key: cord-0781125-hauvdu9e authors: Maggi, Fabrizio; Novazzi, Federica; Genoni, Angelo; Baj, Andreina; Spezia, Pietro Giorgio; Focosi, Daniele; Zago, Cristian; Colombo, Alberto; Cassani, Gianluca; Pasciuta, Renee; Tamborini, Antonio; Rossi, Agostino; Prestia, Martina; Capuano, Riccardo; Azzi, Lorenzo; Donadini, Annalisa; Catanoso, Giuseppe; Grossi, Paolo Antonio; Maffioli, Lorenzo; Bonelli, Gianni title: Imported SARS-CoV-2 Variant P.1 in Traveler Returning from Brazil to Italy date: 2021-04-03 journal: Emerg Infect Dis DOI: 10.3201/eid2704.210183 sha: 842cabb658702421d8e450bcb4ff5f543f262228 doc_id: 781125 cord_uid: hauvdu9e We report an imported case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant P.1 detected in an asymptomatic traveler who arrived in Italy on an indirect flight from Brazil. This case shows the risk for introduction of SARS-CoV-2 variants from indirect flights and the need for continued SARS-CoV-2 surveillance. with JSF (10) . The patient showed no other skin eruptions besides the eschar at the site of the tick bite (Figure) . It is highly possible that the eschar on this patient could have been caused by an inflammatory response induced by the local R. japonica infection. R. japonica did not induce systemic symptoms in this patient for 2 possible reasons. First, the incubation time for SFTS might be shorter than that of JSF. Second, the initiation of antimicrobial drugs in the early phase of disease might have ameliorated the clinical course of the diseases. In conclusion, we describe a patient with a generalized SFTSV infection and a localized skin lesion caused by R. japonica at the site of a tick bite. This study suggests that SFTS patients with eschar at the site of a tick bite should be treated with appropriate antimicrobial drugs, such as doxycycline and minocycline. The study was carried out partially with financial support from the Japan Agency for Medical Research and Development (AMED, 19fk0108081j and 20fk0108081j). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. T.F. and K.Y. contributed to clinical management and writing of the manuscript. M.S. contributed to writing of the manuscript. T.Y., T.K., and M.S. contributed to the virological diagnosis. All authors had full access to all data in the study and all take responsibility for the integrity of the data and the accuracy of the data analysis. https://virological.org/t/sars-cov-2-reinfection-bythe-new-variant-of-concern-voc-p-1-in-amazonasbrazil/596). Another lineage, P.2, was reported in Rio de Janeiro, Brazil, but has been associated with spike mutations only in E484K; >2 cases of reinfection have been documented several months after primary B.1.1.33 infections (P. Resende et al., unpub. data, https://virological.org/t/spike-e484kmutation-in-the-first-sars-cov-2-reinfection-case-confirmed-in-brazil-2020/584; C.K. Vasques Nonaka et al., unpub. data, https://doi.org/10.20944/pre-prints202101.0132.v1). Among the spike mutations, E484K is considered the main driver of immune evasion to mAbs and convalescent serum After visiting São Paulo, Brazil, during November 23, 2020-January 16, 2021, a family, including a 33-year-old man, his 38-year-old wife, and his 7-yearold daughter, flew back to their home in Italy. During their time in Brazil, the family did not travel outside of São Paulo, which is >2,000 miles from Amazonas. The family took an indirect return flight; they flew from São Paulo/Guarulhos International Airport in Brazil to Madrid, Spain, and from there flew to Milan Malpensa Airport in Italy. Molecular tests were performed on all 3 family members at the departure airport in Brazil, and all were SARS negative. The family arrived in Milan on the afternoon of January 17 and took a train and a car to their home, 30 miles from Milan. Under current recommendations in Italy, all persons entering the country can decide to be screened for SARS-CoV-2. After consulting a general practitioner on January 21, the father went to the hospital for a screening nasopharyngeal swab sample. The sample was tested by using the Alinity platform (Abbott, https://www.abbott.com), which returned a positive result for SARS-CoV-2 RNA with a cycle threshold of 23. Reverse transcription PCR (RT-PCR) fragments corresponding to the receptor-binding domain (RBD) in the spike gene of SARS-CoV-2 were amplified from purified viral RNA by using a OneStep RT-PCR Kit (QIAGEN, https://www.qiagen.com). We used a reference sequence from GSAID (https:// www.gisaid.org; accession no. EPI_ISL_402124) and We report an imported case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant P.1 detected in an asymptomatic traveler who arrived in Italy on an indirect flight from Brazil. This case shows the risk for introduction of SARS-CoV-2 variants from indirect flights and the need for continued SARS-CoV-2 surveillance. nucleotide sequences of primer sets to map genome locations (Figure; Appendix, https://wwwnc.cdc.gov/ EID/article/27/4/21-0183-App1.pdf). The sequence of RBD from the patient included the P.1 barcoding mutations K417T, E484K, and N501Y. We deposited these data in GenBank (accession no. MW517286) and GISAID (accession no. EPI-ISL-869166). SARS-CoV-2 variant P.1 is characterized by K417N, but K417T also has been reported in several cases before our patient (1), suggesting ongoing evolution. On January 22, 2021, after we reported the sequencing results, the patient was admitted to the infectious and tropical diseases unit of ASST dei Sette Laghi-Ospedale di Circolo e Fondazione Macchi (Varese, Italy) for observation. The patient remained asymptomatic and was discharged on January 29. The patient's spouse also tested positive for SARS-CoV-2 RNA via a nasopharyngeal swab sample. Antibody tests conducted by using Liaison Analyzer (DiaSorin, https://www.diasorin.com) were negative for SARS-CoV-2 S1/S2 IgG in serum of both the man and his wife, suggesting a primary infection. Direct flights from Brazil to Italy were canceled upon the unilateral decision of the government of Italy on January 16, 2021, but our findings confirm the risk for introducing SARS-CoV-2 variants from indirect Fever with thrombocytopenia associated with a novel bunyavirus in China The first identification and retrospective study of severe fever with thrombocytopenia syndrome in Japan SFTS epidemiological research group-Japan. Epidemiological and clinical features of severe fever with thrombocytopenia syndrome in Japan Distribution of tick-borne diseases in Japan: Past patterns and implications for the future Circulation of severe fever with thrombocytopenia syndrome virus (SFTSV) in nature: transmission of SFTSV between mammals and ticks Sensitive and specific PCR systems for detection of both Chinese and Japanese severe fever with thrombocytopenia syndrome virus strains and prediction of patient survival based on viral load Specific amplification of Rickettsia japonica DNA from clinical specimens by PCR Severe fever with thrombocytopenia syndrome virus antigen detection using monoclonal antibodies to the nucleocapsid protein Cross-reactivity of Rickettsia japonica and Rickettsia typhi demonstrated by immunofluorescence and Western immunoblotting Japanese spotted fever: report of 31 cases and review of the literature This case also suggests wider circulation of SARS-CoV-2 variant P.1 in areas other than Amazonas in Brazil. P.1-specific primer sets recently have been designed Brief report: new variant strain of SARS-CoV-2 identified in travelers from Brazil Dr. Fujikawa is a chief director in the Department of General Internal Medicine, Kagawa, Mitoyo General Hospital, Japan. His research interests include general internal medicine and medical education. Prof. Maggi is on the Faculty of Medicine at the University of Insubria and directs the Virology Unit of Ospedale di Circolo and Fondazione Macchi in Varese, Lombardia, Italy. His primary research interest is emerging viral pathogens.