Macrolides versus other antibiotics in pediatric scrub typhus: A meta-analysis.

BACKGROUND: While Doxycycline is the recommended drug for treating scrub typhus, there is a growing trend of using Macrolides and Other antibiotics due to their perceived advantages. In this study, we compared the efficacy of Macrolides versus Other antibiotics in the treatment of pediatric scrub typhus. METHODS: Meta-analysis of randomized controlled trials (RCTs) with GRADE (Grading of Recommendations, Assessment, Development and Evaluation) application. Major databases were searched till 30th December 2022. Children of all age groups were included. Primary outcomes included mortality rate and time to defervescence (h). RESULTS: Of the 103 citations retrieved, 5 trials, including 383 children up to 15 years of age with probable and confirmed cases of scrub typhus, were included. None of the trials reported mortality rate. The pooled results from the trials found no significant difference between Azithromycin and Other antibiotics for any of the outcome measures. The certainty of evidence for the primary outcome was deemed to be of "very low certainty", while the certainty of evidence for the secondary outcomes ranged from "low to moderate certainty". CONCLUSIONS: The current meta-analysis revealed that there was no significant difference between Azithromycin and Other antibiotics (such as Doxycycline and Chloramphenicol) in the treatment of scrub typhus in children. However, it's important to note that the evidence generated for the primary outcome was of "very low certainty". PROSPERO REGISTRATION NUMBER: CRD42021276577.

Scalp eschar and neck lymph adenopathy after a tick bite (SENLAT) in Tuscany, Italy (2015-2022).

INTRODUCTION: The Scalp Eschar and Neck Lymph Adenopathy After a Tick Bite (SENLAT) syndrome is frequently caused by Rickettsia slovaca and Rickettsia raoultii. Only six microbiologically confirmed SENLAT cases have been reported in Italy between 1996 and 2021. We report ten cases of SENLAT seen between 2015 and 2022 in a tertiary care center in Tuscany, Italy. CASES PRESENTATION: All patients were women; most common symptoms were scalp eschar on the site of tick bite (100%) and cervical lymphadenopathy (90%). No microbiological identification was obtained. Persistent alopecia, for several months to years, was observed in four patients. The known difficulty of microbiological diagnosis in SENLAT was worsened, in our cases, by factors as the absence of ticks available for identification and microbiological study, and antibiotic treatment administration previous to microbiological tests. CONCLUSION: The report highlights the presence of SENLAT in Italy, aiming to raise the awareness toward the emergence of this clinical entity.

Epidemiology and risk factors of scrub typhus in Taiwan: A nationwide database study from 1996 to 2014.

BACKGROUND: Scrub typhus (ST) is one of the most underdiagnosed, potentially fatal febrile diseases in the Asia-Pacific region. We conducted a comprehensive review of the risk factors of ST over 19 years using data from a nationwide database. METHODS: We used data on ST from the nationwide database of the Taiwan Centers for Disease Control from 1996 to 2014 to analyse the incidence rates and relative risks of ST according to different regions. The trends of incidence rates over the study period were also evaluated. The distribution of confirmed ST cases was mapped using geographic information system software. The characteristics of confirmed ST cases and non-ST cases (cases with suspected ST but negative test findings) were compared. RESULTS: Among the 38,127 reported cases, there were 6,791 (17.8%) confirmed ST cases. The overall incidence rate of ST in Taiwan was 1.49 per 100,000 residents per year. The trend of incidence rates increased over time. The Island region had the highest incidence rate (56.55 per 100,000 residents per year), followed by the Eastern region (15.13 per 100,000 residents per year). More confirmed ST cases were distributed in mountainous areas of Taiwan Main Island and Island region. Compared to non-ST cases, individuals with confirmed ST were younger (median [interquartile range] age: 44 [26-57] years versus 45 [30-60] years, p < .001) and more likely to engage in at-risk occupations (29.4% versus 13.3%, p < .001), including farming and animal husbandry (16.6% versus 9.0%, p < .001) and the armed forces (12.3% versus 3.5%, p < .001); however, they had a lower rate of animal contact (12.8% versus 20.1%, p < .001). CONCLUSIONS: ST is an endemic disease in Taiwan, particularly in the Island region, Eastern region and mountainous areas. Patients engaged in at-risk occupations and presenting with acute febrile diseases should undergo investigations for ST.

