 Aug 31 [cited 2012 Mar 21]. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131045549

2. Jones N, Bohnsack JF, Takahashi S,Oliver KA, Chan MS, Kunst F, et al.Multilocus sequence typing system forgroup B Streptococcus. J Clin Micro-

biol. 2003;41:25306. http://dx.doi.org/10.1128/JCM.41.6.2530-2536.2003

3. Evans JJ, Bohnsack JF, Klesius PH, Whit-ing AA, Garcia JC, Shoemaker CA, et al.Phylogenetic relationships among Strep-tococcus agalactiaeisolated from piscine,dolphin, bovine and human sources: a dol-

phin and piscine lineage associated with afish epidemic in Kuwait is also associatedwith human neonatal infections in Japan. JMed Microbiol. 2008;57:136976. http://dx.doi.org/10.1099/jmm.0.47815-0

4. Janda JM, Abbott SL. The genusAeromo-nas: taxonomy, pathogenicity, and infec-tion. Clin Microbiol Rev. 2010;23:3573.http://dx.doi.org/10.1128/CMR.00039-09

5. Jones MK. Oliver, JD. Vibrio vulnificus:disease and pathogenesis. Infect Im-

mun. 2009;77:172333. http://dx.doi.org/10.1128/IAI.01046-08 6. Morris JG. NonO group-1 Vibrio chol-

eraa look at the epidemiology of anoccasional pathogen. Epidemiol Rev.1990;12:17991.

7. Wagner D, Young LS. Nontuberculousmycobacterial infections: a clinical re-view. Infection. 2004;32:25770. http://dx.doi.org/10.1007/s15010-004-4001-4

8. Skoff TH, Farley MM, Petit S, Craig AS,Schaffner W, Gershman K, et al. Increas-ing burden of invasive group B strepto-coccal disease in non-pregnant adults,19902007. Clin Infect Dis. 2009;49:8592. http://dx.doi.org/10.1086/599369

9. Verner-Jeffreys DW, Welch TJ, SchwarzT, Pond MJ, Woodward MJ, Haig SJ, etal. High prevalence of multidrug-tolerant

bacteria and associated antimicrobial re-sistance genes isolated from ornamentalfish and their carriage water. PLoS ONE.2009;4:e8388. http://dx.doi.org/10.1371/

journal.pone.000838810. De Groote MA, Huitt G. Infections due

to rapidly growing mycobacteria. Clin In-fect Dis. 2006;42:175663. http://dx.doi.org/10.1086/504381

Address for correspondence: David W. Verner-

Jeffreys, Cefas Weymouth Laboratory, The

Nothe, Barrack Rd, Weymouth, Dorset DT4

8UB, UK; email: david.verner-jeffreys@cefas.

co.uk

R ic k e t t s i a c o n o r i i Indian Tick Typhus

Strain andR . s l o vac ain

Humans, Sicily

To the Editor: Rickettsiae arevector-borne pathogens that affecthumans and animals worldwide(1). Pathogens in the Rickettsiaconorii complex are known to causeMediterranean spotted fever (MSF) (R.conoriiMalish strain), Astrakhan fever(R. conorii Astrakhan strain), Israelispotted fever (R. conoriiIsraeli spottedfever strain), and Indian tick typhus(R. conorii Indian tick typhus strain)in the Mediterranean basin and Africa,

southern Russia, the Middle East,and India and Pakistan, respectively(2). These rickettsioses share someclinical features, such as febrile illnessand generalized cutaneous rash,and are transmitted to humans byRhipicephalusspp. ticks (2).

MSF is endemic to Sicily (Italy);fatal cases occur each year, and the

prevalence of R. conorii in dogsis high (36). Recently, R. conoriiMalish strain and R. conorii Israelispotted fever strain were confirmed

in humans in Sicily in whom MSFwas diagnosed (4), which suggeststhat other R. conorii strains might

be present and diagnosed as causingMSF. The rickettsiae within the R.conorii complex, which are relevantfor the study of bacterial evolutionand epidemiology, can be properlyidentified only by appropriate geneticanalyses.

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