Case report: Infectious cerebral vasculitis due to rickettsiosis

Rickettsiosis is a widespread infection throughout the world and in Africa, it covers a wide range of infectious diseases caused by Rickettsia species. Rickettsial infections, with the exception of Q fever, typically present with fever, rash, and vasculitis. The central nervous system (CNS) can be affected by all rickettsial diseases and is an important target for several of them. Clinical manifestations are suggestive of rickettsial infection, but serology and skin biopsy provide confirmation. Although the presence of abnormal neuroimaging is rare, its presence is associated with a worse clinical prognosis. Computed tomography (CT) and magnetic resonance imaging (MRI) scans mainly show signs of vasculitis, which may be reversible if appropriate treatment is initiated early in the course of the disease. We present here a case of infectious cerebral vasculitis due to rickettsiosis with some MRI features.

Imported scrub typhus in Europe: Report of three cases and a literature review

BACKGROUND

Scrub typhus is a vector-borne rickettsial infection, which can cause relevant morbidity and mortality. While the number of cases is around a million per year globally, the infection is seldom diagnosed in travellers from Europe.

METHODS

We herein report three cases diagnosed in Italian travellers and review the literature about imported cases in Europe in the last 60 years.

RESULTS

Three participants to the same hiking trip to the forest of northern Laos presented fever and other symptoms, including eschars (2 individuals) and skin rash (2 individuals). Overall, they didn't report complications, and recovered soon after doxycycline treatment. Diagnosis was retrospectively confirmed with PCR in one of them. The review collected data from 40 patients. Almost all of them (95%) presented fever, more than a half had headache, skin rash, eschars, arthromyalgias. 73% of them were hospitalized, and 16.2% needed intensive care. Diagnosis was confirmed by serology in almost all cases (94.6%). Most patients (88%) were treated with doxycycline. All patients survived, although one case resulted in incomplete tetraparesis.

CONCLUSIONS

Scrub typhus should be considered in all travellers coming back from endemic areas and presenting with acute febrile illness. Laboratory diagnosis can be challenging, as specific tests are not widely available. In case of clinical suspicion, a prompt treatment with oral doxycycline could avoid severe complications.

Scrub eschar

A 60-year-old female presented to the emergency room with fever and myalgias for four days and shortness of breath for two days. On clinical examination, she was tachypneic and blood oxygen saturation of 86 % on room air. There was an eschar of size 1 × 1 cm on the left infraclavicular area (Fig. 1). Chest examination showed bilateral interscapular crepitations. CXR showed bilateral lower zone infiltrates. Scrub typhus IgM was found to be positive by rapid diagnostic kit test, Eschar biopsy was also positive for scrub typhus by Polymerase Chain Reaction. The patient was started on doxycycline, clinically improved and discharged after ten days. Presence of eschars is considered pathognomonic of scrub typhus. Incidence of eschar varies widely from 7 % to 97 %. The main reason for low detection is eschars being missed on routine clinical examination as these are painless lesions consisting of a black scab, with an erythematous halo and minimal edema. Eschars are usually found over the covered areas of the body, such as the groin, axilla, chest, and lower back which appears a few days after at chigger-bite sites, even before the disease manifestation. This case emphasizes the importance of thorough clinical examination to look for eschar and early diagnosis and initiation of treatment while routine laboratory assays are awaited.

An outbreak investigation of scrub typhus in Nepal: confirmation of local transmission

Background

Scrub typhus is a largely ignored tropical disease and a leading cause of undifferentiated febrile illness in the areas of tsutsugamushi triangle caused by Orientia tsutsugamushi. It is frequently diagnosed in South Asian countries, although clear epidemiological information is not available from Nepal. After the 2015 earthquake in Nepal, a sudden upsurge in scrub typhus cases was reported. The objective of this study was to investigate epidemiology of scrub typhus and its causative agents in humans, animals, and chigger mites to understand the ongoing transmission ecology.

Methods

Scrub typhus cases with confirmed diagnosis throughout the country were included in the analysis. Studies were concentrated in the Chitwan district, the site of a major outbreak in 2016. Additional nation-wide data from 2015 to 2017 available from the government database included to analyse the disease distribution by geographical mapping.

Results

From 2015 to 2017, 1239 scrub typhus cases were confirmed with the largest outbreak occurring in 2016 with 831 (67.1%) cases. The case fatality rate was 5.7% in 2015 which declined to 1.1% in 2017. A nationwide outbreak of scrub typhus was declared as the cases were detected in 52 out of the 75 districts of Nepal. Seasonal trend was observed with a peak during August and September. In addition to the human cases, the presence of O. tsutsugamushi was also confirmed in animals (rodents) and chigger mites (Leptotrombidium imphalum) from the outbreak areas of southern Nepal.

Conclusion

The detection of O. tsutsugamushi in humans, animals, and chigger mites from outbreak locations and wide-spread reports of scrub typhus throughout the country consecutively for 3 years confirms the ongoing transmission of O. tsutsugamushi with a firmly established ecology in Nepal. The country’s health system needs to be strengthened for systematic surveillance, early outbreak detection, and immediate actions including treatment and preventive measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05866-6.

