Tsutsugamushi-Fieber nach Südostasienreise

Rickettsiosis in Southeast Asia: Summary for International Travellers during the COVID-19 Pandemic

Rickettsiosis is an important cause of febrile illness among travellers visiting Southeast Asia (SEA). The true incidence of rickettsiosis is underestimated; however, murine typhus and scrub typhus are widely distributed across SEA. Among travellers visiting SEA, scrub typhus was mostly reported from Thailand, whereas murine typhus was frequently found in Indonesia. Although most cases are self-limited or present with mild symptoms, a few cases with severe clinical manifestations have been reported. Doxycycline remains the key treatment of rickettsiosis. Some travellers, such as backpackers, trekkers, or cave explorers, are at a higher risk for rickettsiosis than others. Therefore, in resource-limited conditions, empirical treatment should be considered in these travellers. The coronavirus disease 2019 (COVID-19) pandemic has contributed to difficulty in the diagnosis of rickettsiosis because of the clinical similarities between these diseases. In addition, physical distancing mandated by COVID-19 management guidelines limits accurate physical examination, resulting in misdiagnosis and delayed treatment of rickettsiosis. This review summarises the characteristics of murine typhus and scrub typhus, describes travel-associated rickettsiosis, and discusses the impact of the COVID-19 pandemic on rickettsiosis.

Rickettsiosis with Pleural Effusion: A Systematic Review with a Focus on Rickettsiosis in Italy

Background: Motivated by a case finding of Mediterranean spotted fever (MSF) associated with atypical pneumonia and pleural effusion in which Rickettsia conorii subsp. israelensis was identified by molecular methods in the pleural fluid, we wanted to summarize the clinical presentations of rickettsiosis in Italy by systematic research and to make a systematic review of all the global cases of rickettsiosis associated with pleural effusion. Methods: For the literature search, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. We chose to select only the studies published in last 25 years and confirmed both with serological and molecular assays. Results: Human cases of rickettsiosis in Italy were reported in 48 papers describing 2831 patients with very different clinical presentations; the majority was MSF accounted to R. conorii and was reported in Sicily. Pleural effusion associated with infection with microorganisms belonging to Rickettsiales was described in 487 patients. It was rarely associated with microorganisms different from O. tsutsugamushi; also rarely, cases of scrub typhus were reported outside Southeast Asia and in the largest majority, the diagnosis was achieved with serology. Conclusions: MSF, especially when caused by R. conorii subsp. israelensis, 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

Imported scrub typhus in Europe: Report of three cases and a literature review

BACKGROUND

Scrub typhus is a vector-borne rickettsial infection, which can cause relevant morbidity and mortality. While the number of cases is around a million per year globally, the infection is seldom diagnosed in travellers from Europe.

METHODS

We herein report three cases diagnosed in Italian travellers and review the literature about imported cases in Europe in the last 60 years.

RESULTS

Three participants to the same hiking trip to the forest of northern Laos presented fever and other symptoms, including eschars (2 individuals) and skin rash (2 individuals). Overall, they didn't report complications, and recovered soon after doxycycline treatment. Diagnosis was retrospectively confirmed with PCR in one of them. The review collected data from 40 patients. Almost all of them (95%) presented fever, more than a half had headache, skin rash, eschars, arthromyalgias. 73% of them were hospitalized, and 16.2% needed intensive care. Diagnosis was confirmed by serology in almost all cases (94.6%). Most patients (88%) were treated with doxycycline. All patients survived, although one case resulted in incomplete tetraparesis.

CONCLUSIONS

Scrub typhus should be considered in all travellers coming back from endemic areas and presenting with acute febrile illness. Laboratory diagnosis can be challenging, as specific tests are not widely available. In case of clinical suspicion, a prompt treatment with oral doxycycline could avoid severe complications.

Imported scrub typhus: first case in South America and review of the literature

BACKGROUND

Scrub typhus is a neglected vector-borne zoonosis causing life-threatening illnesses, endemic in the Asian-Pacific region and, as recently discovered, in southern Chile. Scrub typhus is rarely reported in travelers, most probably due to the lack of clinical experience and diagnostic tests in non-endemic countries. We report the first case of imported scrub typhus in South America.

CASE PRESENTATION

A 62-year-old tourist from South Korea presented severely ill with fever, rash, and eschar in Santiago, Chile. Laboratory exams showed thrombocytopenia and elevated inflammation parameters, hepatic enzymes, and LDH. With the clinical suspicion of scrub typhus, empirical treatment with doxycycline was initiated and the patient recovered rapidly and without complications. The diagnosis was confirmed by IgM serology and by real-time PCR, which demonstrated infection with Orientia tsutsugamushi (Kawasaki clade).

CONCLUSIONS

Only due to the emerging clinical experience with endemic South American scrub typhus and the recent implementation of appropriate diagnostic techniques in Chile, were we able to firstly identify and adequately manage a severe case of imported scrub typhus in South America. Physicians attending febrile travelers need to be aware of this rickettsiosis, since it requires prompt treatment with doxycycline to avoid complications.

Rickettsioses and Q fever in travelers (2004-2013)

Rickettsioses (also called typhus) are associated with arthropods, including ticks, mites, fleas, and lice, although Q fever is more frequently acquired through the inhalation of contaminated aerosols or the consumption of milk. These zoonoses first emerged in the field of travel medicine 20 years ago. Here, we review rickettsioses and Q fever in travelers, highlighting cases reported in the past decade. African tick bite fever and Mediterranean spotted fever are the two most frequent spotted fevers. While the presentation of these fevers is typically benign, cardiac and neurological complications due to African tick bite fever have been reported, and Mediterranean spotted fever has been complicated by multi-organ failure and death in a few cases. Murine typhus and Q fever remain difficult to recognize and diagnose because these illnesses often present with only fever. New molecular tools, particularly when deployed with samples obtained from eschar swabs, might be easily implemented in laboratories with PCR facilities. Doxycycline must be introduced upon clinical suspicion of rickettsioses or Q fever and should be considered in cases of fever of unknown origin in travelers who are returning from at-risk geographic areas.

Scrub typhus imported to Scandinavia

We present the first 3 cases of confirmed scrub typhus imported to Scandinavia. The patients were infected in Thailand, Laos and Sri Lanka, respectively. Treatment with ciprofloxacin and doxycycline lead to rapid cure in 2 of the patients, while the third patient, who was not treated, had a prolonged convalescence. Specific antibodies against Orientia tsutsugamushi, the causative agent of scrub typhus, were detected in all 3 cases.