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Varadarajan R, Patel AP, Rashidi K, Oh A, Rahman R, Neal R. Flea-Borne Typhus Presenting with Acalculous Cholecystitis and Severe Anemia. Case Rep Infect Dis 2023; 2023:5510295. [PMID: 37954983 PMCID: PMC10637845 DOI: 10.1155/2023/5510295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/05/2023] [Accepted: 10/18/2023] [Indexed: 11/14/2023] Open
Abstract
Background Flea-borne typhus (FBT), an uncommon illness in the United States, typically presents as a high continuous fever with commonly associated symptoms including headache, myalgias, and rashes on the trunk and extremities. Patients infected with FBT may also present with atypical symptoms. As such, the combination of its relatively low incidence in the United States coupled with its variability in associated symptoms poses a diagnostic challenge for clinicians; early empiric treatment with doxycycline is warranted prior to a definitive diagnosis to reduce the risk of damage to vital organs. Case Report. This case describes a 54-year-old male who presented to an emergency room in Houston, Texas, with one week of constant right upper quadrant abdominal pain and fevers up to 40°C. The patient was initially diagnosed with Grade III severe acute cholangitis after abdominal ultrasound revealed gallbladder sludge and wall thickening without ductal dilatation, but a subsequent endoscopic retrograde cholangiopancreatography was unremarkable. Following intermittent fevers and worsening anemia, the patient was started on oral doxycycline for atypical infection, and an infectious disease workup subsequently returned a positive titer for Rickettsia typhi. He experienced rapid symptomatic and clinical improvement, and the patient was discharged home with a final diagnosis of flea-borne typhus. Conclusion Albeit uncommon, the presentation of this patient's symptoms and final diagnosis of flea-borne typhus demonstrates the importance of (1) keeping atypical infections such as FBT in the differential diagnosis and (2) beginning empiric treatment to prevent damage to vital organs if suspicion of FBT is high.
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Affiliation(s)
- Ramya Varadarajan
- Texas A&M College of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Ashmi P. Patel
- Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Keyvon Rashidi
- Texas A&M College of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Albert Oh
- Texas A&M College of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Rashmeen Rahman
- Department of Endocrinology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Ryan Neal
- Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
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Davis K, Ahmado A, Warrell CE, Downs LO, Furneaux J, Sithamparanathan K. Mediterranean spotted fever with multiorgan involvement. BMJ Case Rep 2022; 15:15/12/e249426. [PMID: 36543366 PMCID: PMC9772677 DOI: 10.1136/bcr-2022-249426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Kimberly Davis
- Microbiology/Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Headington, UK
| | - Ahmad Ahmado
- Ophthalmology, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - Clare E Warrell
- Rare & Imported Pathogens Laboratory (RIPL), UK Health Security Agency, Manor Farm Road, Porton Down, Wiltshire
| | - Louise O Downs
- Microbiology/Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Headington, UK
| | - Jenna Furneaux
- Rare & Imported Pathogens Laboratory (RIPL), UK Health Security Agency, Manor Farm Road, Porton Down, Wiltshire
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Xia J, Shrestha S, Saca JC. Murine Typhus Presenting as Septic Acute Cholangitis in a Young Woman From South Texas. Cureus 2021; 13:e19209. [PMID: 34873539 PMCID: PMC8638779 DOI: 10.7759/cureus.19209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 11/19/2022] Open
Abstract
Murine (endemic) typhus is a zoonotic disease spread by fleas carrying Rickettsia typhi bacteria. Typically, murine typhus presents with mild and nonspecific flu-like symptoms. However, it can manifest with severe systemic complications potentially leading to delayed treatment or unnecessary interventions. We present the case of a young woman from South Texas who presented to the emergency department after 10 days of fever, myalgia, headache, nausea, and right-sided abdominal pain. She was found to be febrile, severely hypotensive, suffering from acute liver injury with a predominantly cholestatic pattern, acute kidney injury, severe thrombocytopenia, and hyponatremia. She was initially managed with broad-spectrum antibiotics for undifferentiated septic shock, and doxycycline was added due to suspicion of a Rickettsial infection. Although radiographic findings showed some evidence of biliary involvement, they were not typical for common biliary diseases. However, due to her severe clinical presentation and findings suggesting possible acute cholangitis, she underwent an endoscopic ultrasound with endoscopic retrograde cholangiopancreatography, which revealed no evidence of acute obstructive biliary disease. Without strong evidence to explain her presentation, an extensive chronic liver disease workup was done, which was negative. The patient ultimately clinically improved with antibiotics alone. This case demonstrates an atypical presentation of murine typhus, presenting with septic shock and masquerading as acute cholangitis. With the rising incidence of murine typhus in endemic areas of the United States, this case reinforces the importance of being cognizant of the typical and atypical presentations of murine typhus, which may allow for early appropriate treatment and potentially avoid unnecessary interventions. Additionally, in this study, we conducted a literature review of murine typhus cases associated with acute biliary dysfunction.
