Severe case of Mediterranean spotted fever in Greece with predominantly neurological features

Rickettsial fever leading to upper disphagya: A rare neurovascular conflict between vertebral artery and glossopharyngeal nerve

Rickettsial fevers are a common type of zoonosis with potential neurological involvement, mostly in form of meningoencephalitis. However, there are some rare cases that could compromise cranial nerves function through vascular inflammation. In this paper, we describe a rare case of dysphagia related to glossopharyngeal involvement by juxtaposed vertebral artery vasculitis.

Tick-Borne Pathogens and Diseases in Greece

Tick-borne diseases (TBDs) are recognized as a serious and growing public health epidemic in Europe, and are a cause of major losses in livestock production worldwide. This review is an attempt to present a summary of results from studies conducted over the last century until the end of the year 2020 regarding ticks, tick-borne pathogens, and tick-borne diseases in Greece. We provide an overview of the tick species found in Greece, as well as the most important tick-borne pathogens (viruses, bacteria, protozoa) and corresponding diseases in circulation. We also consider prevalence data, as well as geographic and climatic conditions. Knowledge of past and current situations of TBDs, as well as an awareness of (risk) factors affecting future developments will help to find approaches to integrated tick management as part of the ‘One Health Concept’; it will assist in avoiding the possibility of hotspot disease emergencies and intra- and intercontinental transmission. Increased surveillance in Greece is required to ensure clear and effective policies for TBD control.

Epidemiology, Clinical Aspects, Laboratory Diagnosis and Treatment of Rickettsial Diseases in the Mediterranean Area During COVID-19 Pandemic: A Review of the Literature

The purpose of the present review is to give an update regarding the classification, epidemiology, clinical manifestation, diagnoses, and treatment of the Rickettsial diseases present in the Mediterranean area.

We performed a comprehensive search, through electronic databases (Pubmed – MEDLINE) and search engines (Google Scholar), of peer-reviewed publications (articles, reviews, and books).

The availability of new diagnostic tools, including Polymerase Chain Reaction and nucleotide sequencing has significantly modified the classification of intracellular bacteria, including the order Rickettsiales with more and more new Rickettsia species recognized as human pathogens. Furthermore, emerging Rickettsia species have been found in several countries and are often associated with unique clinical pictures that may challenge the physician in the early detection of the diseases.

Rickettsial infections include a wide spectrum of clinical presentations ranging from a benign to a potentially life treating disease that requires prompt recognition and proper management. Recently, due to the spread of SARS-CoV-2 infection, the differential diagnosis with COVID-19 is of crucial importance. The correct understanding of the clinical features, diagnostic tools, and proper treatment can assist clinicians in the management of Rickettsioses in the Mediterranean area.

Rickettsial infections of the central nervous system

As a result of migrations and globalization, people may face a possible increase in the incidence of central nervous system rickettsial infections (CNS R). These diseases, caused by Rickettsia species and transmitted to humans by arthropod bites, are putatively lethal. However, the diagnosis of CNS R is challenging and often delayed due to their nonspecific clinical presentation and the strict intracellular nature of rickettsiae. Furthermore, transfer of rickettsiae to the brain parenchyma is not yet understood. The aim of this review is to analyze and summarize the features and correlated findings of CNS R in order to focus attention on these intriguing but frequently neglected illnesses. We also incorporated data on CNS infections caused by Rickettsia-related microorganisms.

Murine Typhus with Marked Thrombocytopenia in a Child in Northern Greece and Literature Review

We report a case of murine typhus in a 4-year-old boy living in northern Greece. Although the illness started with mild symptoms, a maculopapular rash appeared by the end of the first week of illness followed by marked thrombocytopenia. The detection of IgM antibodies against Rickettsia typhi in the patient's blood and a positive polymerase chain reaction result combined with sequencing confirmed the diagnosis of infection by Rickettsia typhi. Clinicians in northern Greece should be aware of the disease, even in cases presenting with no specific initial symptoms.

Update on tick-borne rickettsioses around the world: a geographic approach

Tick-borne rickettsioses are caused by obligate intracellular bacteria belonging to the spotted fever group of the genus Rickettsia. These zoonoses are among the oldest known vector-borne diseases. However, in the past 25 years, the scope and importance of the recognized tick-associated rickettsial pathogens have increased dramatically, making this complex of diseases an ideal paradigm for the understanding of emerging and reemerging infections. Several species of tick-borne rickettsiae that were considered nonpathogenic for decades are now associated with human infections, and novel Rickettsia species of undetermined pathogenicity continue to be detected in or isolated from ticks around the world. This remarkable expansion of information has been driven largely by the use of molecular techniques that have facilitated the identification of novel and previously recognized rickettsiae in ticks. New approaches, such as swabbing of eschars to obtain material to be tested by PCR, have emerged in recent years and have played a role in describing emerging tick-borne rickettsioses. Here, we present the current knowledge on tick-borne rickettsiae and rickettsioses using a geographic approach toward the epidemiology of these diseases.

