72-year-old man • fever • new-onset urinary frequency • altered mental state • Dx?

► Fever ► New-onset urinary frequency ► Altered mental state.

Murine Typhus Presenting With Mucosal Involvement.

Lipschutz ulcers (LU) present as painful genital ulcers in nonsexually active females. Associated infections include Epstein Barr virus, Mycoplasma pneumoniae, Cytomegalovirus, and influenza. To our knowledge, this is the first report of LU occurring with murine typhus. Murine typhus is caused by Rickettsia typhi, a Gram-negative, obligate intracellular organism. Rat fleas (Xenopsylla cheopis) are the classic vector, although cat fleas (Ctenocephalides felis) found on cats, dogs, and opossums have been implicated in maintaining the life cycle of R. typhi in suburban areas. Murine typhus can have a nonspecific presentation making a strong index of suspicion crucial to its diagnosis. The most common presenting signs include fever, poor appetite, malaise, and headache. Laboratory abnormalities may include elevated C-reactive protein, elevated erythrocyte sedimentation rate, hypoalbuminemia, elevated transaminases, elevated neutrophil band count, and thrombocytopenia. The treatment of choice for R. typhi is doxycycline.

Fatal murine typhus with hemophagocytic lymphohistiocytosis in a child.

Hemophagocytic lymphohistiocytosis is a rare complication in Rickettsia typhi infections. We report the case of a 2-year-old boy with sudden night-onset fever, pallor, neck adenopathy and erythematous macular rash on the thorax, thighs and buttocks. During admission, he developed hyponatremia, hypoalbuminemia, anemia, thrombocytopenia, leukopenia, neutropenia, liver damage, hemorrhages and persistent fever. No hematological improvement was observed after the initial management, neoplastic diseases were discarded by bone marrow aspiration and lymph node biopsy; hemophagocytic lymphohistiocytosis was diagnosed. By immunohistochemistry and indirect immunofluorescence, murine typhus was also diagnosed and doxycycline was started with transitory recovery. Later, the child developed kidney failure and distributive shock that evolved to cardiac arrest and death. This is the first case report in Mexico on a fatal murine typhus associated with hemophagocytic lymphohistiocytosis in which the etiology was evidenced by histopathology.

First description of a clinical case of murine typhus in Campeche, Mexico

Abstract Murine typhus is a flea-borne disease caused by Rickettsia typhi, which was first detected in Mexico in 1927. It was not until 1996 that the first systematized study involving this pathogen was conducted in two coastal states of Mexico. We now report the first confirmed case of murine typhus in the state of Campeche, which occurred in a male patient who exhibited fever, thrombocytopenia, hyperbilirubinemia, and a rash. Furthermore, the patient reported having had previous contact with Rickettsia reservoirs.

An Unusual Presentation of Murine Typhus and Mononucleosis.

A 20-year-old female presented to the emergency department complaining of fever, cough, and dyspnea after a recent camping trip. The patient remained ill appearing, persistently tachycardic and dyspneic despite nebulizer treatments, and fluids in the emergency department. She was admitted for observation and gradually improved over the next 4 d. Inpatient laboratory studies indicated acute Epstein-Barr virus infection and she was discharged with a presumptive diagnosis of infectious mononucleosis. However, further testing showed a simultaneous rickettsial infection producing murine typhus. The patient ultimately recovered uneventfully once proper treatment was initiated. This patient's presentation represents a unique description of simultaneous infectious mononucleosis and murine typhus which underscores the importance of maintaining a broad differential diagnosis in the approach to febrile illnesses.

An Unusual Cutaneous Manifestation in a Patient with Murine Typhus.

Murine typhus is a flea-borne febrile illness caused by Rickettsia typhi. Although often accompanied by rash, an inoculation lesion has not been observed as it is with many tick- and mite-transmitted rickettsioses. We describe a patient with murine typhus and an unusual cutaneous manifestation at the site of rickettsial inoculation.

[Clinical features of four atypical pediatric cases of endemic typhus with pneumonia].

