The case of Mediterranean spotted fever of the traveler returned from Zambia

We report the case of a traveler who returned from Zambia and was diagnosed with Mediterranean spotted fever (MSF), an infectious disease caused by Rickettsia conorii conorii. The patient presented to Sapporo City General Hospital with symptoms of fever, malaise, headache, and rash. The pathogen was identified by Polymerase Chain Reaction assays and subsequent analyses. The patient improved with 10-day treatment of oral doxycycline. Although some cases of MSF have been reported in sub-Saharan Africa, none have been reported in Zambia. Rhipicephalus sanguineus sensu lato, the vector of the Rickettsia conorii conorii, has been found in various areas of Zambia. Our case report highlights the potential threat of Mediterranean spotted fever in urban areas of Zambia.

A case series of Mediterranean spotted fever and murine typhus with neurological manifestations

BACKGROUND OBJECTIVES

Severe cases with neurological manifestations of rickettsiosis have been reported. We aimed to identify the epidemiological, clinical and laboratory features of central nervous system rickettsial infections and to describe the treatment.

METHODS

We carried out a retrospective study that included all patients hospitalized with rickettsiosis in the infectious diseases department of Hedi Chaker University Hospital in Sfax, Tunisia between 1993 and 2018.

RESULTS

We identified 47 patients with central nervous system rickettsial infections among 440 patients with rickettsial infections (10.7%). Skin rash (31.9% vs 87.8%; p<0.001) and eschar (4.2% vs 27.7%; p<0.001) were less frequent among patients with central nervous system rickettsial infections. Complications (6.4% vs 0.5%; p=0.01) and death (4.2% vs 0.3%; p=0.03) were more frequent among patients with central nervous system rickettsial infections.

INTERPRETATION CONCLUSION

Cardinal clinical features and typical laboratory results including thrombocytopenia were less frequent, and prognosis was more severe in patients with central nervous system rickettsial infections.

Rickettsia conorii: Unusual case of acute aortic thrombosis

OBJECTIVES

Mediterranean spotted fever is a common zoonosis in Europe caused by Rickettsia conorii bacterium. Among its wide range of clinical presentations, arterial thrombosis of large vessels has never been described before.

METHODS

We report a case of a complete acute infrarenal aortic thrombosis in a 61-year-old male with R. conorii infection.

RESULTS AND CONCLUSION

The patient was successfully operated using open aortic surgery and subsequent treatment with doxycycline. To our knowledge, this is the first report of aortic thrombosis associated with infection by this parasite, extending the clinical spectrum of the disease.

Rickettsia conorii subsp. israelensis infection in a pediatric patient presenting skin rash and abdominal pain: a case report from Southeast Iran

BACKGROUND

The healthcare system in Iran appears to overlook Mediterranean spotted fever (MSF) as an endemic disease, particularly in pediatric cases, indicating the need for greater attention and awareness.

CASE PRESENTATION

A six-year-old patient with fever, abdominal pain, headache, skin rashes, diarrhea, vomiting, and black eschar (tache noire) from southeast Iran was identified as a rickettsiosis caused by Rickettsia conorii subsp. israelensis through clinical and laboratory assessments, including IFA and real-time PCR. The patient was successfully treated with doxycycline.

CONCLUSIONS

Symptoms like rash, edema, eschar, and abdominal pain may indicate the possibility of MSF during the assessment of acute febrile illness, IFA and real-time PCR are the primary diagnostic methods for this disease.

Mediterranean Spotted Fever in Children: Study of a Portuguese Endemic Region

INTRODUCTION

Mediterranean spotted fever is an infectious disease included in the human rickettsiosis group, with its main distribution in the Mediterranean and South European countries. It is an endemic disease in Portugal, with dogs acting as the main domestic reservoir. Children are a particularly vulnerable group due to their close contact with household animals and by frequently playing outdoors. In this study, we aim to describe the local epidemiology and characterize the clinical features and treatment options in a Portuguese endemic region.

MATERIALS AND METHODS

We performed a prospective descriptive study of the Mediterranean spotted fever cases admitted to the paediatrics emergency department of a of a group II hospital, between January 1st 2013 and December 31st 2015. All patients were examined by a physician, who was later asked to fill out a detailed questionnaire regarding clinical presentation, diagnostic attitudes and treatment of their patients. Parents were later interviewed and questioned about post-discharge disease evolution.