Leptospirosis and rickettsiosis, a diagnostic challenge for febrile syndrome in endemic areas / [Leptospirosis y rickettsiosis, reto diagnóstico para el síndrome febril en zonas endémicas].

This is the case of a 50-year-old male from the region of Urabá, Colombia, with a mixed infection by Rickettsia rickettsii and Leptospira interrogans serovar Copenhageni ST78 and negative test for malaria and dengue fever. The patient presented with febrile syndrome and was unresponsive to systemic antibiotic treatment, who finally died in the intensive care unit. We established the postmortem diagnosis through molecular typification of the two etiological agents. In the inspection at the patient's home, we found a Rattus rattus specimen infected with L. interrogans of the same serovar found in him. We found no ticks parasitizing the domestic animals cohabitating with the patient. This case of a mixed infection with progressive and fatal symptoms in a patient with occupational risk in a tropical disease endemic zone highlights the importance of considering the potential presentation of simultaneous etiologies in patients with multiple medical visits for unresolved febrile syndromes associated with risky exposure during agricultural activities.

Se presenta el caso de un hombre de 50 años de edad proveniente de la región de Urabá, Colombia, con una infección mixta por Rickettsia rickettsii y Leptospira interrogans serovar Copenhageni ST78, y pruebas negativas para malaria y dengue. El paciente presentó un síndrome febril que no mejoró con el tratamiento antibiótico sistémico y, finalmente, falleció en la unidad de cuidados intensivos. El diagnóstico post mortem se hizo mediante tipificación molecular de los dos agentes etiológicos. En la inspección del domicilio del paciente, se encontró un ejemplar de Rattus rattus infectado con L. interrogans del mismo serovar detectado en él. No se encontraron garrapatas en los animales domésticos que habitaban con el paciente. Se reporta una infección mixta con síntomas clínicos progresivos y fatales en un paciente con antecedentes laborales de riesgo en una zona endémica para enfermedades tropicales, lo que obliga a tener presente la posibilidad de infecciones simultáneas en personas procedentes de áreas endémicas que consulten reiteradamente por síndrome febril sin resolución y tengan riesgo laboral relacionado con actividades agrícolas.

Leptospirosis y rickettsiosis, reto diagnóstico para el síndrome febril en zonas endémicas / Leptospirosis and rickettsiosis, a diagnostic challenge for febrile syndrome in endemic areas

Resumen. Se presenta el caso de un hombre de 50 años de edad proveniente de la región de Urabá, Colombia, con una infección mixta por Rickettsia rickettsii y Leptospira interrogans serovar Copenhageni ST78, y pruebas negativas para malaria y dengue. El paciente presentó un síndrome febril que no mejoró con el tratamiento antibiótico sistémico y, finalmente, falleció en la unidad de cuidados intensivos. El diagnóstico post mortem se hizo mediante tipificación molecular de los dos agentes etiológicos. En la inspección del domicilio del paciente, se encontró un ejemplar de Rattus rattus infectado con L. interrogans del mismo serovar detectado en él. No se encontraron garrapatas en los animales domésticos que habitaban con el paciente. Se reporta una infección mixta con síntomas clínicos progresivos y fatales en un paciente con antecedentes laborales de riesgo en una zona endémica para enfermedades tropicales, lo que obliga a tener presente la posibilidad de infecciones simultáneas en personas procedentes de áreas endémicas que consulten reiteradamente por síndrome febril sin resolución y tengan riesgo laboral relacionado con actividades agrícolas.

