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.

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.

Mediterranean spotted fever: clinical and laboratory characteristics of 415 Sicilian children

BACKGROUND

Mediterranean spotted fever (MSF) is an acute febrile, zoonotic disease caused by Rickettsia conorii and transmitted to humans by the brown dogtick Rhipicephalus sanguineus. Nearly four hundred cases are reported every year (mainly from June to September) on the Italian island of Sicily. The aim of the study was to analyze the clinical and laboratory characteristics of patients with MSF and the efficacy of the drugs administered.

METHODS

Our study was carried out on 415 children with MSF, during the period January 1997-December 2004, at the "G. Di Cristina" Children's hospital in Palermo, Sicily, Italy. On admission patients' clinical history, physical and laboratory examination and indirect immunofluorescence antibody test (IFAT) for Rickettsia conorii were performed. Diagnosis was considered confirmed if the patients had an MSF diagnostic score greater than or equal to 25 according to the Raoult's scoring system. All patients were treated with chloramphenicol or with macrolides (clarithromycin or azithromycin).

RESULTS

Fever, rash and tache noire were present in 386 (93%), 392 (94.5%) and 263 (63.4%) cases respectively. Eighteen (4.6%) children showed atypical exanthema. Chloramphenicol and newer macrolides all appeared to be effective and safe therapies.

CONCLUSION

Clinical features of 415 children with MSF were similar to those reported by other authors except for a lower incidence of headache, arthralgia and myalgia and a higher frequency of epato-splenomegaly. Concerning therapy, clarithromycin can be considered a valid alternative therapy to tetracyclines or chloramphenicol especially for children aged < eight years.

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

Rickettsia conorii is endemic in Greece, though only a few cases of infection have been published to date. The case of a 58-year-old man from northern Greece with a severe form of Mediterranean spotted fever and rapid neurological deterioration is presented here. The patient received antibiotic treatment with doxycycline, showing immediate clinical and laboratory improvement. Diagnosis was confirmed later, during the second week after disease onset, by detection of elevated titres of IgM and IgG antibodies against R. conorii using an indirect immunofluorescence assay.

Mediterranean spotted fever: A review of fifteen cases

We aimed to determine the following things: the frequency of patients with Mediterranean spotted fever (MSF) during the last 10 years among those patients admitted with fever and rash, their clinical features, and the factors predicting the diagnosis of MSF among patients admitted with fever and rash. Between 1993-2002, the files of all patients admitted to our hospital with fever and rash were collected. The clinical features and serologic results of the patients diagnosed with MSF were further investigated. The diagnosis of MSF was established by epidemiological and clinical features and also by the clinical response within 2 days after doxycycline treatment. During the previous 10 years, 140 patients were admitted with fever and rash, and 15 (10%; four females, 11 males; mean age: 41 years; range: 17-70) of them were diagnosed with MSF. Clinical features were as follows: fever (100%), rash (100%), myalgia and/or arthralgia (93%), headache (87%), petechiae (27%), tache noire (13%), leucocytosis (74%), thrombocytopenia (33%), and accelerated erythrocyte sedimentation rate (100%). In nine of these patients, the diagnosis of MSF was established by epidemiological and clinical features and was confirmed by serologic studies. As a complication, one patient developed facial paralysis. Six (40%) were given several antibiotics. In conclusion, MSF should be considered in the differential diagnosis when a patient is admitted with fever, maculopapular rash, headache, myalgia and/or arthralgia, especially in spring, summer, or autumn.

Effect of Antibiotic Treatment in Patients with DEBONEL/TIBOLA

DEBONEL/TIBOLA is a tick-borne acute/sub-acute infection transmitted in our environment by Dermacentor marginatus and mainly caused by Rickettsia slovaca. The aim of our study was to know the effect of starting early treatment in the course of the DEBONEL/TIBOLA.

Anterior ischemic optic neuropathy associated with rickettsia conorii infection

A 43-year-old man with fever, headache, and skin rash developed unilateral acute anterior ischemic optic neuropathy. The indirect immunofluorescence test was positive for Rickettsia conorii. Although retinal lesions have been described in Rickettsia conorii infection, this is the first reported case of ischemic optic neuropathy. This infection should be considered in a patient with nonarteritic anterior ischemic optic neuropathy with high fever or skin rash who inhabits or travels from an endemic area.