Distribution and Ecological Drivers of Spotted Fever Group Rickettsia in Asia

Spotted fever group and related rickettsia (SFGR) are a neglected group of pathogens that belong to the genus Rickettsia. SFGR are zoonotic and are transmitted by arthropod vectors, primarily ticks, fleas and mites to accidental hosts. These emerging and re-emerging infections are widely distributed throughout the world. Land-use change and increasing human-wildlife conflict compound the risk of SFGR infection to local people in endemic areas and travelers to these regions. In this article, we discuss the rickettsial organisms causing spotted fever and related diseases, their arthropod vectors in Asia and the impact of land-use change on their spread.

Emergence of Rickettsial Infection in Rainbow Trout (Oncorhynchus mykiss) Fry Displaying the Appearance of Red Mark Syndrome in Korea

Red mark syndrome (RMS) is a fish disease caused by the infection of Rickettsial agents, especially affecting rainbow trout (Oncorhynchus mykiss). The disease is prevalent in many countries in Europe (France, Switzerland, Italy, and Slovenia), South America (Chile), North America (USA), and even Asia (Japan). However, it has not been reported in Korean aquaculture. In February 2019, rainbow trout presenting red spot lesions with swollen features on the lateral side of their body were observed at a hatchery in Korea. Fishes showing those clinical signs were fry weighing 25 ± 5 g. Moreover, the fish showing the red spot lesions were found dead, which suggests an outbreak of a mortality-causing disease. The symptoms were similar to those of RMS, and we identified the presence of Rickettsia-like organisms associated with this disease using polymerase chain reaction (PCR), sequencing, histopathologic examination, and transmission electron microscopy. The distinct features of this infection, compared to that in previous reports, were that RMS occurred in small-sized fish and accompanied mortality. Additionally, the presence of the Rickettsia agent was accompanied with outbreak of the disease. Therefore, this is the first report of RMS outbreak in rainbow trout fisheries in Korea.

Fatal Rickettsia rickettsii infection in a child, Northwestern Colombia, 2017

This report describes a new lethal case of Rickettsia rickettsii infection in a child from Northwestern Colombia, after ten years of the last outbreaks in the same region. Colombian public-health authorities should consider to include this severe rickettsiosis in the compulsory-reporting diseases, with the aim of knowing its burden in the country.

Detection of Rickettsia spp. in ticks associated to wild mammals in Northeastern Brazil, with notes on an undetermined Ornithodoros sp. collected from marsupials

We report tick infestations and rickettsial detection in ticks infesting free-living wild mammals (Monodelphis domestica, Tolypeutes tricinctus, Thrichomys inermis and Kerodon rupestris) captured in the Caatinga ecoregion of Bahia state, northeastern Brazil, during September to December 2016. Overall, 117 ticks (61 larvae, 25 nymphs, 25 males, 6 females) belonging to two genera, and at least three species were collected: Amblyomma auricularium, Amblyomma parvum, Amblyomma sp., Ornithodoros rietcorreai and an unidentified Ornithodoros sp. We provide new host records to the rodent T. inermis parasitized by larva and nymphs of A. auricularium and to the marsupial M. domestica infested by larvae of A. auricularium. Furthermore, we describe new tick-host association for larvae of O. rietcorreai on the rodents K. rupestris and T. inermis. Concerning tick-Rickettsia associations, we detected Rickettsia amblyommatis and an uncharacterized species of Rickettsia belonging to the spotted fever group (SFG) in both A. auricularium and A. parvum. Additionally, 'Candidatus Rickettsia andeanae' was detected in A. parvum as well.

[Haemophagocytic syndrome secondary to Mediterranean spotted fever]

INTRODUCTION

Haemophagocytic syndrome (HS) is a rare disease with a severe prognosis that is defined by clinical, laboratory and histopathological criteria. Infections represent the classical cause of HS. HS secondary to Mediterranean spotted fever (MSF) is rare with only a few cases being reported in the literature.

OBSERVATIONS

We report two cases of HS secondary to MSF in 2 men aged 77 and 63 years presenting a febrile maculo-purpuric eruption with inoculation ulcer associated with laboratory abnormalities (cytopenia, elevated ferritin, hypertriglyceridaemia). Haemophagocytosis was present in 2 cases. Serology and PCR for Rickettsia conorii were positive and militated in favour of recent infection responsible for the diagnosis of MSF.

DISCUSSION

The first case of HS was described in 1979. Sixteen cases of HS secondary to MSF are described in the literature. Cytopenia associated with hyperferritinaemia and hypertriglyceridaemia strongly suggests MSF complicated by HS. The prognosis depends on the time elapsed since diagnosis and host-specific factors. Immunosuppressants and antibiotics may be necessary to ensure healing.

CONCLUSION

Rickettsioses can induce HS, and this potential complication with a severe prognosis must be known.