Abstract. This is the case of a 50-year-old male from the region of Urabá, Colombia, with a mixed infection by Rickettsia rickettsii and Leptospira interrogans serovar Copenhageni ST78 and negative test for malaria and dengue fever. The patient presented with febrile syndrome and was unresponsive to systemic antibiotic treatment, who finally died in the intensive care unit. We established the postmortem diagnosis through molecular typification of the two etiological agents. In the inspection at the patient's home, we found a Rattus rattus specimen infected with L. interrogans of the same serovar found in him. We found no ticks parasitizing the domestic animals cohabitating with the patient. This case of a mixed infection with progressive and fatal symptoms in a patient with occupational risk in a tropical disease endemic zone highlights the importance of considering the potential presentation of simultaneous etiologies in patients with multiple medical visits for unresolved febrile syndromes associated with risky exposure during agricultural activities.

Infección y enfermedad por Rickettsia spp. del grupo de las fiebres manchadas en pacientes febriles del Urabá antioqueño, Colombia / Rickettsia spp. infection of the group of spotted fevers in febrile patients of the Urabá Antioquia, Colombia

RESUMEN Objetivo: determinar la frecuencia de la infección y enfermedad por Rickettsia spp. del grupo de las fiebres manchadas en pacientes febriles del Urabá antioqueño, que asistieron a centros hospitalarios de la región. Métodos: se incluyeron en el estudio pacientes febriles provenientes de 9 instituciones de salud de la región del Urabá, los cuales fueron encuestados para determinar sus variables clínicas y demográficas. De estos pacientes se obtuvieron muestras de suero durante las fases aguda y convaleciente de la enfermedad. Para cada muestra se determinó la seropositividad (título ≥ 64) y su título de anticuerpos seriados dobles mediante inmunofluorescencia indirecta para IgG contra el antígeno de Rickettsia rickettsii. Resultados: se analizaron 89 pacientes febriles con 89 muestras de fase aguda y 60 en fase convaleciente. Los síntomas más comunes de los pacientes fueron cefalea, ictericia, mialgias, náuseas, dolor abdominal, trombocitopenia y vómito. El 55,1 % de los pacientes provenía de áreas rurales. Se obtuvo seropositividad del 40,4 % con títulos entre 64-512, infección previa en un 33,7 % y rickettsiosis en 6 pacientes (6,7 %). Los pacientes con seroconversión o serorefuerzo provenían de los municipios de Apartadó (n = 2), Chigorodó (n = 1), Necoclí (n = 2) y Turbo (n = 1); el hallazgo clínico más destacado fue la trombocitopenia. Conclusiones: se demostró que la infección y la enfermedad rickettsial continúan siendo activas en la zona del Urabá. Este hallazgo permite alertar a las autoridades de salud de la región para que se brinde tratamiento con antibióticos a los casos sospechosos de manera temprana y de esta forma evitar las muertes o secuelas derivadas de este tipo de infecciones.

SUMMARY Objective: Determine the frequency of infection and disease by Rickettsia spp. of the spotted fever group in febrile patients from Urabá Antioquia attended by hospital centers of the region. Methods: Patients from nine health institutions of the Urabá region were included in the study. These patients received a survey with questions about their clinical and socio-demographic variables. Eighty-nine acutephase serum samples, and 60 convalescent serum samples, were obtained from these patients, and each sample was tested (IgG) by Indirect Immunofluoerscence Assay (IIFA) using a dilution of 1:64 against R. rickettsii. Furtherly, positive sera were tittered by two-fold serial dilutions using the same antigen. Results: Patients showed symptoms such as fever, headache, jaundice, myalgias, nausea, abdominal pain, petechiae, thrombocytopenia and vomiting. Most of these patients came from rural areas (55,1 %). Seropositivity was obtained in 40,4 % patients with titers between 64-512, a 33,7 % with previous infection and the disease was found in 6 patients (6,7 %). Patients with seroconversion, or a fourlfold rise antibody titer between acute and convalescent samples, came from the municipalities of Apartadó (n = 2), Chigorodó (n = 1), Necoclí (n = 2) and Turbo (n = 1), and the most relevant clinical finding was thrombocytopenia in four of the patients. Conclusions: This study demonstrated that infection and rickettsial disease continues being active in the Urabá region. This situation represents a warning for the health authorities of the region and suggests them to provide appropriate treatment to avoid deaths or sequelae derived from this type of infections.

