Table 1.

Clinical manifestations of emerging and neglected zoonoses in non-transplant and transplant population

Pathogen	Clinical presentation		Laboratory diagnosis	Ref.
	Immunocompetent patients	Immunocompromised patients
Vector-borne zoonoses
Tick-borne encephalitis virus	Asymptomatic infection to severe encephalitis	Few data: One cluster of fatal TBE	ELISA (IgM, IgG), Avidity; VNT; RT-PCR	[4,14-16]
Borrelia burgdorferi	Erythema migrans, arthritis, peripheral neuropathy, acrodermatitis chronica atrophicans, neuroborreliosis	Possible dissemination with severe neurological and cardiac symptoms	ELISA (IgM, IgG); IFA (IgM, IgG); Immunoblot (IgM, IgG); PCR	[4,18-20]
Anaplasma phagocytophilum	Mostly self-limiting disease, non-specific symptoms, rash, gastrointestinal and CNS involvement	Unusual presentations: Acute respiratory distress syndrome, haemorrhagic manifestations, pancreatitis, acute renal failure, orchitis	Microscopy of peripheral blood (morulae); IFA (seroconversion of 4-fold increase in IgG titer); PCR	[4,26,32,33,43]
Ehrlichia spp.	Self-limiting febrile illness to fatal multi-organ failure	More frequently severe manifestations: Fatal multiorgan failure, acute respiratory distress syndrome meningoencephalitis, toxic and septic-like syndromes	Microscopy of peripheral blood (morulae); IFA (seroconversion of 4-fold increase in IgG titer); PCR	[4,25,36,37,42]
Rickettsia spp.	Self-limiting disease, flu-like symptoms, with or without eschar and rash; vasculitis-mediated organ failure	Few data: More frequently severe manifestations, splenic rupture	IFA (IgM, IgG); PCR	[4,49,51]
Orientia tsutsugamushi	Nonspecific febrile illness to fatal multiorgan failure, eschar, CNS involvement	Few data: Only one case with eschar and renal graft dysfunction	IFA (IgM, IgG); PCR	[4,53,54]
Rift Valley Fever virus	Subclinical to severe febrile illness, fatal haemorrhagic fever	Few data: Only one case with meningoencephalitis	ELISA (IgM, IgG); VNT; RT-PCR	[4,59,61]
St. Louis encephalitis virus	Majority asymptomatic, febrile illness, aseptic meningitis and encephalitis	Few data: Meningoencephalitis	ELISA (IgM, IgG); VNT; RT-PCR	[4,63,65]
Zika virus	Asymptomatic infection to severe neurological disorders	Infectious complications and graft rejection	ELISA (IgM, IgG); VNT; RT-PCR	[4,69-71]
Chikungunya virus	Mild febrile illness and polyarthralgia, rarely meningoencephalitis, myocarditis	No impact on graft function	ELISA (IgM, IgG); VNT; RT-PCR	[4,74,75,77,79,80]
Dengue virus	Asymptomatic infection to severe fatal illness	More commonly prolonged course with complications and graft rejection	ELISA (IgM, IgG); VNT; NS1 antigen; RT-PCR	[4,82,84-86]
West Nile virus	Asymptomatic infection, mild febrile disease, neuroinvasive disease (elderly)	Fatal neuroinvasive disease more frequent	ELISA (IgM, IgG); VNT; Avidity; VNT; RT-PCR	[4,87,96,97,108,109]
Usutu virus	Asymptomatic infection, neuroinvasive disease (elderly)	Fatal neuroinvasive disease more frequent	ELISA (IgM, IgG); VNT; RT-PCR	[4,114-119]
Eastern equine encephalitis virus	Asymptomatic, neuroinvasive disease (meningitis, encephalitis)	Few data: Neuroinvasive disease	ELISA (IgM, IgG); VNT; RT-PCR	[4,123,124]
Leishmania spp.	Cutaneous, mucocutaneus and visceral leishmaniasis	The same as in immunocompetent; organomegaly may be less frequent in visceral leishmaniasis	Microscopy; Culture; PCR; IFA (IgM, IgG)	[4,129,130]
Non-vector-borne zoonoses
Hepatitis E virus	Asymptomatic infection, fulminant hepatitis, acute-on-chronic liver failure, extrahepatic manifestations	Chronic hepatitis, cirrhosis, extrahepatic manifestations	ELISA (IgM, IgG); Immunoblot (IgM, IgG); RT-PCR	[4,131-133,135,136]
Rabies virus	Fatal encephalitis	Fatal encephalitis	Microscopy (Negri bodies); DFA (antigen detection); IHC (antigen detection); RT-PCR, RFFIT, FAVN	[4,143-146]
Lymphocytic choriomeningitis virus	Asymptomatic infection, nonspecific febrile illness, aseptic meningitis	More severe clinical presentation, hepatitis, meningoencephalitis, multiorgan failure	ELISA (IgM, IgG); IFA (IgM, IgG); RT-PCR	[4,99,151,152]
Toxoplasma gondii	Asymptomatic, mononucleosis-like symptoms	More severe clinical presentation, cerebral toxoplasmosis, fatal disseminated disease	ELISA (IgM, IgG); IFA (IgM, IgG); Avidity, Immunoblot (IgM, IgG); PCR	[4,156-158]

CNS: Central nervous system; DFA: Direct immunofluorescence assay; ELISA: Enzyme-linked immunosorbent assay; FAVN: Fluorescent antibody virus neutralization test; IFA: Indirect immunofluorescence assay; IgG: Immunoglobulin G; IgM: Immunoglobulin M; IHC: Immunohistochemistry; NS1: Non-structural protein 1; PCR: Polymerase chain reaction; RT-PCR: Reverse-transcriptase polymerase chain reaction; TBE: Tick-borne encephalitis; RFFIT: Rapid fluorescent focus inhibition test; VNT: Virus neutralization test.