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Affiliation(s)
- Jeffrey Xia
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Sabi Shrestha
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - James C Saca
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
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Markaki I, Konsoula A, Markaki L, Spernovasilis N, Papadakis M. Acute acalculous cholecystitis due to infectious causes. World J Clin Cases 2021; 9:6674-6685. [PMID: 34447814 PMCID: PMC8362504 DOI: 10.12998/wjcc.v9.i23.6674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/08/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder not associated with the presence of gallstones. It usually occurs in critically ill patients but it has also been implicated as a cause of cholecystitis in previously healthy individuals. In this subgroup of patients, infectious causes comprise the primary etiology. We, herein, discuss the pathophysiological mechanisms involved in AAC, focusing on the infectious causes. AAC associated with critical medical conditions is caused by bile stasis and gallbladder ischemia. Several mechanisms are reported to be involved in AAC in patients without underlying critical illness including direct invasion of the gallbladder epithelial cells, gallbladder vasculitis, obstruction of the biliary tree, and sequestration. We emphasize that multiple pathogenic mechanisms may concurrently contribute to the development of AAC in varying degrees. Awareness of the implicated pathogens is essential since it will allow a more focused examination of the histopathological specimens. In conclusion, additional research and a high degree of clinical suspicion are needed to clarify the complex spectrum of mechanisms that are involved in the pathogenesis of AAC.
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Affiliation(s)
- Ioulia Markaki
- Department of Emergency, General Hospital of Kythira “Trifyllio”, Kythira 80200, Greece
| | - Afroditi Konsoula
- Department of Emergency, General Hospital of Mytilene "Vostaneio", Lesvos 81132, Greece
| | - Lamprini Markaki
- Department of Pediatrics, "Agia Sofia" Children's Hospital, Athens 11527, Greece
| | | | - Marios Papadakis
- Department of Surgery II, University of Witten-Herdecke, Wuppertal 40235, NRW, Germany
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Sunbathing, a possible risk factor of murine typhus infection in Greece. PLoS Negl Trop Dis 2021; 15:e0009186. [PMID: 33711035 PMCID: PMC7990230 DOI: 10.1371/journal.pntd.0009186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 03/24/2021] [Accepted: 01/27/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There are few studies about the presence of murine typhus in Greece. Our objective was to conduct a large scale retrospective investigation to determine the clinical and epidemiological features of patients diagnosed with murine typhus in Greece. METHODOLOGY/PRINCIPAL FINDINGS From 2012 to 2019 serum samples from hospitalized patients and outpatients throughout Greece suspected for murine typhus infection were tested by immunofluorescence assay for Rickettsia typhi. Immunofluorescence positive samples obtained since 2016 were also tested by qPCR targeting R. typhi. Clinical and epidemiological data were retrospectively collected for the patients with confirmed murine typhus. Overall, we tested 5,365 different patients and, in total, 174 patients from all geographic regions of Greece were diagnosed with murine typhus. The most frequently reported sign or symptom was fever (89%), followed by headache (84%) and rash (81%). The classical triad of fever, headache, and rash was present in 72% of patients during their illness. Severe infections with complications including acute renal failure or septic shock were not recorded. The majority of cases (81%) occurred during May-October and peaked in June and September. Most of patients (81%) infected in Athens, recalled that their only activity the last weeks before symptoms onset was swimming on the beach and 59% of them also reported an insect bite while sunbathing. CONCLUSIONS/SIGNIFICANCE Our results may reflect the reemergence of murine typhus in Greece and we highlight the importance of awareness of this difficult-to-recognize undifferentiated febrile illness.
