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 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.

A case of Mediterranean spotted fever mimicking severe sepsis.

Mediterranean spotted fever (MSF) is a tick-borne acute endemic infectious disease caused by Rickettsia conorii. While MSF may progress asymptomatically, it may lead to clinical pictures like severe hemorrhagic fever. In this article, we are presenting an MSF case with signs of high fever, headache, nausea, weakness and generalized maculopapular rash. The diagnosis of the female patient who had a history of contact with a tick-infested dog was confirmed with her clinical and laboratory data. The clinical and laboratory findings of the patient who was given doxycycline by 200 mg/day for 7 days were improved in a short time. Rickettsia conorii serology by indirect immunofluorescence assay method confirmed the diagnosis of MSF. In cases of severe sepsis accompanied by high fever and generalized maculopapular rash where the source of the infection cannot be determined in the short term, carefully questioning exposure to ticks by considering the existing geographical, seasonal and endemic environmental factors may be life-saving in terms of early diagnosis and treatment of MSF, which may become fatal even in the absence of eschars (tache noire). The symptomatology of hemorrhagic fever associated with Rickettsia conorii may be confused with that of sepsis in clinical practice.

Mediterranean spotted fever with multiorgan involvement.

A previously well man in his 50s returned to the UK after a trip to the Mediterranean. The day after returning he developed malaise, fevers, rigors and severe headache. He was hospitalised with sepsis, multiorgan involvement, a maculopapular rash and an eschar on each hip. Serology was positive for Rickettsia spp (spotted fever group) with a rise in titre from 1:64 to 1:1024 eight days later. Blood and tissue PCR were also positive for Rickettsia spp. He had cardiac, pulmonary, renal, ocular and neurological involvement. He completed a 14-day course of doxycycline and recovered well. This is a case of likely Mediterranean spotted fever (MSF) caused by Rickettsia conorii, which is endemic to the Mediterranean basin. We highlight the need for awareness and early treatment to prevent severe complications. This case is also the first to describe Purtscher-like retinopathy in the context of likely MSF.

Mediterranean spotted fever and peripheral facial nerve palsy: a rare neurological complication.

Mediterranean spotted fever (MSF) caused by the bacterium Rickettsia conorii is one of the oldest known tick-borne diseases. It is transmitted by the brown dog tick Rhipicephalus sanguineus and occurs mainly in the Mediterranean area. MSF usually presents with a skin rash, high fever, and characteristic eschar at the site of the tick bite. The course of this disease may be benign or life-threatening. Focal neurological manifestations are unusual. We report the case of a patient who presented with an isolated peripheral facial nerve palsy complicating R conorii conorii infection.

A severe case of Israeli spotted fever with pleural effusion in Italy.

BACKGROUND: The most common Italian rickettsiosis is Mediterranean Spotted Fever (MSF). MSF is commonly associated with a symptom triad consisting of fever, cutaneous rash, and inoculation eschar. The rash is usually maculopapular but, especially in severe presentations, may be petechial. Other typical findings are arthromyalgia and headache. Herein, we describe for the first time an unusual case of Israeli spotted fever (ISF) associated with interstitial pneumonia and pleural effusion in which R. conorii subsp. israelensis was identified by molecular methods in the blood, as well as in the pleural fluid. CASE PRESENTATION: A 72-year-old male presented with a 10-day history of remittent fever. On admission, the patient's general condition appeared poor with confusion and drowsiness; the first assessment revealed a temperature of 38.7°, blood pressure of 110/70 mmHg, a blood oxygen saturation level of 80% with rapid, frequent, and superficial breathing using accessory muscles (28 breaths per minute), and an arrhythmia with a heart rate of 90 beats per minute. qSOFA score was 3/3. Chest CT revealed ground-glass pneumonia with massive pleural effusion. Petechial exanthema was present diffusely, including on the palms and soles, and a very little eschar surrounded by a violaceous halo was noted on the dorsum of the right foot. Awaiting the results of blood cultures, broad-spectrum antibiotic therapy with meropenem 1 g q8h, ciprofloxacin 400 mg q12h, and doxycycline 100 mg q12h was initiated. Doxycycline was included in the therapy because of the presence of petechial rash and fever, making us consider a diagnosis of rickettsiosis. This suspicion was confirmed by the positivity of polymerase chain reaction on whole blood for R. conorii subsp. israelensis. Thoracentesis was performed to improve alveolar ventilation. R. conorii subsp. israelensis was again identified in the pleural fluid by PCR technique. On day 4 the clinical condition worsened. Blood exams showed values suggestive of secondary hemophagocytic lymphohistiocytosis; 4 out of 8 diagnostic criteria were present and empirical treatment with prednisone was started resulting in a gradual improvement in general condition. CONCLUSIONS: Israeli spotted fever may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis.

