Pathogenesis of trachoma: the stimulus for inflammation

Active trachoma is characterized by chronic inflammation of the conjunctiva, and repeated episodes of reinfection are thought to be necessary to sustain this inflammation. It is currently believed that much of the tissue damage is immunologically mediated. To identify which antigens might be responsible for stimulating this continued inflammation, cynomolgus monkeys that had recovered from a previous ocular infection with Chlamydia trachomatis were challenged with various antigen preparations. Purified preparations of formalin- or UV-inactivated elementary bodies did not elicit any inflammation even with daily inoculation. In addition, neither purified chlamydial major outer membrane protein nor lipopolysaccharide, including recombinant organisms expressing the lipopolysaccharide group antigen, elicit inflammation. A soluble triton extract of the organism rapidly induced marked inflammation when inoculated in the eyes of immune monkeys but had no effect in naive animals. These studies suggest that the continual inflammation in trachoma may not be due to repeated exposure to chlamydial surface antigen(s) but rather to a labile product released by the living organisms.     

The Development of an Age-Structured Model for Trachoma Transmission Dynamics,Pathogenesis and Control

Background

Trachoma, the worldwide leading infectious cause of blindness, is due to repeated conjunctival infection with Chlamydia trachomatis. The effects of control interventions on population levels of infection and active disease can be promptly measured, but the effects on severe ocular sequelae require long-term monitoring. We present an age-structured mathematical model of trachoma transmission and disease to predict the impact of interventions on the prevalence of blinding trachoma.

Methodology/Principal Findings

The model is based on the concept of multiple reinfections leading to progressive conjunctival scarring, trichiasis, corneal opacity and blindness. It also includes aspects of trachoma natural history, such as an increasing rate of recovery from infection and a decreasing chlamydial load with subsequent infections that depend upon a (presumed) acquired immunity that clears infection with age more rapidly. Parameters were estimated using maximum likelihood by fitting the model to pre-control infection prevalence data from hypo-, meso- and hyperendemic communities from The Gambia and Tanzania. The model reproduces key features of trachoma epidemiology: 1) the age-profile of infection prevalence, which increases to a peak at very young ages and declines at older ages; 2) a shift in this prevalence peak, toward younger ages in higher force of infection environments; 3) a raised overall profile of infection prevalence with higher force of infection; and 4) a rising profile, with age, of the prevalence of the ensuing severe sequelae (trachomatous scarring, trichiasis), as well as estimates of the number of infections that need to occur before these sequelae appear.

Conclusions/Significance

We present a framework that is sufficiently comprehensive to examine the outcomes of the A (antibiotic) component of the SAFE strategy on disease. The suitability of the model for representing population-level patterns of infection and disease sequelae is discussed in view of the individual processes leading to these patterns.     

Staphylococcus saprophyticus as a urinary pathogen: a six year prospective survey.

Over six years (1978-83, inclusive) weekly laboratory records of organisms causing urinary tract infection in women aged 15-25 not attending hospital were kept prospectively and analysed. The incidence of infection with Staphylococcus saprophyticus defined by age and sex was confirmed. This organism caused an increasing proportion of infections in young women over the six years studied, and these infections showed noticeable seasonality. All but four isolates of S saprophyticus were sensitive to all the commonly used antimicrobial agents that were tested. This might be because the organism is not often present in the body as a commensal and therefore not subject to the selection pressures exerted by such agents. As infection with S saprophyticus has different clinical connotations from infection with other coagulase negative staphylococci it should be differentiated from them in routine laboratory practice.     

CT694 and pgp3 as Serological Tools for Monitoring Trachoma Programs

Background

Defining endpoints for trachoma programs can be a challenge as clinical signs of infection may persist in the absence of detectable bacteria. Antibody-based tests may provide an alternative testing strategy for surveillance during terminal phases of the program. Antibody-based assays, in particular ELISAs, have been shown to be useful to document C. trachomatis genital infections, but have not been explored extensively for ocular C. trachomatis infections.