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Lin IF, Lin JN, Tsai CT, Wu YY, Chen YH, Lai CH. Serum C-reactive protein and procalcitonin values in acute Q fever, scrub typhus, and murine typhus. BMC Infect Dis 2020; 20:334. [PMID: 32398008 PMCID: PMC7216490 DOI: 10.1186/s12879-020-05058-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/28/2020] [Indexed: 11/23/2022] Open
Abstract
Background Although C-reactive protein (CRP) and procalcitonin (PCT) are widely used inflammatory markers for infectious diseases, their role and potential application for rickettsioses were rarely studied. Methods A retrospective chart review and serological study were conducted in patients with rickettsioses. The clinical presentations, characteristics, laboratory data, and treatment responses were recorded and their associations with CRP and PCT values were analyzed. Results A total of 189 cases of rickettsioses, including 115 cases of acute Q fever (60.8%), 55 cases of scrub typhus (29.1%), and 19 cases of murine typhus (10.1%) were investigated. Both CRP and PCT values increased in the acute phase and declined in the convalescent phase. In the acute phase, mean CRP and PCT values were 78.2 ± 63.7 mg/L and 1.05 ± 1.40 ng/mL, respectively. Percentages of patients falling under different cut-off values of CRP and PCT were calculated systematically. Only 10.8% of CRP was > 150 mg/L and 14.2% of PCT was > 2.0 ng/mL. Patients with delayed responses to doxycycline treatment (> 3 days from treatment to defervescence) had significantly higher CRP values (102.7 ± 77.1 vs. 72.2 ± 58.2 mg/L, p = 0.041) and more PCT > 1.0 ng/ml (48.4% vs. 26.0%, p = 0.019) in the acute phase; higher CRP values (19.1 ± 37.4 vs. 3.6 ± 13.1 mg/L, p = 0.049) and more PCT > 0.5 ng/ml (19.2% vs. 1.4%, p = 0.005) in the convalescent phase. Correlation analysis was conducted for patients with acute Q fever. CRP and PCT values were positively correlated to each other, and both markers also had a positive correlation with serum aspartate transaminase values. Both CRP and PCT values and white blood cell counts were positively correlated to the days needed from doxycycline treatment to defervescence. Conclusion CRP and PCT values might be useful in clinical investigations for patients with suspected rickettsioses and in predicting the response to doxycycline treatment for rickettsioses.
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Affiliation(s)
- I-Fan Lin
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital, I-Shou University, No.1, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung City, 824, Taiwan
| | - Jiun-Nong Lin
- School of Medicine, College of Medicine, I-Shou University, No.1, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung City, 824, Taiwan.,Department of Critical Care Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chia-Ta Tsai
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital, I-Shou University, No.1, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung City, 824, Taiwan.,Department of Infection Control, E-Da Hospital, I-Shou University, Kaohsiung City, 824, Taiwan
| | - Yu-Ying Wu
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung City, 824, Taiwan
| | - Yen-Hsu Chen
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsung, Taiwan.,School of Medicine, Graduate Institute of Medicine, Sepsis Research Center, Center of Dengue Fever Control and Research, Kaohsiung Medical University, Kaohsung, Taiwan.,Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Chung-Hsu Lai
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital, I-Shou University, No.1, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung City, 824, Taiwan. .,School of Medicine, College of Medicine, I-Shou University, No.1, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung City, 824, Taiwan.
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