Concomitant Mediterranean spotted fever and systemic lupus erythematosus: a rare case report.

Infections are an important cause of morbidity and mortality in Systemic Lupus Erythematosus (SLE). Mediterranean spotted fever (MSF) is a tick-borne disease caused by Rickettsia conorii. This infection is endemic in Tunisia with summer seasonality. Herein, the case of a 45 years old woman, admitted to hospital with fever and erythema nodosum. On examination, she had a diffuse skin rash, malar rash, and polyarthritis. Serology demonstrated Rickettsia Conoriiinfection. The diagnosis of MSF was made and the patient had a course of doxycycline for 5 days with a prompt improvement of the fever, the skin lesions but she had a persistent malar rash, polyarthritis, and lymphopenia. The immunological profile was positive for antinuclear antibodies (ANA), anti-DNA antibodies, anti-nucleosomes antibodies, and anti-citrullinated protein antibodies (ACPA). The diagnosis of SLE was established. We report the first case of SLE associated with MSF and with erythema nodosum as the initial presentation.

Early Findings of Rickettsioses in Morocco.

BACKGROUND & OBJECTIVES: Rickettsioses are zoonoses transmitted to humans by arthropods. They are due to strict intracellular bacteria belonging to the family Rickettsiaceae. Our purpose is to present the clinical and paraclinical characteristics of 14 new cases diagnosed in Al-Hoceima region, Morocco; indeed, the patients associated a diagnosis of Mediterranean Spotted Fever (MSF). RESULTS: The average age of patients was 55 years. The patients were hospitalized for infectious syndrome, renal deficiency, pneumonia, and suspected meningitis. All cases had a general papular rash with palmo-plantar involvement, 12 out of 14 patients showed an escarotic spot, while neurological disorders were observed in 2 patients. Ophthalmic involvement was represented by retinal vasculitis in a single patient. Thrombocytopenia and cytolysis were constant in all patients. Renal deficiency was found in 3 cases and 2 cases had interstitial syndrome. The serology was positive in only one patient. All cases had been treated with doxycycline 200mg/day for 7 days with a good improvement of the clinical and biological symptoms. INTERPRETATION & CONCLUSION: The frequency of MSF in Morocco is not completely elucidated. A good knowledge of the clinical form allows an early diagnosis in order to institute an effective treatment.

Mediterranean spotted fever in the elderly: a prospective cohort study.

The objective of this study is to evaluate the characteristics and outcome of elderly patients with Mediterranean spotted fever (MSF). This study was a prospective observational cohort study of all adult cases with confirmed MSF treated in a teaching hospital (1984-2015) to compare the characteristics of elderly patients (> 65 years) with younger adults. We identified 263 adult patients with MSF, and 53 (20.2%) were elderly. Severe MSF was more frequent in the elderly (26.4% vs. 10.5%; p = 0.002). Gastrointestinal symptoms, impaired consciousness, lung infiltrate, oedema, acute hearing loss, raised alanine transaminase, hyponatremia, and thrombocytopenia occurred more frequently in elderly patients, and arthromyalgia occurred less frequently. Most patients were treated with a single-day doxycycline regimen (two oral doses of 200 mg for 1 day). All patients recovered uneventfully. Fever disappeared 2.55 ± 1.16 days after treatment initiation in elderly patients, and the remaining symptoms disappeared after 3.65 ± 1.42 days. These figures were similar to non-elderly patients. Severe MSF was more frequent in elderly patients. Some clinical manifestations occurred with different frequencies in the elderly compared with younger patients. Single-day doxycycline therapy is an effective and well-tolerated treatment for MSF in elderly patients.

[A Rickettsia case caused by Rickettsia conorii]. / Rickettsia conorii'nin neden oldugu riketsiyal enfeksiyon olgusu.