Methodology/Principal Findings

An antibody-based multiplex assay was used to test two C. trachomatis antigens, pgp3 and CT694, for detection of trachoma antibodies in bloodspots from Tanzanian children (n = 160) collected after multiple rounds of mass azithromycin treatment. Using samples from C. trachomatis-positive (by PCR) children from Tanzania (n = 11) and control sera from a non-endemic group of U.S. children (n = 122), IgG responses to both pgp3 and CT694 were determined to be 91% sensitive and 98% specific. Antibody responses of Tanzanian children were analyzed with regard to clinical trachoma, PCR positivity, and age. In general, children with more intense ocular pathology (TF/TI = 2 or most severe) had a higher median antibody response to pgp3 (p = 0.0041) and CT694 (p = 0.0282) than those with normal exams (TF/TI = 0). However, 44% of children with no ocular pathology tested positive for antibody, suggesting prior infection. The median titer of antibody responses for children less than three years of age was significantly lower than those of older children. (p<0.0001 for both antigens).

Conclusions/Significance

The antibody-based multiplex assay is a sensitive and specific additional tool for evaluating trachoma transmission. The assay can also be expanded to include antigens representing different diseases, allowing for a robust assay for monitoring across NTD programs.     

INFECTIVE ORGANISMS IN THE CYTOPLASM OF AMOEBA PROTEUS

Evidence from electron and phase microscopy is given which shows that infective organisms are present in the cytoplasm of Amoeba proteus. Vesicles containing living organisms have been observed after repeated washing and starvation of the amebae for a period of 2 weeks. Exposure to γ-radiation in conjunction with starvation, repeated washing, isolation of single amebae, refeeding with contaminant-free Tetrahymena, and clone selection has produced clones with reduced cytoplasmic infection. These findings are discussed in regard to the autoradiographic studies of other investigators on Amoeba proteus. The controversies over whether DNA and RNA are synthesized in the cytoplasm may be resolved by the finding of cytoplasmic infection.     

Larval toxocariasis and its clinical manifestation in childhood in the Slovak Republic

Results are presented of 90 children aged 1-15 years hospitalized with toxocariasis. Blood count analysis and laboratory examination were done by routine clinical laboratory methods. Anti-Toxocara antibodies were detected in the serum of patients using an ELISA method. Demographic analysis of the children's families exposed to the risk of disease allowed estimation of age-specific rates for clinical toxocariasis. The probability of toxocaral infection and the intensity of its clinical manifestations in children are determined by the epidemiology of this zoonosis and by the risk factors in the family. The presence of high titres of specific IgG antibodies in all age categories correlates with the clinical manifestations of toxocariasis. The highest admission rate is in the age categories of 3-5 years (43.3%) and 6-10 years (36.7%). Laboratory findings show that the most conspicuous changes occur in the age category 1-5 years. The high percentage of seropositive dog-keeping and puppy-breeding families and the possibility of infection with repeated doses of larvae stimulate eosinophilia, which prevails in children under the age of five years. We present the percentage of patients whose parameters showed deviations from the reference values for a particular age category. Analyses of laboratory indices and of clinical manifestations will contribute to the accuracy of diagnosis and effectiveness of treatment of this disease.     

Antigenic specificity of human antibody to chlamydia in trachoma and lymphogranuloma venereum

An understanding of the molecular basis of the humoral immune response to chlamydial infections in man requires the identification of target antigens to which antibodies are directed. The antigenic specificity of antibody from patients with lymphogranuloma venereum (LGV) or trachoma was therefore assessed by Western blotting. Surface polypeptides were first identified using purified chlamydial outer membrane complex as antigen. Antibodies in sera from patients with LGV but not from control negative sera reacted with a wide range of chlamydial surface polypeptides with molecular masses of 19, 29, 41, 58, 63 and 65 kDa. The major component of the antibody response detected by both immunoblotting and immunoprecipitation assay was directed against the major outer membrane protein (MOMP). Antibody to MOMP was species-specific on Western blotting, whereas antibody to several other polypeptides recognized common immunodeterminants on polypeptides of C. psittaci Cal-10 of equivalent molecular mass. Immunologically C. psittaci Cal-10 was more closely related to LGV strains of C. trachomatis than a guinea pig inclusion conjunctivitis strain of C. psittaci. Trachoma sera collected from a village in southern Iran showed predominantly type-specific antibody on micro-immunofluorescence to serotype A or B trachoma agents. These sera showed a weak immune response to MOMP, a pronounced response to a polypeptide of 36 kDa and much less widespread reactivity with other chlamydial polypeptides. The lack of an immune response to SDS-stable immunodeterminants on MOMP might contribute to the susceptibility of trachoma patients to repeated cycles of ocular infection with chlamydiae.     