RESULTS

We registered 32 cases (93.9% reported between July and October). After fever, the most frequent reported symptoms were myalgia (37.5%), abdominal pain (25%) and headache (25%). Exanthema was present in 84.4% of cases by the third day of fever:maculonodular (53.1%), papular (37.5%) and macular (9.4%). Eschars were found in 59% of patients, with regional lymphadenopathypresent in 46.9% of cases. Azithromycin (84.4%) and doxycycline (15.5%) were the selected treatments in our population, with no cases of therapeutic failure or side-effects reported.

CONCLUSION

The incidence of Mediterranean spotted fever is higher in our population in comparison with the rest of the country. Fever, myalgia, abdominal pain and headache were the most common presenting symptoms, while exanthema was the predominant cutaneous finding. Azithromycin was the preferred treatment and it proved to be successful and safe in all cases.

[Symmetrical peripheral gangrene: 4 cases]

BACKGROUND

Symmetric peripheral gangrene (SPG) is a symmetrical distal ischemic lesion on at least 2 or more extremities in the absence of proximal arterial obstruction and vasculitis. It is a rare and severe clinical entity. The aim of this study was to describe clinical symptoms, etiological agents and the management of SPG through a series of 4 cases.

PATIENTS AND METHODS

We included all cases of SPG hospitalized between 2000 and 2014. The inclusion criterion was the presence of distal ischemic damage at two or more sites in the absence of large vessel obstruction.

RESULTS

Four patients (2 men and 2 women) were included. The mean age was 43.2±12 years. Two patients had a history of splenectomy. All patients had blackening of the tips of the fingers and toes. Three patients presented with septic shock. The etiology was bacteremia involving Streptococcus pneumoniae in two cases and a malignant form of Mediterranean spotted fever (MSF). In addition to specific antibiotics, we used a potent vasodilator (iloprost) in two cases and curative heparin therapy in two cases. The outcome was favorable in 3 cases, with regression of necrotic lesions. One case required the amputation of non-perfused necrotic fingers and toes.

CONCLUSION

SPG can complicate MSF in some rare cases. Thorough and repeated skin examinations are essential to ensure timely diagnosis and treatment of GPS in order to improve the prognosis.

[South African tick bite fever in a group of Russian tourists]

The paper describes a clinical case of South African tick bite fever in a group of Russian tourists. The group of 5 people who had been ill with this disease after a tourist trip to the South African Republic (the Kruger National Park in the north-eastern province of Mpumalanga) were followed up. During their trip, all of them were bitten by different insects many times. The disease exhibited different clinical presentations; however, all the patients were noted to have a fever with slight intoxication and a maculopapular rash at different sites of the body; 3 had lymphadenopathy and one had a primary effect at the site of tick sticking. The diagnosis was verified by indirect immunofluorescence for the detection of high titers to Rickettsia conorii. The course of the disease was favorable in all the patients treated with antibiotics (doxycycline or ceftriaxone).

[Mediterranean spotted fever in paediatric and adult patients: two clinical aspects of the same disease]

Mediterranean Spotted Fever is an acute febrile disease caused by Rickettsia conorii and transmitted to humans by the brown dog tick Rhipicephalus sanguineus. Nearly 400 cases are reported every year in Sicily, mainly from June to September. The aim of this study is to compare the clinical and laboratory features of two different groups of patients , one of adults and one of children. The analysis included all adult patients with MSF diagnosed at the Institute of Infectious Diseases, Paolo Giaccone University Polyclinic in Palermo, during the period January 2007- August 2010 and all the children diagnosed with MSF at the G. Di Cristina Children Hospital in Palermo during the period January 1997- December 2004. On admission, a complete physical and laboratory examination was carried out on every patient. An indirect immunofluorescence assay for Rickettsia conorii was performed in every case, a PCR assay was performed with blood samples from some adult patients. Analysis of the results confirms that MSF is a benign, and self-limiting disease in children, while severe complications can often arise in adults.

[Emergence of tick-borne spotted fever group rickettsiosis in Moscow]

AIM

Analysis of clinical cases of tick-borne spotted fever (TSF) group rickettsiosis in 2005 - 2010.

MATERIALS AND METHODS

General clinical, biochemical and serological parameters were determined in 10 tick-borne spotted fever group rickettsiosis patients who had visited various geographical regions of the World.