OBJECTIVE: To analyze clinical manifestations, treatment and prognosis of 4 cases with endemic typhus. METHOD: The clinical data of four endemic typhus patients in prognosis were retrospectively analyzed. These four atypical cases of endemic typhus with pneumonia were treated in our department from October 2011 to March 2012. They were all male, with an age range of 15 months to 7 years. The four patients had long history, mild respiratory symptom and no improvement was found after treatment with cephalosporins. There were no evidences of bacterial, viral, or fungal infections and we thought they might have infection with other pathogen. Three were from rural areas. Routine blood tests, Weil-Felix reaction, blood smear (Giemsa staining) , and indirect immunofluorescence assay were performed. RESULT: Blood smear and IFA tests showed evidences for endemic typhus. The clinical presentations were atypical, the patients had no headache, but all had fever, rash, and pneumonia of varying severity. None of the patients had a severe cough, but bronchial casts were observed in one case. Recurrent fever was reported in three cases. Physical examinations showed no eschars, but one patient had a subconjunctival hemorrhage, and one had skin scratches, cervical lymphadenopathy, pleural effusion, pericardial effusion, and cardiac dilatation. Two patients had remarkably increased peripheral blood leukocyte counts; both these patients also had high alanine aminotransferase (ALT) levels and one had a high C-reactive protein (CRP) level. Weil-Felix testing was negative or the OX19 titer was low. The peripheral blood smear (Giemsa stain) showed intracellular pathogens in all four cases. After combined therapy with doxycycline and macrolide antibiotics, all four patients recovered well. CONCLUSION: The endemic typhus children often come from rural areas. The clinical presentations were atypical, they usually have no headache, but have fever (often Periodic fever) , rash, and pneumonia of varying severity in these four cases. Combined therapy with doxycycline and macrolide antibiotics was effective in all four patients.

Fibrin ring granulomas in Rickettsia typhi infection.

We describe a 71-year-old man hospitalized for fever and productive cough. Laboratory investigation showed anemia, thrombocytopenia, elevated transaminases, hyponatremia, and hypoalbuminemia. Computerized tomography of the abdomen, thorax, and sinuses, echocardiography, and a gallium scan did not reveal the source of the fever. The patient remained febrile despite courses of piperacillin-tazobactam/azithromycin and ceftriaxone/vancomycin. A bone marrow biopsy showed fibrin ring granulomas, and 2 rickettsial serologic panels were positive for Rickettsia typhi infection and negative for Q fever. The patient was given doxycycline, and the fever resolved within 48 h. We propose that fibrin ring granulomas also occur in murine typhus.

No olvidar al tifo murino: informe de dos casos / Co not forget murine typhus: a report of two cases

El reconocimiento del tifo murino es importante desde el punto de vista epidemiológico, el diagnóstico diferencial es amplio y debe descartarse en los pacientes con infección del sistema reticuloendotelial. Se presentan dos casos clínicos de tifo murino: un hombre de 34 años de edad residente de la Ciudad de México, con historia de viajes a Morelia y Guadalajara, que desarrolló síndrome febril, con reacción febril positiva para Proteus OX-19 (1:160) y serología positiva por inmunofluorescencia (IFA) para Rickettsia typhi, IgM e igG a títulos mayores de 1:128. El segundo caso corresponde a una mujer de 22 años de edad, residente de la ciudad de Matamoros, Tamaulipas, con cuadro clínico compatible y reacción febril positiva para Proteus OX-19 a títulos de 1:320, sin realizarse IFA. Los dos pacientes se curaron, en el primer caso se administró cloramfenicol oral y en el segundo ciprofloxacina. Presentamos estos dos casos como refuerzo al llamado del Instituto Nacional de Diagnóstico y Referencia Epidemiológicos (INDRE) para considerar el diagnóstico de rickettsiosis en pacientes febriles de áreas endémicas en México. Creemos que estas afecciones están subdiagnosticadas en nuestro país

Diagnostic tests for Rocky Mountain spotted fever and other rickettsial diseases.

Rickettsial diseases continue to confound physicians because of their usually sporadic occurrence and nonspecific clinical presentation. In past years, diagnosis was confirmed only during convalescence; however, newer, more widely available methods, such as antigen detection and improved in vitro cultivation, have enabled a diagnosis at a time when therapeutic decisions are made. Molecular nucleic acid-based techniques have also expanded the spectrum of etiologic agents and illnesses caused by rickettsiae.

[Acute suppurative arthritis: an unusual manifestation of murine typhus (endemic)]. / Artritis aguda supurada: una manifestación excepcional del tifus murino (endémico).