Campylobacter-induced enteritis and diarrhea in captive cotton-top tamarins (Saguinus oedipus) during the first year of life

A prospective study of 43 cotton-top tamarins, from infancy to 6 to 17 months of age, was conducted to determine the epidemiology of Campylobacter spp. infection. Nine infants followed for one year in an isolation unit, where attendants wore protective clothing, did not become infected. In the main facility where 32 of 34 animals had repeated infections with C. coli, 6% of the infections developed initially in incubators, 66% in the nursery room, and 28% after transfer to the main colony. Fifteen of these tamarins also were infected with C. jejuni. Twenty percent of the infections developed initially in the nursery room and 80% in the colony. Polyacrylamide gel electrophoresis analysis of C. jejuni cultures revealed multiple reinfections with different strains. Both types of infections were most prevalent between 3 and 9 months of age. Campylobacterjejuni infection developed most frequently between April and June and C. coli infection developed between October and December. In the nursery, diarrhea developed most frequently at times when there was no infection with Campylobacter spp. Forty percent of animals with diarrhea in the nursery had C. coli and none had C. jejuni, whereas, in the colony, 49% had C. jejuni and 11% had C. coli infections. There was no association between these infections and diet or idiopathic colitis.     

Selective medium for Corynebacterium kutscheri and localization of the organism in mice and rats

A new selective medium for isolation of Corynebacterium kutscheri (CK) from animals suffering subclinical infection was made by adding furazolidone, nalidixic acid and corimycin to the heart infusion agar base, this being named FNC agar. The FNC agar inhibited the growth of gram-negative rods, Pseudomonas aeruginosa, Proteus sp. and gram-positive cocci but did not affect the growth of CK. When this medium was used to isolate CK from the oral cavity and cecal contents of mice and rats, two of 6 conventional mouse colonies and three of 8 conventional rat colonies were found to be infected, with isolation of the organism from 19 mice and 12 rats in total. The animals showed neither clinical signs nor lesions, but the antibody was positive in 11 mice and 10 rats. In mice and rats inoculated orally with 4 x 10(8) and 1 x 10(9) organisms, respectively, CK was isolated for 20 weeks post-inoculation by use FNC agar. The isolation rate of the organism was the highest in the oral cavities of both inoculated mice and rats, and also in the submaxillary lymph nodes of the inoculated rats. The organism was also recovered from the cecal contents of more than half of the inoculated mice and rats. Thus, it was considered that FNC agar was useful in isolating CK from the oral cavity and cecal contents of mice and rats with subclinical infection of the organism.     

Serology for Trachoma Surveillance after Cessation of Mass Drug Administration

Background

Trachoma, caused by Chlamydia trachomatis (Ct), is the leading infectious cause of blindness worldwide. Yearly azithromycin mass drug administration (MDA) plays a central role in efforts to eliminate blinding trachoma as a public health problem. Programmatic decision-making is currently based on the prevalence of the clinical sign “trachomatous inflammation-follicular” (TF) in children. We sought to test alternative tools for trachoma surveillance based on serology in the 12-year cohort of Kahe Mpya, Rombo District, Tanzania, where ocular chlamydial infection was eliminated with azithromycin MDA by 2005.

Methodology and Principal Findings

The present study was a community-based cross-sectional survey in Kahe Mpya. Of 989 residents, 571 people aged 6 months to 87 years were enrolled: 58% of the total population and 73% of 1–9 year olds, the key WHO indicator age group. Participants were examined for TF, had conjunctival swabs collected for nucleic acid amplification test (NAAT)-based detection of Ct, and blood collected for analysis of antibodies to the Ct antigens pgp3 and CT694 by multiplex bead-based immunoassay. Seroconversion rate was used to estimate changes in the force of infection in a reversible catalytic model. No conjunctival swabs tested positive for Ct infection by NAAT. Among 1–9 year olds, TF prevalence was 6.5%, whereas only 3.5% were seropositive. Force of infection modelling indicated a 10-fold decrease in seroconversion rate at a time corresponding to MDA commencement. Without baseline serological data, the inferences we can make about antibody status before MDA and the longevity of the antibody response are limited, though our use of catalytic modelling overcomes some of these limitations.