RESULTS

TSF group rickettsiosis diagnostic criteria, optimal serological diagnostics timing were determined. Possible diagnostic errors, features of serological diagnostics and antibacterial therapy of this nosologic form are discussed.

CONCLUSION

Indication for TSF examination are primarily epidemiologic including tick attachment indication and clinical data. Serological studies are positive only in 3 - 4 weeks after the onset of the infection and thus can not be used for early diagnostics.

Mediterranean spotted fever, a diagnostic challenge in travellers

Mediterranean spotted fever or boutonneuse fever is caused by Rickettsia conorii and transmitted by the brown dog tick. The commonest symptoms are pyrexia, a maculopapular rash, lymphadenopathies and an inoculation eschar. Increasingly, it is recognised as a cause of serious illness in southern Europe. Rickettsial infections of the spotted fever group are rarely reported in Belgium. We report the case of a 20-year-old traveller returning from Morocco who presented with fever and a markedly swollen inguinal lymph node. Our case report illustrates the challenges rickettsioses can pose to physicians facing febrile travellers. Awareness of the epidemiology and the spectrum of clinical manifestations of this acute zoonosis can help physicians to promptly start appropriate empiric antibiotic therapy.

Rickettsial diseases in Haryana: not an uncommon entity

Rickettsioses have not been reported from the plains of North India and Haryana in particular. Here we are reporting three cases of scrub typhus and one cases of Indian tick typhus in the state of Haryana, all of which presented with fever and multi organ dysfunction, rash and without eschar. All were successfully treated with doxycycline.

Tick bite fever and Q fever - a South African perspective

Tick bite fever (TBF) and Q fever are zoonotic infections, highly prevalent in southern Africa, which are caused by different genera of obligate intracellular bacteria. While TBF was first described nearly 100 years ago, it has only recently been discovered that there are several rickettsial species transmitted in southern Africa, the most common of which is Rickettsia africae. This helps to explain the highly variable clinical presentation of TBF, ranging from mild to severe or even fatal, that has always been recognised. Q fever, caused by Coxiella burnetii, is a protean disease that is probably extensively under-diagnosed. Clinically, it also shows a wide spectrum of severity, with about 60% of cases being clinically inapparent. Unlike TBF, Q fever may cause chronic infection, and a post-Q fever chronic fatigue syndrome has been described. The molecular pathophysiology of these diseases provides insight into different strategies that intracellular parasites may use to survive and cause disease. While newer macrolide and quinolone antibiotics show activity against these pathogens and may be useful in young children and pregnant women, the treatment of choice for acute infection in both diseases is still tetracycline-group antibiotics. Chronic Q fever remains challenging to treat.

[Mediterranean spotted fever in north Dalmatia: is there a problem?]

We analyzed clinical and therapeutic characteristics of Mediterranean spotted fever (MSF) in north Dalmatia. Analysis was conducted in 93 patients hospitalized with MSF at Zadar General Hospital during the 1988-2000 period. The most frequently found signs of the disease were high fever (91; 97.8%), maculopapular rash (89; 95.7%), headaches (84; 90.3%), arthralgia (75; 80.6%), exhaustion (75; 80.6%) and nausea (65; 69.9%). Tache noire, as a pathognomonic sign of MSF, was found in 22 (23.7%) patients. The most frequently indicated diagnoses were febris cum exanthemate (43; 46.2), rickettsiosis suspecta (21; 22.6%) and exanthema maculopapulosum (15; 16.1%). Early therapeutic efficiency was achieved by doxycycline in 34/43 (79.1%), and by ciprofloxacin in 10/14 (71.4%) treated adult patients, and by azithromycin in 7/9 (77.8%) children. The identification of MSF endemic rickettsiosis in north Dalmatia, serious clinical forms of the disease and the success of early and adequate anti-rickettsial antibiotic therapy are a clear warning that our physicians must be very familiar with this disease and include this rickettsial disease in differential diagnosis of acute febrile diseases accompanied by rash.