Bell's palsy and sudden deafness associated with Rickettsia spp. infection in Sweden. A retrospective and prospective serological survey including PCR findings

BACKGROUND AND PURPOSE

Sixty patients with facial palsy and 67 with sudden deafness were retrospectively or prospectively examined for serological evidence of rickettsial infection; in six cases where cerebrospinal fluid was available, patients were also examined for presence of rickettsial DNA.

METHODS

Rickettsial antibodies were detected in single or paired serum samples using immunofluorescence with Rickettsia helvetica as the antigen and in four cases also using western blot. Using PCR and subsequent direct cycle sequencing, the nucleotide sequences of the amplicons (17 kDa protein gene) in cerebrospinal fluid were analysed.

RESULTS

Five out of 60 (8.3%) patients with facial palsy and eight of 67 (11.9%) with hearing loss showed confirmative serological evidence of infection with Rickettsia spp. An additional three and four patients in the facial palsy and hearing loss groups, respectively, showed evidence of having a recent or current infection or serological findings suggestive of infection. In four cases, the specificity of the reaction was confirmed by western blot. An additional 70 patients were seroreactive with IgG or IgM antibodies higher than or equal to the cut-off of 1:64, whereas 37 patients were seronegative. Only two of 127 patients had detectable antibodies to Borrelia spp. In three of six patients, rickettsial DNA was detected in the cerebrospinal fluid, where the obtained sequences (17 kDa) shared 100% similarity with the corresponding gene sequence of Rickettsia felis.

CONCLUSIONS

These results highlight the importance of considering Rickettsia spp. as a cause of neuritis, and perhaps as a primary cause of neuritis unrelated to neuroborreliosis.

Severe Mediterranean spotted fever complicated by acute renal failure and herpetic oesophagitis

Mediterranean spotted fever (MSF) is a tick-borne disease caused by Rickettsia conorii. Recently, complicated cases have been more frequently reported, even in previously healthy patients. We describe a case of severe MSF complicated by acute renal failure and associated with herpetic oesophagitis. Acyclovir therapy resulted in remission of oesophageal symptoms within 48 h.

First detection of Rickettsia slovaca in Greece

Seven hundred and three ticks collected in November and June of 2004-2006 from domestic animals in four localities of Halkidiki prefecture, Northern Greece, were tested for the presence of ricketsial DNA. Rickettsia slovaca was detected in one pool of Rhipicephalus bursa ticks, representing the first report of detection of R. slovaca in Greece.

Mediterranean spotted fever with encephalitis

Rickettsia conorii infection is endemic in the Mediterranean basin, where it is known as Mediterranean spotted fever, also known as Boutonneuse fever and Marseilles fever. We report the case of a 66-year-old diabetic man who presented a severe form of the disease, complicated by acute renal failure, thrombocytopenia and encephalitis. Diagnosis was confirmed by indirect immunofluorescence assay. Despite appropriate treatment, severe neurological sequelae have remained. Medical literature on encephalitis caused by R. conorii is also reviewed.

Atrial fibrillation in Mediterranean spotted fever

Mediterranean spotted fever (MSF) is a tick-borne acute febrile disease caused by Rickettsia conorii and characterized by fever, maculo-papular rash and a black eschar at the site of the tick bite (‘tache noir’). We describe the case of a 58-year-old man affected by MSF who developed atrial fibrillation. The patient presented himself to the hospital after 7 days of fever, malaise and severe headache. Cardiac auscultation revealed a chaotic heart rhythm and an electrocardiogram confirmed atrial fibrillation with a fast ventricular response. Diagnosis of MSF was made after the appearance of a maculo-papular skin rash, and treatment with oral doxycycline was started. An immunofluorescence antibody test confirmed R. conorii infection. The patient recovered after 7 days of treatment. Cardiac arrhythmia is a rare complication of MSF. Inflammation may play a role in the pathogenesis of atrial fibrillation. R. conorii is an intracellular bacterium which could trigger atrial fibrillation. Our patient was previously healthy and had no reported history of cardiac disease. This suggests that heart function should be monitored in MSF patients even in the absence of underlying risk factors.

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.