A 37-year-old patient had fever, diffuse maculopapular rash and acute suppurative arthritis of both knees, which was totally cured with doxycycline without sequelae. Skin biopsy showed characteristic findings of rickettsiosis. In the serological investigation the Weil-Felix reaction was positive and antibodies against Rickettsia typhi but not against Rickettsia conorii were detected by indirect immunofluorescence. No similar case has found in the reviewed literature.

Scrub and murine typhus in children with obscure fever in the tropics.

Between October, 1985, and February, 1987, 28 (8.7%) cases of scrub and murine typhus were diagnosed among 320 children with greater than or equal to 1 week history of obscure fever. Scrub typhus is a rural disease and characterized by fever, tachypnea and hepatosplenomegaly. Skin rash was rare and eschar was absent. Four patients had pneumonia and two had meningitis. Murine typhus, more an urban disease, was milder and half the patients presented exclusively because of night fever. Slightly enlarged liver and skin rash were the only significant physical signs. Lacking the classical textbook presentations, both rickettsioses often were missed or diagnosed as enteric fever. Recognition is important because patients with either disease respond well to treatment with chloramphenicol or doxycycline.

Acute febrile cerebrovasculitis: a syndrome of unknown, perhaps rickettsial, cause.

In late 1983, five patients living near Charlottesville, Virginia, were treated for an unusual syndrome of fever, headache, altered mentation, multifocal neurologic signs, and cerebrospinal fluid pleocytosis. Clinical signs of brainstem disease developed in four patients. All five had had recent exposure to forests or wood and contact with flea-infested dogs. Two patients died; one survivor has had recurrent seizures. Brain biopsy samples in two patients and autopsy findings in another showed cerebral vasculitis and perivasculitis involving mostly venules and capillaries. In the autopsy, the severest vascular lesions involved the brainstem and thalami, where they were accompanied by acute fibrinoid necrosis, but discrete vascular lesions of lesser intensity were randomly distributed in the white matter and cortex. Serologic studies on paired specimens in four patients showed significant cross-reacting antibody responses to rickettsial (typhus-group) antigens in the indirect hemagglutination, latex agglutination, and IgM microimmunofluorescence tests, but no agent was visualized or isolated. The cause of this serious inflammatory disorder is unknown.

Tifo murino: a propósito de um caso / Murine typhus: apropos of a case

Relata-se um caso de tifo murino ocorrido em Belo Horizonte-MG, comentando-se alguns aspectos clínicos sobre a doença

Isolation of species-specific protein antigens of Rickettsia typhi and Rickettsia prowazekii for immunodiagnosis and immunoprophylaxis.

A simple procedure for the selective isolation of the protective species-specific protein antigens (SPAs) of Rickettsia typhi and Rickettsia prowazekii was developed to permit use of the SPAs in the immunodiagnosis and immunoprophylaxis of typhus infections. Although the SPAs were readily extracted from lysozyme- or detergent-treated rickettsiae, as measured by rocket immunoelectrophoresis, other polypeptides were also present, as shown by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. In contrast, both water and seven buffers, each at a 10 mM concentration and pH 7.6, were nearly equally effective in the selective release of the SPAs from whole cells by extraction for 30 min at 45 degrees C. High-ionic-strength buffers and MgCl2 abolished this SPA release, thus suggesting that divalent cations were important in the binding of the SPAs to the cell envelope. The efficacy of the dilute buffer extraction procedure for isolation of large amounts of SPAs was tested by further characterization of the supernatants obtained by centrifugation (200,000 x g) of two successive tris-(hydroxymethyl)aminomethane-hydrochloride buffer (Tris) extracts. With this procedure, between 10 and 15 mg of SPA was obtained from 100 mg of purified rickettsiae. Although low-molecular-weight ribonucleic acid fragments were released into the Tris extracts in significant amounts, only the SPAs were detected, in significant quantities, as measured by polyacrylamide gel electrophoresis and rocket immunoelectrophoresis. The Tris extracts contained the same major and minor SPA polypeptides as those observed previously in SPA preparations obtained by extensive diethylaminoethyl-cellulose column chromatography, but the Tris SPAs were more satisfactory antigens in an enzyme-linked immunosorbent assay.