Update on Spotted Fever Group Rickettsiae in South Africa

Until very recently, Mediterranean spotted fever caused by Rickettsia conorii was the only spotted fever group (SFG) rickettsioses recognized in southern Africa. However, increasing medical awareness of tick-borne infections, together with the introduction of improved isolation methods and the availability of molecular techniques, have led to the identification of several new SFG rickettsioses in the region. African tick bite fever, caused by Rickettsia africae, is currently the most important of these new rickettsioses, affecting large numbers of international travellers each year, but infections due to Rickettsia aeschlimannii and Rickettsia mongolotimonae have also been recently encountered. In this review, we describe the current status of the epidemiology, microbiology, clinical presentation, diagnosis, treatment, and prevention of SFG rickettsioses in southern Africa.

Boutonneuse fever in a child: a case report and overview

A five and half year-old boy presented with an acute febrile illness associated with abdominal pain, generalised myalgia, arthralgia and skin rash. An elder sibling had a similar illness and had expired three days back. Initially crystalline penicillin and chloramphenicol were started. Investigations to diagnose the cause of fever viz, peripheral blood smear for malarial parasite, blood and urine cultures, Widal test and dot-ELISA for leptospirosis were negative. Weil-Felix test revealed a positive OX-2 titre of 1:100. Retrospectively, a history of close contact with dogs was elicited and a tick bite mark on the hand detected. Within five days of antibiotic therapy the fever resolved. Chloramphenicol was given totally for two weeks and the child recovered fully. Rickettsial infection should be considered in a child presenting with an acute febrile illness with skin rash since the response to specific antimicrobial therapy is dramatic and life saving.

[Neurological feature of Mediterranean spotted fever: a study of four cases]

BACKGROUND

Rickettsia conorii is the etiologic agent of Mediterranean spotted fever that is endemic in Mediterranean.

EXEGESIS

We report four cases of serious form of Mediterranean spotted fever with neurological feature. Two of them 56 and 62 years old had meningoencephalitis. Two others had cerebellitis, they are aged 43 and 56. The course has been favourable with ciprofloxacin.

CONCLUSION

It is a benign well-known illness in spite of apparition of severe visceral complications, which can drag the death in 2.5% of cases. Neurological feature is more frequent and present in 28% of cases. Precocious treatment prevents this unfavourable evolution.

[An unsuspected imported disease: meningo-encephalitis contracted in Spain]

A 13-year-old boy consulted a doctor during a holiday in Spain because of high fever, headache and exanthema. A local physician prescribed josamycin, but the medication was lost due to vomiting. A few days later, shortly after returning to the Netherlands, he was hospitalised with a life-threatening neurologic and multi-organ failure. It took two weeks before the diagnosis 'Mediterranean spotted fever' was made and an appropriate antibiotic treatment was started. The patient made a slow but successful recovery. Rereading the hand-written Spanish medical report revealed that it had mentioned a correct diagnosis and adequate treatment. An apparently safe holiday destination thus does not exclude an imported disease. Knowledge of local epidemiology and good communication with the locally consulted medical system are essential for a correct diagnosis and therefore for appropriate treatment and a good prognosis.

Clinical and epidemiologic investigation of two Legionella-Rickettsia co-infections

BACKGROUND

We treated two patients diagnosed with legionellosis and simultaneous Rickettsia conorii co-infection.

OBJECTIVES

To report the clinical and laboratory characteristics of this unusual combination, and to describe the execution and results of our environmental and epidemiologic investigations.

METHODS

Serial serologic testing was conducted 1, 4 and 7 weeks after initial presentation. Water samples from the patients' residence were cultured for Legionella. Follow-up cultures were taken from identical points at 2 weeks and at 3 months after the initial survey.

RESULTS

Both patients initially expressed a non-specific rise in anti-Legionella immunoglobulin M titers to multiple serotypes. By week 4 a definite pattern of specifically elevated IgG titers became apparent, with patient 1 demonstrating a rise in specific anti-L. pneumophila 12 IgG titer and patient 2 an identical response to L. jordanis. At 4 weeks both patients were positive for both IgM and IgG anti-R. conorii antibodies at a titer > or = 1:100. Heavy growth of Legionella was found in water sampled from the shower heads in the rooms of both patients. Indirect immunofluorescence of water cultures was positive for L. pneumophila 12 and for L. jordanis.

CONCLUSIONS

Although most cases of community-acquired Legionella pneumonia in our region appear simultaneously with at least one other causative agent, co-infection with R. conorii is unusual and has not been reported to date. This report illustrates the importance of cooperation between clinicians and public health practitioners.