Conclusions/Significance

Serologic tests support NAAT findings of very low to zero prevalence of ocular Ct in this community and have potential to provide objective measures of transmission and useful surveillance tools for trachoma elimination programs.     

Simian foamy virus isolated from an accidentally infected human individual.

Evidence for natural foamy virus (FV) infections in humans is still lacking. However, accidental infections of humans with simian FV have been demonstrated by serology and PCR, but all previous attempts to recover infectious virus in such cases have failed. Here we describe the isolation of a simian FV from peripheral blood mononuclear cells (PBMC) of a healthy animal caretaker, who acquired the virus 20 years ago from an African green monkey (AGM) bite. Properties of the human isolate such as host range in cell cultures including human PBMC and ability to induce neutralizing antibodies in the primate host proved to be similar to those of FV obtained from AGM. The genomic sequence of the isolate was found to be virtually identical to the proviral sequence present in the host lymphocytes and related to AGM isolates but distinct from those of all FV isolates handled in the laboratory. For successful virus isolation, it was essential to stimulate the host lymphocytes by phytohemagglutinin and interleukin-2 for 2 weeks prior to cocultivation with permissive cells. In contrast to the situation found in FV-infected monkeys, virus isolation from the saliva of the animal caretaker was not possible, and no evidence for FV transmission to family contacts was obtained. We conclude that, in contrast to active infection in monkeys, FV persists in a state of latency following accidental infection of humans.     

Chemotherapy of Mice Experimentally Infected with Shigella flexneri

A chronic infection with Shigella flexneri 2a has been established in mice for the evaluation of compounds for therapeutic potential. Evidence of infection is indicated by prolonged symptomless excretion in the feces and by positive isolation of organisms from different segments of the intestinal tract and from mesenteric lymph nodes. Serum antibody titer reaches a maximum after 9 days of infection and remains at a low level until 32 days postinfection. In this model, five drugs used in human shigellosis were evaluated for efficacy. Ampicillin was found to be the most active followed by oxytetracycline and kanamycin. Neomycin and colistin were the least active in this system.     

Differential antimicrobial activity of human mononuclear phagocytes against the human biovars of Chlamydia trachomatis

The antimicrobial activities of human mononuclear phagocytes against Chlamydia trachomatis were investigated. Phagocytes cultured for 7 days or less were efficiently microbicidal. Almost complete inactivation of organisms from both human biovars was observed after 48 hr of incubation. However, organisms from the lymphogranuloma venereum (LGV) biovar survived in mononuclear phagocytes infected after 8 days or more in culture, whereas those from the trachoma biovar continued to be killed by such cells. Phagocytes cultured as long as 21 days killed the trachoma organisms with the same effectiveness as those cultured for 7 days or less. An ultrastructural study of inoculated phagocytes illustrated phagolysosomal fusion with degradation of organisms from either biovar in phagocytes which had been cultured for 24 hr before infection. Phagolysosomal fusion was not observed in cells which had been cultured for 8 days or more and then infected with LGV. The addition of interferon-gamma to these macrophages partially restored the phagocytes' microbicidal activity for LGV. Furthermore, a synergistic effect was observed when eosinophil peroxidase was added with interferon. Specific antibody failed to neutralize the infectivity of LGV organisms in 8-day or older mononuclear phagocytes. The findings may reflect the differences in disease syndromes between the two biovars, with the trachoma biovar causing more peripheral diseases and the LGV biovar causing a more systemic disease, with lymph node involvement as its main syndrome.     

Molecular epidemiological investigation of enterohaemorrhagic Escherichia coli isolates in Japan

We have established several measures for control and prevention of EHEC infection including designation of the disease as notifiable since there was the sudden increase in the incidence of infection with EHEC O157:H7 in Japan in 1996, involving multiple outbreaks. Improvements in methodologies for isolation of these organisms and enhanced laboratory screening have revealed a variety of sources in food and animals. Although there seems to be a bovine reservoir for O157 EHEC in Japan as well as North America and UK, different foods have been linked to EHEC infection including salads, radish sprouts and salmon roe. There is clear evidence that divergent clones of EHEC O157:H7 are prevalent throughout Japan based on laboratory surveillance, however, we still need to better define the role of EHEC serogroups other than Escherichia coli O157 as important causes of human infection.     