Caso probable de tifus murino con falla ventilatoria en una adolescente del área urbana de Cali, Colombia / Probable case of murine typhus with respiratory failure in an adolescent from the urban area of Cali, Colombia

El tifus murino es una enfermedad infecciosa de carácter zoonótico causada por Rickettsia typhi . Se presenta el caso de una paciente femenina de 13 años edad, procedente del área urbana de la ciudad de Cali, quien presentó un cuadro febril asociado a taquipnea y exantema maculopapular generalizado en tronco y extremidades. Durante las primeras 48 h en la UCI pediátrica desarrolló rápido deterioro clínico, fiebre persistente, aumento de reactantes de fase aguda, presencia de infiltrados pulmonares intersticiales bilaterales y derrame pleural, requiriendo ventilación mecánica no invasiva. Se inició tratamiento con doxiciclina frente a la sospecha de una posible infección por agentes rickettsiales. Veinticuatro horas más tarde la paciente presentó mejoría clínica, resolución del exantema y retiro de la ventilación no invasiva. Por medio de la prueba de inmunofluorescencia indirecta se evidenciaron títulos de 1:512 frente al grupo del tifus, constatando el diagnóstico probable de tifus murino.

Murine typhus is a zoonotic infectious disease caused by Rickettsia typhi . We report a case of a 13-year old female patient from the urban area of the city of Cali, who presented with fever, associated with tachypnoea and generalised maculopapular exanthema on the trunk and limbs. During the first 48 h in the paediatric ICU, she rapidly deteriorated, with persistent fever, increased acute phase reactants, bilateral interstitial pulmonary infiltrates and pleural effusion requiring noninvasive ventilation. Treatment with doxycycline was initiated due to a suspected infection by rickettsial agents. Twenty-four hours later the patient presented clinical improvement and resolution of the exanthema, thus the non-invasive ventilation was withdrawn. By means of a indirect immunofluorescence test, titres of 1:512 were shown against the typhus group, leading to the probable diagnosis of murine typhus.

Serologic evidence of human Rickettsia infection found in three locations in Panamá / Evidencia serológica de infecciones de Rickettsia en humanos provenientes de tres localidades de Panamá

Introduction: Since the middle of last century, cases of rickettsiosis have been found in Panamá when outbreaks of murine typhus and spotted fever were reported. Since then, little information exists about its prevalence in this country, since it is most often is misdiagnosed as another disease. Objectives: The aim of this paper is to demonstrate the presence of Rickettsia infections in humans in three locations in Panamá. These locations are agricultural areas, near forested areas or those who work in zoo. Materials and methods: Three locations where chosen for this study: Tortí, El Valle de Antón and workers in the Summit Municipal Park in Panamá City. All volunteers signed an informed consent and answered a questionnaire. The samples were analyzed for the detection of rickettsial spotted fever and typhus group by the indirect immunofluorescence (using commercial kits) and antigens of Rickettsia rickettsii and R. amblyommii. Results: Blood samples were taken from 97 volunteers in Tortí (25), El Valle de Anton (37) and Summit Municipal Park (35). Of these, a total of 38 (39%) samples reacted to one of the two methods: eight (32%) in Tortí, 18 (48%) in El valle and 12 (34%) in Summit Municipal Park. Conclusion: The results show a high prevalence of antibodies to Rickettsia belonging to the spotted fever group in each of the three study areas, in addition to presenting evidence of the typhus group Rickettsia in El Valle de Anton. These areas could be considered endemic for rickettsiosis as there are conditions for maintaining them.