Mediterranean spotted fever during pregnancy: case presentation and literature review

Mediterranean spotted fever (MSF) is caused by Rickettsia conorii, an obligate intracellular parasite of eukaryotic cells. Although, usually this disease has a benign course, a rapidly fatal outcome can occur even in young healthy adults. We describe a case of a 40-year-old Bedouin woman gravida 11, para 10, who was admitted at 36 weeks gestation with this rickettsial disease. During pregnancy, the treatment of choice for Mediterranean spotted fever is chloramphenicol, but it seems that Azithromycin could be another possible option.

[Status of cellular immunity in patients with Astrakhan fever]

AIM

To ascertain regularities of development of cellular immunity in patients with Astrakhan fever (AF) with reference to AF severity, treatment and course.

MATERIAL AND METHODS

Cellular factors of immunity--relative and absolute contents of T-lymphocytes (early and late), T-helpers and T-suppressors, B-lymphocytes, neutrophils (early and late)--were studied in 75 patients with AF (63 patients with moderate and 12 patients with severe disease) in the course of the disease progression (weeks 1-5). The patients received antibacterial treatment--doxicyclin, rifampicin and doxicycline in combination with alpha 2-realdiron and gamma-reaferon.

RESULTS

Examination of immunocompetent cells has revealed suppression of T- and B-immunity for 2 weeks in moderate AF and 3 weeks in severe AF. The number of T-helpers was low for 3 weeks while of T-suppressors rose beginning from week 2. Immunoregulatory index Tx/Tc remains low till the end of the disease. The number of early and late neutrophils increased since weeks 2 of the disease in moderate and week 3 in severe AF.

CONCLUSION

Doxicycline efficiency was higher than that of rifampicin. Interferon preparations decrease relative number of early and late T-lymphocytes, neutrocytes and T-helpers but their absolute number is at the control level. Relative content of T-suppressors and B-lymphocytes is as in controls but their absolute content is higher.

[Encephalitis caused by Rickettsia conorii without exanthema]

INTRODUCTION

Mediterranean boutonneuse fever, caused by Rickettsia conorii, is an endemic disease in the Mediterranean area. The serious forms of the disease, which include encephalitis, are infrequent but are associated with a high mortality rate. Diagnostic suspicion is backed up by the development of exanthema. We report the case of a patient who developed encephalitis caused by Rickettsia conorii without exanthema. Clinical case. A 27 year old woman who had nauseas, headache, fever, abdominal upset and generalised pain during the days before being admitted to hospital. On the day she was admitted, she noticed reduced strength in the left limbs, together with numbness and pins and needles in the left side of the body. In the casualty department she presented tonic seizures in the left extremities and later generalised tonic clonic seizures. Exploration showed facial paresis and 4/5 hemiparesis on the left side. Complementary tests carried out in casualty, including cerebrospinal fluid (CSF), did not reveal any significant findings. She was admitted after a loading dose of phenytoin. After 48 hours she presented fever and repeated complex partial seizures. A new CSF analysis was normal. She was treated with valproate, clonazepam, ceftriaxone, doxycycline and acyclovir. An electroencephalogram (EEG) showed theta activity in the left centroparietal areas and slow delta waves in the right temporal regions. Magnetic resonance imaging (MRI) of the brain showed contrast enhancement in the meninges. 24 later, due to the frequency of the seizures, phenobarbital and methylprednisolone were added, which enabled the seizures to be controlled. The posterior brain MRI revealed a right parasylvian lesion. Serological Rickettsia conorii IgM +, IgG 1/256 was administered. After eight months, she has presented no seizures or neurological deficit.

CONCLUSIONS

There are cases of encephalitis from Rickettsia conorii that can present without exanthema. This means that in endemic areas early treatment with doxycycline could be advisable when faced with encephalitis of unknown aetiology, bearing in mind the high mortality rate that occurs when no early treatment is administered and the good tolerance to doxycycline.

[Macrolides in the treatment of children with Mediterranean spotted fever]

Till now there is not a gold standard therapy for Mediterranean spotted fever (MSF) in children. Standard treatment for MSF is the administration of tetracycline or chloramphenicol, however both these drugs can cause significant adverse effects in children (tetracyclines can cause staining of teeth, chloramphenicol severe hematological adverse events such as aplastic anemia, gray baby syndrome and hemolytic anemia in patients with the Mediterranean form of G6PD deficiency). We conducted two randomized clinical trials; the first compared clarithromycin versus chloramphenicol: mean time to defervescence was 36.7 +/- 18.1 h in the clarithromycin group and 47.1+/- 21.9 h in the chloramphenicol group (P= 0.047). The second trial compared clarithromycin versus azithromycin and did not show any statistically significant difference: mean time to defervescence was 46.2 +/- 36.4 h in the clarithromycin group and 39.3 +/- 31.3 h in the azithromycin group (P= 0.34). On the basis of these studies we think that clarithromycin and azithromycin could constitute an acceptable alternative to chloramphenicol and to tetracyclines for the treatment of MSF in children