Surveillance for peri-elimination trachoma recrudescence: Exploratory studies in Ghana

IntroductionTo date, eleven countries have been validated as having eliminated trachoma as a public health problem, including Ghana in 2018. Surveillance for recrudescence is needed both pre- and post-validation but evidence-based guidance on appropriate strategies is lacking. We explored two potential surveillance strategies in Ghana.Methodology/principal findingsAmongst randomly-selected communities enrolled in pre-validation on-going surveillance between 2011 and 2015, eight were identified as having had trachomatous-inflammation follicular (TF) prevalence ≥5% in children aged 1–9 years between 2012 and 2014. These eight were re-visited in 2015 and 2016 and neighbouring communities were also added (“TF trigger” investigations). Resident children aged 1–9 years were then examined for trachoma and had a conjunctival swab to test for Chlamydia trachomatis (Ct) and a dried blood spot (DBS) taken to test for anti-Pgp3 antibodies. These investigations identified at least one community with evidence of probable recent Ct ocular transmission. However, the approach likely lacks sufficient spatio-temporal power to be reliable.A post-validation surveillance strategy was also evaluated, this reviewed the ocular Ct infection and anti-Pgp3 seroprevalence data from the TF trigger investigations and from the pre-validation surveillance surveys in 2015 and 2016. Three communities identified as having ocular Ct infection >0% and anti-Pgp3 seroprevalence ≥15.0% were identified, and along with three linked communities, were followed-up as part of the surveillance strategy. An additional three communities with a seroprevalence ≥25.0% but no Ct infection were also followed up (“antibody and infection trigger” investigations). DBS were taken from all residents aged ≥1 year and ocular swabs from all children aged 1–9 years. There was evidence of transmission in the group of communities visited in one district (Zabzugu-Tatale). There was no or little evidence of continued transmission in other districts, suggesting previous infection identified was transient or potentially not true ocular Ct infection.Conclusions/significanceThere is evidence of heterogeneity in Ct transmission dynamics in northern Ghana, even 10 years after wide-scale MDA has stopped. There is added value in monitoring Ct infection and anti-Ct antibodies, using these indicators to interrogate past or present surveillance strategies. This can result in a deeper understanding of transmission dynamics and inform new post-validation surveillance strategies. Opportunities should be explored for integrating PCR and serological-based markers into surveys conducted in trachoma elimination settings.     

Stopping azithromycin mass drug administration for trachoma: A systematic review

The World Health Organization (WHO) recommends continuing azithromycin mass drug administration (MDA) for trachoma until endemic regions drop below 5% prevalence of active trachoma in children aged 1–9 years. Azithromycin targets the ocular strains of Chlamydia trachomatis that cause trachoma. Regions with low prevalence of active trachoma may have little if any ocular chlamydia, and, thus, may not benefit from azithromycin treatment. Understanding what happens to active trachoma and ocular chlamydia prevalence after stopping azithromycin MDA may improve future treatment decisions. We systematically reviewed published evidence for community prevalence of both active trachoma and ocular chlamydia after cessation of azithromycin distribution. We searched electronic databases for all peer-reviewed studies published before May 2020 that included at least 2 post-MDA surveillance surveys of ocular chlamydia and/or the active trachoma marker, trachomatous inflammation–follicular (TF) prevalence. We assessed trends in the prevalence of both indicators over time after stopping azithromycin MDA. Of 140 identified studies, 21 met inclusion criteria and were used for qualitative synthesis. Post-MDA, we found a gradual increase in ocular chlamydia infection prevalence over time, while TF prevalence generally gradually declined. Ocular chlamydia infection may be a better measurement tool compared to TF for detecting trachoma recrudescence in communities after stopping azithromycin MDA. These findings may guide future trachoma treatment and surveillance efforts.     

Correlation of clinical trachoma and infection in Aboriginal communities

Background

Trachoma is the leading infectious cause of blindness due to conjunctival infection with Chlamydia trachomatis. The presence of active trachoma and evidence of infection are poorly correlated and a strong immunologically-mediated inflammatory response means that clinical signs last much longer than infection. This population-based study in five Aboriginal communities endemic for trachoma in northern Australia compared a fine grading of clinical trachoma with diagnostic positivity and organism load.

Methods

A consensus fine grading of trachoma, based on clinical assessment and photograding, was compared to PCR, a lipopolysacharide (LPS)-based point-of-care (POC) and a 16S RNA-based nucleic acid amplification test (NAAT). Organism load was measured in PCR positive samples.