Spotted fever rickettsioses in southern and eastern Europe

Mediterranean spotted fever due to Rickettsia conorii conorii was thought, for many years, to be the only tick-borne rickettsial disease prevalent in southern and eastern Europe. However, in recent years, six more species or subspecies within the spotted fever group of the genus Rickettsia have been described as emerging pathogens in this part of the world. Tick-borne agents include Rickettsia conorii israelensis, Rickettsia conorii caspia, Rickettsia aeschlimannii, Rickettsia slovaca, Rickettsia sibirica mongolitimonae and Rickettsia massiliae. Many Rickettsia of unknown pathogenicity have also been detected from ticks and could represent potential emerging pathogens to be discovered in the future. Furthermore, a new spotted fever rickettsia, Rickettsia felis, was found to be associated with cat fleas and is an emerging human pathogen. Finally, the mite-transmitted Rickettsia akari, the agent of rickettsialpox, is also known to be prevalent in Europe. We present here an overview of these rickettsioses, focusing on emerging diseases.

[Abnormal liver function in Mediterranean spotted fever]

In this study we retrospectively assessed the prevalence of impaired liver function in all 49 patients suffering from Mediterranean Spotted Fever (MSF) consecutively admitted to our department over the last four years. The main parameters of liver function and ultrasound of upper abdomen were performed at entry and at the end of treatment. At admission mean values of transaminases were above the normal limits and significantly higher when compared to mean serum levels at recovery. 55% and 51% of patients had serum values of GOT and GPT, respectively, above the normal limits versus 1% and 2% at the end of treatment. Mean serum values of alkaline phosphatase (AP) were within the normal limits at entry in hospital, but 22 of them had serum values above the normal limits. The same proportion was seen for gamma glutamiltranspeptidase values. Eighteen patients (36.7%) had both transaminases and AP above the normal limits. There were no significant differences among serum values of albumin, bilirubin and gamma globulin before and after therapy. Platelet count, on the contrary, was significantly reduced at admission (p < 0.0001). At ultrasound half of the patients showed hepatomegaly with a hepatitis-like pattern and 39% of patients had splenomegaly. In conclusion, this study confirms previous data from the literature showing a high frequency of liver impairment during the course of MSF, which is usually mild-moderate. In a few cases, however, the increase of transaminases could be serious and the recovery delayed, but never, in our experience, has there been progression toward chronic liver disease.

Febrile illness associated with Rickettsia conorii infection in dogs from Sicily

We report serologic and molecular evidence of acute, febrile illness associated with Rickettsia conorii in 3 male Yorkshire terriers from Sicily (Italy).

A case of acute quadriplegia complicating Mediterranean spotted fever

Mediterranean spotted fever is a rickettsiosis caused by Rickettsia conorii. Mediterranean spotted fever is considered to be a benign disease, however, approximately 10% of patients present with a severe systemic manifestation in which neurologic involvement occurs. We present a case of an 80-year-old man with a R. conorii infection who developed an acute quadriplegia secondary to an axonal polyneuropathy. The characteristic tache noire was observed on the lateral region of the thigh and elevated IgM antibody titres against R. conorii were detected by an indirect immunofluorescence test.

Une fièvre boutonneuse méditerranéenne compliquée d'une embolie pulmonaire

INTRODUCTION

Thromboembolic complications were uncommon in mediterranean spotted fever.

OBSERVATION

We report a case of 55-years- old man who was admitted for mediterranean spotted fever. Two days later, the patient developed chest pain due to a pulmonary thrombosis confirmed by angio-CT. The outcome was good with heparin therapy. The investigation for another cause of thrombosis was negative.

CONCLUSION

Mediterranean spotted fever is usually a moderately severe self-limited illness. Pulmonary thrombosis was uncommon associated with severe disease.

Epidemiology and clinical features of Mediterranean spotted fever in Italy

Mediterranean Spotted Fever is caused by Rickettsia conorii and is transmitted to humans by Rhipicephalus sanguineus, the common dog tick. It is characterized by the symptomatologic triad: fever, exanthema and "tache noire", the typical eschar at the site of the tick bite. In Italy the most affected region is Sicily. The seasonal peak of the disease (from June through September) occurs during maximal activity of immature stage ticks. Severe forms of the disease have been reported in 6% of patients, especially adults with one of the following conditions: diabetes, cardiac disease, chronic alcoholism, glucose-6-phosphate dehydrogenase deficiency, end stage kidney disease. The mortality rate may reach 2.5%. Oral or parenteral administration of tetracyclines or chloramphenicol represent the standard treatment. Recent studies indicate that oral clarithromycin and azithromycin could constitute an acceptable alternative for the treatment of the disease in children; furthermore, they could be recommended during pregnancy.