Kinetics of antibody responses in Rickettsia africae and Rickettsia conorii infections

African tick-bite fever, caused by Rickettsia africae, is the most common tick-borne rickettsiosis in sub-Saharan Africa. Mediterranean spotted fever due to Rickettsia conorii also occurs in the region but is more prevalent in Mediterranean countries. Using microimmunofluorescence, we compared the development of immunoglobulin G (IgG) and IgM titers in 48 patients with African tick-bite fever and 48 patients with Mediterranean spotted fever. Doxycycline treatment within 7 days from the onset of disease significantly prevented the development of antibodies to R. africae. In patients with African tick-bite fever, the median times to seroconversion with IgG and IgM were 28 and 25 days, respectively, after the onset of symptoms. These were significantly longer by a median of 6 days for IgG and 9 days for IgM than the times for seroconversion in patients with Mediterranean spotted fever (P < 10(-2)). We recommend that sera collected 4 weeks after the onset of signs of patients with suspected African tick-bite fever should be used for the definitive serological diagnosis of R. africae infections.

Clarithromycin versus azithromycin in the treatment of Mediterranean spotted fever in children: a randomized controlled trial

We conducted an open-label randomized controlled trial to compare the efficacy and safety of clarithromycin (15/mg/kg/day in 2 divided doses for 7 days) with those of azithromycin (10 mg/kg/day in 1 dose for 3 days) in the treatment of children with Mediterranean spotted fever. Until now, there has not been a gold-standard therapy for this rickettsial disease in children. Eighty-seven children were randomized to receive 1 of the 2 drugs. The mean time to defervescence (+/- standard deviation) was 46.2+/-36.4 h in the clarithromycin group and 39.3+/-31.3 h in the azithromycin group. These differences were not statistically significant and both drugs were equally well-tolerated. Clarithromycin and azithromycin could be acceptable therapeutic alternatives to chloramphenicol and tetracyclines for children aged < or =8 years with Mediterranean spotted fever. Azithromycin, because it has a long half-life, offers the advantages of administration in a single daily dose and a shorter duration of therapy, which could increase compliance in children.

Rickettsial phospholipase A2 as a pathogenic mechanism in a model of cell injury by typhus and spotted fever group rickettsiae

Phospholipase A2 activity by typhus group rickettsiae causes hemolysis in vitro. Rickettsial phospholipase A2 has been proposed to mediate entry into the host cell, escape from the phagosome, and cause injury to host cells by both typhus and spotted fever group rickettsiae. In a rickettsial contact-associated cytotoxicity model, the interaction of Rickettsia prowazekii or R. conorii with Vero cells caused temperature-dependent release of 51Cr from the cells. Treatment of rickettsiae, but not the cells, with a phospholipase A2 inhibitor (bromophenacyl bromide) or with antibody to king cobra venom inhibited cell injury. Rickettsial treatment with bromophenacyl bromide inhibited the release of free fatty acids from the host cell. Neither the inhibitor nor antivenom impaired rickettsial active transport of L-lysine. Thus, host cell injury was mediated by a rickettsial phospholipase A2-dependent mechanism.

Efficacy and safety of clarithromycin as treatment for Mediterranean spotted fever in children: a randomized controlled trial

Fifty-one children with Mediterranean spotted fever (MSF) were randomized to receive either clarithromycin, 15 mg/kg/day orally in 2 divided doses, or chloramphenicol, 50 mg/kg/day orally in 4 divided doses, for 7 days. Mean time to defervescence was 36.7 h in the clarithromycin group and 47.1 h in the chloramphenicol group (P=.047). Clarithromycin could be an acceptable therapeutic alternative to chloramphenicol and to tetracyclines for children aged <8 years with MSF.

Facial nerve palsy associated with Rickettsia conorii infection

Facial nerve palsy has been occasionally attributed to infectious agents, but Rickettsiae species have not been documented as causative agents. We report two adolescent girls with facial nerve palsy and serological evidence of R conorii infection. These cases indicate that rickettsioses should be included among the causes of facial nerve palsy, particularly in endemic areas.