Unusual clinical presentations of scrub typhus, a neglected tropical disease: A case series from north India.

BACKGROUND & OBJECTIVES: Scrub typhus is a neglected tropical disease common in Asia and Africa. It usually presents with non-specific symptoms like fever, rashes, and lymphadenopathy. It has a varying range of clinical picture that often leads to misdiagnosis and initiation of non-specific treatment. This disease is thus associated with high morbidity and mortality. We aim to highlight the uncommon presentations of this common disease to create awareness regarding the unusual presentations of scrub typhus. METHODS: This prospective study was performed over a period of two months enrolling eleven adult patients with serological evidence of anti-scrub typhus IgM antibodies. RESULTS: All enrolled 11 cases [5 males (45.5%) and 6 females (54.5%)] were positive for anti-ST IgM antibodies and negative for other tested microbial agents. 7/11 (63.6%) patients were admitted with a clinical diagnosis of acute encephalitis syndrome (AES as per standard WHO definition), 3/11 (27.3%) patients presented with jaundice and 1/11 (9.1%) patients presented with rashes. Two out of 7 (28.6%) AES cases had developed peripheral gangrene of extremities. INTERPRETATION & CONCLUSION: Scrub typhus is a common tropical disease that can have various unusual clinical presentations like meningoencephalitis, vasculitis, acute kidney injury, jaundice, MODS. It closely mimics other infective etiologies making its diagnosis difficult. A high index of suspicion and clinical awareness is required in clinical practice to identify the different presentations of this disease so that early treatment can be initiated to reduce morbidity and mortality associated with this disease.

Bevacizumab in choroidal neovascularization secondary to Indian tick typhus: A rare case report.

Tick typhus causes hemorrhagic lesions over the skin. Retina also shows hemorrhages and exudates. Many cases have been reported in western literature about this condition. To our best of knowledge, this is the first case report of tick typhus in India which was also associated with inflammatory choroidal neovascularization.

Cluster of sylvatic epidemic typhus cases associated with flying squirrels, 2004-2006.

In February 2006, a diagnosis of sylvatic epidemic typhus in a counselor at a wilderness camp in Pennsylvania prompted a retrospective investigation. From January 2004 through January 2006, 3 more cases were identified. All had been counselors at the camp and had experienced febrile illness with myalgia, chills, and sweats; 2 had been hospitalized. All patients had slept in the same cabin and reported having seen and heard flying squirrels inside the wall adjacent to their bed. Serum from each patient had evidence of infection with Rickettsia prowazekii. Analysis of blood and tissue from 14 southern flying squirrels trapped in the woodlands around the cabin indicated that 71% were infected with R. prowazekii. Education and control measures to exclude flying squirrels from housing are essential to reduce the likelihood of sylvatic epidemic typhus.

Typhus fever: an overlooked diagnosis.

A case of typhus fever is presented. On admission, the clinical diagnosis was typhoid fever. Forty-eight hours after admission, the presence of subconjunctival haemorrhage, malena, and jaundice raised the possibility of a different aetiology, the two most likely differentials being dengue and typhus. Finally, a co-infection of typhoid and typhus was discovered. This uncommon clinical scenario should be taken into account in the management of patients with high fever on admission being treated as a case of typhoid fever.

Autochthonous epidemic typhus associated with Bartonella quintana bacteremia in a homeless person.

Trench fever, a louse-borne disease caused by Bartonella quintana, is reemerging in homeless persons. Epidemic typhus is another life-threatening louse-borne disease caused by Rickettsia prowazekii and known to occur in conditions of war, famine, refugee camps, cold weather, poverty, or lapses in public health. We report the first case of seroconversion to R. prowazekii in a homeless person of Marseilles, France. This was associated with B. quintana bacteremia. Although no outbreaks of typhus have been notified yet in the homeless population, this disease is likely to reemerge in such situation.

Jakub Penson and his studies on acute renal failure during typhus epidemics in Warsaw Ghetto.

In the Warsaw Ghetto established by the German Nazis as a special district for Polish Jews in 1940 there were two typhus epidemics. Many patients affected by this disease (1500 during the first and 6500 during second epidemic) were treated at The Department of Infectious Disease of Czyste Hospital headed by Dr Jakub Penson--a Polish physician of Jewish origin. A heroic group of 20 physicians not only treated patients in these tragic circumstances, but also performed in defiance of Nazi prohibition, scientific studies on the clinical course of typhus with special attention on hyperazotemia and renal complication. The results of their observations were presented in 1941-42 during clinical meetings in Czyste Hospital and later published by Penson in 1946 in the Polish Physicians Weekly. Among other clinical statements a description of acute renal failure of extrarenal origin, caused by dehydration and toxic influence of primary disease seems the most important one. It has to be taken into account that acute renal failure appearing during Crush Syndrome was described by Bywaters in 1941. Jakub Penson survived the German Nazi occupation and later become a head of the Internal Medicine Department in Gdansk Medical University and one of the precursors of clinical nephrology in Poland.

Murine typhus as a common cause of fever of intermediate duration: a 17-year study in the south of Spain.