Introducción. Desde mediados del siglo pasado, se conocen en Panamá casos de rickettsiosis, cuando fueron reportados brotes de tifus en ratones y de fiebres manchadas. A partir de entonces, poca información se tiene sobre su prevalencia en este país, lo cual se debe principalmente a que son confundidos con otras enfermedades. Objetivos. El objetivo de este trabajo fue demostrar la presencia de rickettsiosis en humanos provenientes de tres localidades de Panamá, que corresponden a zonas agropecuarias, cercanas a bosques, o que trabajaban en zoológicos. Materiales y métodos. Se escogieron tres localidades para este estudio: Tortí (provincia de Panamá), El Valle de Antón (provincia de Coclé) y el Parque Municipal Summit en Ciudad de Panamá. Los voluntarios firmaron un consentimiento informado, además de responder un cuestionario. De cada voluntario se extrajo sangre venosa, la que fue analizada por medio de inmunoflorescencia indirecta, utilizando kits comerciales y láminas sensibilizadas con antígenos cultivados de Rickettsia rickettsii y Rickettsia amblyommii . Resultados. Se tomaron muestras de 97 voluntarios, 25 en Tortí, 37 en El Valle de Antón y 35 en el Parque Municipal Summit. De estos, 38 (39 %) de las muestras fueron positivas en algunas de las dos técnicas practicadas: 8 (32 %) en Tortí, 18 (48 %) en El Valle y 12 (34 %) en el Parque Municipal Summit. Conclusión. Se demuestra una alta prevalencia de anticuerpos contra Rickettsia del grupo de las fiebres manchadas en las tres áreas de estudio, además de presentarse evidencia de títulos para Rickettsia del grupo tifus en El Valle de Antón. Estas zonas podrían considerarse como endémicas por rickettsiosis, ya que existen condiciones que permiten el mantenimiento de las mismas.

Epidemiological characteristics of Brazilian spotted fever in Minas Gerais State, Brazil, 2000-2008 / Aspectos epidemiológicos dos casos de febre maculosa brasileira ocorridos em Minas Gerais, Brasil, 2000 a 2008

Brazilian spotted fever is the most common rickettsiosis in Brazil, most prevalent in the States of São Paulo and Minas Gerais. The aim of this study was to describe the epidemiological characteristics of Brazilian spotted fever in Minas Gerais from 2000 to 2008. Of the 132 cases of Brazilian spotted fever, 53 patients died, representing a case-fatality rate of 40.2 percent. Males predominated, with 78.8 percent of confirmed cases, and median age was 26.5 years. Absence of rash was associated with increased risk of death (p = 0.005). Greater Metropolitan Belo Horizonte, Rio Doce Valley, and Zona da Mata accounted for 70.6 percent of the cases, which occurred mainly from May to November. There was an increase in the number of cases, which could suggest an expansion of the disease, but probably resulted from an increase in the health system's diagnostic capacity and sensitivity. Despite this improvement, the case-fatality rate remains high and with no apparent tendency to decrease, thus indicating the need for improved prevention and patient care.

A febre maculosa brasileira é a rickettsiose mais comum do território nacional, com maior importância nos estados de São Paulo e Minas Gerais. O objetivo deste estudo foi descrever os aspectos epidemiológicos dos casos de febre maculosa brasileira ocorridos em Minas Gerais no período de 2000 a 2008. Dos 132 casos confirmados, 53 evoluíram para óbito, representando uma letalidade de 40,2 por cento. O sexo masculino foi o mais acometido com 78,8 por cento dos casos confirmados, e mediana de idade de 26,5 anos. Entre os fatores de risco determinantes do óbito, a ausência de exantema apresentou associação significativa (p = 0,005). A Região Metropolitana de Belo Horizonte, o Vale do Rio Doce e a Zona da Mata responderam por 70,6 por cento dos casos, que ocorreram principalmente entre os meses de maio e novembro. Houve crescimento no número de casos, que apesar de sugerir expansão da doença, provavelmente decorreu do aumento da capacidade diagnóstica e sensibilidade do sistema de saúde. Apesar dessa melhora, a letalidade permaneceu alta e sem tendências à diminuição, o que implica a necessidade de medidas preventivas e assistenciais.