Rickettsia species are gram-negative intracellular, small pleomorphic coccobacilli in the Rickettsiaceae family. This genus is serologically and genotypically divided into four groups as spotted fever group, typhus group, Rickettsia belli and Rickettsia canadensis. Rickettsia conorii (R.conorii subsp. conorii) in the spotted fever group was reported to cause mediterranean spotted fever in Europe, especially in mediterranean countries including Turkey. The major vectors of Rickettsia species are ticks, and in some species fleas or mites. In this report a case with R.conorii infection was presented. A 46-year-old female patient, who had anorexia, fatigue, muscle aches, chills and high fever was admitted to a health institution. The patient was diagnosed as influenza. There was no regression in the patient's complaints with the recommended treatment. The patient was examined in our infectious diseases clinic and had several symptoms like severe muscle and joint pain with significant headache, and rashes at her body including hands and feet. The patient had a single eschar in the upper midline of the belly that matched tick biting and pink small maculopapular scars on the trunk, arms, legs, feet, and hands. Considering a Rickettsia pre-diagnosis, liquid electrolyte and doxycycline 2 x 100 mg oral treatment was started. On the third day of treatment, high fever, muscle and joint pain were decreased. On the fifth day, active skin lesions were started to fade. R.conorii IgM and IgG were negative in the first serum sample of the patient. In the biopsy sample taken from eschar tissue, Rickettsia spp. was detected as positive with rt-PCR. PCR was used by using the specific regions of the genetically specific gltA and ompA genes in the biopsy specimens and then the PCR products were determined by DNA sequence analysis. The DNA sequence results were compA red with Genbank data and determined that the gltA sequence was 99%, similar to R.conorii with accession number JN182786 and the ompA sequence was 99%, similar to R.conorii with accession number KR401144. When the phylogenetic tree was created, it was observed that the etiological agent was R.conorii. A week after the treatment, in the second serum sample R.conorii IFA IgM 1/192 titer and IgG 1/320 titer were detected as positive. In this case report, we have presented a Rickettsia case, clinically diagnosed as Rickettsia, serologically negative in the acute phase, PCR positive, with post-treatment seroconversion and etiologic agent determined as R.conorii.

Ocular manifestations of Rickettsia conorii in South India.

PURPOSE: Among the major groups of rickettsiosis, the commonly reported diseases in India are: (a) Typhus group induced-scrub typhus, murine flea-borne typhus; (b) Spotted fever group induced-Indian tick typhus; and (c) Q fever. Though many scrub typhus outbreaks have been reported from India, only one outbreak of spotted fever-serologically proven Indian tick typhus (Rickettsia conorii)-has been reported. We report for the first time ocular manifestations of serologically proven R. conorii infection in a cluster of patients. METHODS: In this retrospective study, case records patients with serologically proven Indian tick typhus (Rickettsia conorii) were reviewed for clinical manifestations and treatment outcomes. RESULTS:: In the months of February to April 2016, a cluster of 12 patients (23 eyes) visited us with defective vision. Examination showed multifocal retinitis; mostly bilateral; patients had a history of fever approximately 4 weeks prior to onset of symptoms. After excluding other causes of multifocal retinitis, a diagnosis of rickettsial retinitis was made after Weil-Felix test (WFT) was significantly positive, and enzyme-linked immunosorbent assay was positive for R. conorii. Course of the disease, visual outcome, and investigations are discussed. Doxycycline along with oral corticosteroids was effective in treating the condition. CONCLUSION:: Systematic fundus examination should be part of the routine evaluation of any patient who presents with fever and/or skin rash living in or returning from a specific endemic area. Clinical clues to diagnosing ocular rickettsiosis could be multifocal retinitis predominantly involving the posterior pole and macular involvement in the form of serous macular detachment or macular hard exudates. A positive WFT still serves as a useful and cheap diagnostic tool for laboratory diagnosis of rickettsial disease. Doxycycline along with oral corticosteroids was effective in treating the condition.

Prospective Cohort Study of Single-Day Doxycycline Therapy for Mediterranean Spotted Fever.