Results

A total of 1282 residents, or 85.2% of the study population, was examined. Taking the findings of both eyes, the prevalence of trachomatous inflammation-follicular (TF) in children aged 1–9 years was 25.1% (96/383) of whom 13 (13.7%) were PCR positive on the left eye. When clinical data were limited to the left eye as this was tested for PCR, the prevalence of TF decreased to 21.4% (82/383). The 301 TF negative children, 13 (4.3%) were PCR positive. The fine grading of active trachoma strongly correlated with organism load and disease severity (rs = 0.498, P = 0.0004). Overall, 53% of clinical activity (TF₁ or TF₂) and 59% of PCR positivity was found in those with disease scores less than the WHO simplified grade of TF.

Conclusion

Detailed studies of the pathogenesis, distribution and natural history of trachoma should use finer grading schemes for the more precise identification of clinical status. In low prevalence areas, the LPS-based POC test lacks the sensitivity to detect active ocular infection and nucleic acid amplification tests such as PCR or the 16S-RNA based NAAT performed better. Trachoma in the Aboriginal communities requires specific control measures.     

Infection prophylaxis in acute leukaemia patients: comparison of selective and total antimicrobial decontamination of the gastrointestinal tract

In a retrospective study, total antimicrobial decontamination with strict reverse isolation (ITD) and selective decontamination without isolation (SD) were compared as means of preventing infection in patients with acute leukaemia. Thirty patients were treated with ITD and 34 patients with SD. The surveillance cultures indicated that aerobic gram-negative bacilli and yeast could be equally eliminated effectively in both the groups. The anaerobic flora was only minimally influenced by SD. The incidence of acquired infections was 1.17 per patient in group ITD as compared to 0.85 in group SD. In group ITD, acquired bacterial infections were mostly caused by gram-negative bacilli (63%) whereas in the group SD these microorganisms accounted only for 25% of the infections. In group SD the total number of fever days was significantly lower and the mean duration of pyrexial episodes was substantially shorter. The results indicate that SD is an effective and inexpensive method for preventing gram-negative infections and might be at least as effective as ITD.     

Retrospective studies of urinary infections in the elderly

Retrospective analysis of the urinary infection course involved 55 elderly patients. The patients were divided into groups basing on the clinical diagnosis. These groups included patients with obstructive chronic pyelonephritis and the patients with lower urinary infections. It was found that reinfections occur in the elderly patients with both upper and lower urinary infections while recurrence is seen in case of the upper urinary infections. Bacteriuria is significantly more frequent in the obstructive chronic pyelonephritis than in other urinary infections. This form of bacteriuria is frequently accompanied by exacerbations than in bacteriuria of periodic origin. Arterial blood hypertension is frequent in the elderly with urinary infections but its incidence does not correlate with the localization of the infection. Decompensated renal failure in the course of the urinary infections in the elderly is nearly always combined with arterial blood hypertension.     

Characterization of Ehrlichia species from Ixodes ovatus ticks at the foot of Mt. Fuji, Japan

A total of 390 adult ticks (288 Ixodes ovatus and 102 I. persulcatus ) collected at the foot of Mt. Fuji and two near cities in Shizuoka prefecture, Japan, were examined for Ehrlichia infection by isolation with laboratory mice from whole tick tissues. Ehrlichial DNAs were detected from the spleens of mice inoculated with tissues from I. ovatus, but not I. persulcatus. The prevalence of ehrlichiae in the ticks was estimated to be ca. 3%. The 16S rDNA analysis revealed that the sequences of 8 ehrlichial isolates (termed "Shizuoka" isolates) obtained were identical, and they were very similar, but not identical, to those of two Ehrlichia species strain variants recently isolated in Japan, followed by Ehrlichia chaffeensis in the US. Analysis of parts of the omp-1 multigene family specific for monocytic ehrlichiosis agents showed that the Shizuoka isolates were distinct from other ehrlichial organisms. The Shizuoka isolates caused death in immunocompetent laboratory mice, suggesting that they are highly pathogenic in mice. The data show that the Shizuoka isolates are likely to be a new strain variant of Ehrlichia species in Japan. Further characterization and surveillance will be required in Japan due to the presence of these human ehrlichiosis agent-like organisms.