BACKGROUND: Fever of intermediate duration (FID), characterized by a febrile syndrome lasting from 7 to 28 days, is a frequent condition in clinical practice, but its epidemiological and etiologic features are not well described. Murine typhus (MT) is a worldwide illness; nevertheless, to our knowledge, no studies describing its epidemiological and clinical characteristics have been performed in the south of Spain. Also, its significance as a cause of FID is unknown. OBJECTIVE: To determine the epidemiological features, clinical characteristics, and prognosis of MT and, prospectively, its incidence as a cause of FID. DESIGN: Prospective study of cases of MT over 17 years (1979-1995) and of all cases of FID treated in a tertiary teaching hospital in Seville, Spain. RESULTS: One hundred and four cases of MT were included, and MT was the cause in 6.7% of 926 cases of FID. Insect bites were reported in only 3.8% of the cases of MT previous to the onset of illness. Most cases (62.5%) occurred in the summer and fall. A high frequency of rash (62.5%) was noted. Arthromyalgia (77%), headache (71%), and respiratory (25%) and gastrointestinal (23%) symptoms were also frequent. Laboratory findings were unspecific. Organ complications were uncommon (8.6%), but they were severe in 4 cases. The mean duration of fever was 12.5 days. Cure was achieved in all cases, although only 44 patients received specific treatment. CONCLUSIONS: Murine typhus is prevalent in the south of Spain and is a significant cause of FID. Clinical signs are benign, but some patients may develop severe complications. A high degree of clinical suspicion is required for diagnosis.

Persistently elevated serum transcobalamin II in a patient with cerebral malaria and typhus infections.

A 25-year-old man presented with a history of fever, chills and vomiting for three days. The parasite count was 207 ring-forms of P. falciparum per 1000 red cells. He developed hemoglobinuria and excreted hemoglobin in the urine 0.20-0.30 g/dl for 14 days during admission. Many blood transfusions were administered for correcting anemia. Although the malarial parasites disappeared one week after anti-malarial therapy, however, the fever and hemoglobinuria persisted. The Weil-Felix reaction OXK was positive with a titre of 1:40 on admission and increased to 1:160 on the second week. Chloramphenical and prednisolone were given for treatment of typhus fever and all symptoms subsided. Serum TCII levels were found to be increased and persisted high during the hemoglobinuria. The clearance of TCII was lower and increased relatively slowly to the normal level on day 30. On the other hand, TCII excretion in the urine was found to be increased during hemoglobinuria. These findings indicate that the catabolism and clearance of TCII in this patients is impaired with increased TCII excretion in the urine in parallel to the hemoglobinuria. Serum TCII level is, therefore, increased and persistently high in a patient with malaria and typhus fever infections with hemoglobinuria.

Dermatologic manifestations of arthropod-borne diseases.

The arthropod-borne rickettsial, borrelial, and bacterial diseases of North America are a diverse group of disorders that produce a wide variety of cutaneous abnormalities. These dermatologic abnormalities are often valuable clinical clues that may reveal or suggest the correct diagnosis to the astute clinician. We review the usual and unusual dermatologic manifestations of Rocky Mountain spotted fever, murine and sylvatic typhus, rickettsialpox, ehrlichiosis, Lyme disease, tick-borne relapsing fever, Colorado tick fever, and tularemia. In some of these diseases, skin manifestations may be diagnostic; in others, dermatologic findings may be the initial and only clues that leads to the initiation of life-saving therapy. In other arthropod-borne infections, the appearance or evolution of the skin rash may be characteristic enough to suggest the proper diagnosis.

[Interstitial nephritis in typhus]. / Interstitielle Nephritis bei Fleckfieber.

A 58-year-old man developed continuous fever of around 40 degrees C and a macular rash on the trunk and limbs one week after an eight-day visit to the island of Rhodos. Typhus was diagnosed on the basis of the clinical findings, the characteristic rash and a rise in antibody titre against Rickettsia prowazekii and mooseri (1:1280). The fever subsided and the patient's general state markedly improved within three days of starting antibiotic treatment with doxycycline. Five days after hospital admission renal function deteriorated, serum creatinine rising from 1.7 to maximally 8.7 mg/dl. Renal biopsy on the eighth day of illness revealed, in concordance with the diagnosis of a rickettsial infection, acute granulomatous interstitial nephritis. Doxycycline administration was continued for a total of 18 days and renal function improved. Two weeks after discharge serum creatinine had fallen to 1.8 mg/dl and to 1.2 mg/dl after 6 months. The antibody titre against Rickettsia prowazekii had fallen to 1:20 about 12 weeks after discharge. Early antibiotic treatment of typhus is of importance to avoid irreversible renal damage.

Epidemic typhus fever and hearing loss: a histological study (Hallpike collection of temporal bone sections).

Hearing loss as a frequent complication of louse-borne epidemic typhus fever has been well documented in the reports of ENT specialists serving in both the Allied and the German armies in the last war. The present paper describes the characteristic histopathological features as noted in sections of the temporal bones from five British soldiers who died in 1944 of typhus fever during the last war in Eastern Asia. The VIIIth nerve showed multiple 'typhus nodules' and there was extensive interstitial neuritis of the VIIIth nerve and demyelination of the nerve fibres. There were also widely scattered aggregations of mononuclear cells in the inner ear. This unique study was based on the Hallpike collection of temporal bone sections.

Fiebre tifoidea en Cartagena / Typhoid fever in Cartagena

Se revisaron 92 historias con diagnostico de fiebre tifoidea comprobada bacteriologicamente que se presentaron en el Hospital Universitario de Cartagena en el periodo comprendido entre enero de 1976 y diciembre de 1987. Se describen los hallazgos epidemiologicos, sintomas, signos, examenes de laboratorio y tratamiento. Se comparan estos resultados ( de una forma endemica de la enfermedad) con otros tres estudios colombianos, encontrando diferencias entre las formas epidemicas y endemicas. Se dicuten nuevos metodos diagnosticos (serologicos) y modalidades terapeuticas prometedoras

Cardiovascular and pulmonary complications of epidemic typhus.

A case of typhus fever associated with cardiac and pulmonary complications is reported. The patient was a 24-year-old Egyptian female with characteristic clinical presentation of rickettsial infection, though no rash was present throughout the course of the disease. We could not find a report of such complications in the English medical literature.