The objective of this study is to evaluate the results of single-day doxycycline therapy for Mediterranean spotted fever (MSF). This is a prospective cohort study of cases with confirmed MSF treated with the single-day doxycycline regimen in a teaching hospital from 1990 to 2015. Patients received two oral doses of 200 mg of doxycycline for 1 day. The outcomes evaluated were the time interval between the start of treatment and apyrexia, the time interval between the start of treatment and disappearance of other symptoms, and the adverse reactions to treatment and death. The study included 158 subjects, 18 of whom (11.4%) had a severe form of MSF and 31 (19.6%) were >65 years. The interval between onset of symptoms and start of treatment was 4.31 ± 1.54 days. All patients recovered uneventfully. Fever disappeared 2.55 ± 1.14 days after the start of treatment. The remaining symptoms (headache, arthromyalgia) disappeared 3.63 ± 1.35 days after the start of treatment. Only one patient had a delay in reaching apyrexia (8 days). The fever disappeared somewhat later in severe cases (median, 3 days; interquartile range [IQR], 2 to 4 days) than in nonsevere cases (median, 2 days; IQR, 2 to 3 days). Likewise, the remaining symptoms disappeared later in severe cases (median, 5 days; IQR, 4 to 6 days) than in nonsevere cases (median, 3 days; IQR, 3 to 4 days). The outcome was similar in both elderly and nonelderly patients. Eight patients had mild adverse effects possibly related to treatment. The results of the study confirm that single-day doxycycline therapy is an effective and well-tolerated treatment for MSF, including elderly patients and severe cases.

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.

Introdução: A febre escaro-nodular é uma doença infeciosa aguda incluída no grupo das rickettsioses humanas, que atinge sobretudo os países da bacia do Mediterrâneo e sul da Europa. É uma doença endémica em Portugal com o cão como principal reservatório doméstico. As crianças são um grupo particularmente vulnerável devido ao contato próximo com animais domésticos e a brincarem em campos e jardins. O principal objetivo deste estudo foi perceber e estudar a epidemiologia local, bem como caracterizar a clinica e a resposta terapêutica da nossa população. Material e Métodos: Foi realizado um estudo prospetivo descritivo de todas as crianças com febre escaro-nodular admitidas no serviço de urgência de um hospital grupo II, entre janeiro de 2013 e dezembro de 2015. Todos os doentes foram avaliados por médico, que respondeu a um questionário referente as manifestações clínicas apresentadas e atitudes de diagnóstico e terapêuticas instituídas. Os pais foram posteriormente contatados, por telefone, e questionados sobre a evolução da doença. Resultados: Foram registados 32 casos (93,9% de julho a outubro). Além da febre, as queixas mais frequentes foram mialgias (37,5%), dor abdominal e cefaleias (25%). O exantema estava presente no terceiro dia de febre em 84,4%: maculopapulonodular (53,1%); papular (37,5%) e macular (9,4%). Foi identificada escara em 59% e adenopatia satélite em 46,9%. Azitromicina (84,4%) ou doxiciclina (15,5%) foram os antibióticos de escolha, com sucesso em qualquer dos casos. Não foram relatadas complicações. Conclusão: A incidência de febre escaro-nodular na nossa população é alta, quando comparada com a incidência no restante país. Febre, mialgias e cefaleias foram os principais sintomas e sinais registados enquanto a presença de exantema foi o achado dermatológico predominante. Azitromicina, antibiótico de escolha na maioria dos casos, mostrou ser eficaz.

Rare presentation of rickettsial infection as purpura fulminans: a case report.

BACKGROUND: Purpura fulminans is an acute life-threatening disorder characterized by intravascular thrombosis and hemorrhagic infarction of the skin complicated with disseminated intravascular coagulation. It is commonly seen in acute infections following meningococcal and streptococcal infections. Few cases of purpura fulminans following rickettsial infections have been described in the literature. CASE PRESENTATION: We report a case of a 55-year-old Sri Lankan woman who presented to Teaching Hospital Peradeniya with a febrile illness, headache, and myalgia that progressed to an erythematous rash starting over the bilateral lover limbs and hands and that became black and necrotic with a few hemorrhagic blebs. She had normocytic anemia, platelet clumps, and monocytosis as well as a deranged clotting profile. The result of immunofluorescence antibody testing for rickettsial immunoglobulin G was strongly positive for Rickettsia conorii with a rise in titer convalescent sera, and a diagnosis of purpura fulminans following rickettsial infection was made. The patient made an excellent recovery with chloramphenicol treatment. CONCLUSIONS: The treating physician should consider the rare but very treatable condition of rickettsial infection as a differential diagnosis in the etiological diagnostic workup of patients presenting with severe purpuric and hemorrhagic rash with fever.

Ocular manifestations of rickettsia in children: common but frequently overlooked.

We review two cases of ocular manifestations of Rickettsia conorii infection in children. A girl who presented unilateral visual loss with focal retinitis and macular oedema and a boy with unilateral central scotoma and bilateral anterior uveitis. Progressive functional and anatomic recovery was observed after oral antibiotics and steroids were initiated.