LETTERS sequences clustered within the Europe/ Turkey clade. The genetic distance be- tween the 2 strains was 1.15%, but the 2 sequences were identical at the amino acid level. Sequences from the present study showed 96.4%–98.8% similar- ity with respective CCHFV sequences from Bulgaria from a former study (BUL10/02 and BUL1/03) (3) but differed from the Kosovo 9553/2001 strain by 0.8%–2.0% and from the Greek 66/08 strain by 1.2%–2.4%. Two additional suspected CCHF cases occurred in the same area, on March 30 and April 9 (7). Both per- sons were negative for CCHFV infec- tion. All 119 ticks of various species (Hyalomma marginatum, Dermacen- tor marginatus, Rhipicephalus bursa, Ixodes ricinus) collected from the area and tested by reverse transcrip- tion–nested PCR were negative for CCHFV. This cluster of CCHF cases has several important highlights. First, it occurred in a region that was consid- ered to have low CCHF endemicity; however, the area is only a few kilo- meters from Greece, where a human fatal case was observed in June 2008 (8). The index case was observed ear- lier in the year than in previous years, and clinical manifestations of the cases were unusual (absence of cran- iopharyngeal syndrome and bleeding from gastrointestinal tract that are typical for CCHF patients from Bul- garia); in the fatal case, autopsy of the patient showed hemorrhages only in the lungs. Two cases were attributable to tick exposure, whereas the other 2 were most likely secondary cases at- tributable to contact with the index case-patient (in this regard, CCHFV sequences of the secondary cases were almost identical). Finally, the longer incubation period of the wife of the index case-patient might be associated with administration of hyperimmune gamma globulin against CCHFV. In conclusion, CCHF emerged in southwestern Bulgaria near the border with Greece. Person-to-person trans- mission emphasizes the need for rapid diagnosis of CCHF, especially in cases with atypical clinical manifestations. Acknowledgments We thank Licia Bordi, Eleonora Lalle, Silvia Meschi, and Roberta Chiappini for valuable help in tick investigations. This work was partially funded by RiViGene (contract no. SSPE-CT-2005- 022639). Iva Christova, Antonino Di Caro, Anna Papa, Concetta Castilletti, Lubena Andonova, Nikolay Kalvatchev, Evangelia Papadimitriou, Fabrizio Carletti, Emad Mohareb, Maria R. Capobianchi, Giuseppe Ippolito, and Giovanni Rezza Author afiliations: National Centre of In- fectious and Parasitic Diseases, Soia, Bulgaria (I. Christova, N. Kalvachev); Na- tional Institute for Infectious Diseases “L. Spallanzani,” Rome, Italy (A. Di Caro, C. Castilletti, F. Carletti, M.R. Capobianchi, G. Ippolito); Aristotelian University of Thes- saloniki, Thessaloniki, Greece (A. Papa, E. Papadimitriou); Infectious Diseases Hospital, Soia (L. Andonova); US Naval Medical Research Unit 3, Cairo, Egypt (E. Mohareb); and Istituto Superiore di Sanità, Rome (G. Rezza). DOI: 10.3201/eid1506.081567 References 1. Ergonul O, Whitehouse CA. Crimean- Congo hemorrhagic fever, a global per- spective. New York: Springer; 2007. 2. Ergonul O. Crimean-Congo haemorrhagic fever. Lancet Infect Dis. 2006;6:203–14. DOI: 10.1016/S1473-3099(06)70435-2 3. Papa A, Christova I, Papadimitriou E, Antoniadis A. Crimean-Congo hemor- rhagic fever in Bulgaria. Emerg Infect Dis. 2004;10:1465–7. 4. Monev V, Dikov I, Kamarinchev B. Crimean-Congo-haemorrhagic fever. In: Serbezov V and Kalvatchev Z, editors. Arbovirus infections viral haemorrhagic fevers and biol-terrorism [in Bulgarian]. Soia; 2005. p. 130–42. 5. Papa A, Drosten C, Bino S, Papadimitriou E, Panning M, Velo E, et al. Viral load in Crimean-Congo hemorrhagic fever. Emerg Infect Dis. 2007;13:805–6. 6. Rodriguez LL, Maupin GO, Ksiazek TG, Rollin PE, Khan AS, Schwarz TF, et al. Molecular investigation of a multisource outbreak of Crimean-Congo hemorrhagic fever in the United Arab Emirates. Am J Trop Med Hyg. 1997;57:512–8. 7. Kunchev A, Kojouharova M. Probable cases of Crimean-Congo-haemorrhagic fever in Bulgaria: a preliminary report. Euro Surveill. 2008;13. pii: 18845. 8. Papa A, Maltezou HC, Tsiodras S, Dalla VG, Papadimitriou T, Pierroutsakos I, et al. A case of Crimean-Congo haemor- rhagic fever in Greece, June 2008. Euro Surveill. 2008;13. pii: 18952. Address for correspondence: Iva Christova, National Center of Infectious and Parasitic Diseases, Blvd Yanko Sakazov 26, Soia 1504, Bulgaria; email: iva_christova@ncipd.org Wohlfahrtiimonas chitiniclastica Bacteremia in Homeless Woman To the Editor: In May 2006, a 60-year-old homeless woman with a history of alcoholism was admitted to the emergency department of the Con- ception Hospital, Marseille, France. Fireighters had just found her in an abandoned container in the outskirts of the city, beside the body of her com- panion, who had died several days ear- lier. She described no symptoms other than fatigue. On examination, she was found to be dirty and covered with thousands of body and hair lice; doz- ens of insect larvae were in her hair. She was mildly febrile (38°C) and had widespread excoriations but no sign of localized bacterial infection. Head shaving exposed supericial ulcers on her scalp but no maggots. Blood analysis showed marked neutropenia Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 6, June 2009 985