Tache Noire in a Patient with Acute Q Fever.

OBJECTIVE: To describe a rare case of acute Q fever with tache noire. CLINICAL PRESENTATION AND INTERVENTION: A 51-year-old man experienced acute Q fever showing tache noire, generally considered a pathognomonic sign of Mediterranean spotted fever (MSF) and MSF-like illness, but not a clinical feature of Q fever. The patient was treated with doxycycline 100 mg every 12 h. CONCLUSION: In the Mediterranean area, tache noire should be considered pathognomonic of MSF but it should not rule out Q fever. Clinical diagnosis should be supported by accurate laboratory diagnostic tests to guide proper management.

Mediterranean spotted fever-like illness in Sardinia, Italy: a clinical and microbiological study.

INTRODUCTION: Rickettsioses represent a group of emerging infectious diseases in Europe. Climate changes and the anthropization of rural environment have favored vectors' biological cycle and geographic spread. In Sardinia, Mediterranean spotted fever (MSF) is endemic and represents an important public health problem. PURPOSE: We investigated the etiology and the clinical presentation of MSF-like illness in northern Sardinia by enrolling patients admitted to the Infectious Disease Unit of the University of Sassari. RESULTS: Diagnostic tests included ELISA, Indirect immunofluorescence (IFI), DNA isolation from blood and from eschar samples with real-time PCR and genotyping. Eighty-seven patients with a mean age of 53 ± 14 years, of whom 65 (75 %) males, were included in the study. The most common diagnosis was MSF (79 %), followed by Q fever (8 %), and anaplasmosis (2 %). A tache noire was found in 58 % of rickettioses and 28 % of Coxiella burnetii infections. MSF was confirmed in 47 % of the cases by IFI and 43 % by ELISA antibody tests. The isolation of rickettsial DNA from the eschar was positive in 10/13 (77 %) of the cases due to Rickettsia conorii. Using this method, we identified the first case of R. monacensis infection in Italy. CONCLUSIONS: In conclusion, antibody-based tests confirmed the diagnosis in less than 50 % of the cases, whereas DNA isolation confirmed the diagnosis in 77 % of tested cases and allowed the identification of a new pathogenic species in Italy. Therefore, DNA isolation should be implemented to better identify the etiology of MSF-like illnesses and help the clinician in the management of patients.

Síndrome de distrés respiratorio agudo secundario a fiebre botonosa mediterránea maligna / Acute respiratory distress syndrome secondary to malignant Mediterranean botonous fever

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Mediterranean spotted fever in Algeria--new trends.

INTRODUCTION: Mediterranean spotted fever (MSF) due to Rickettsia conorii is the most important tick-borne disease occurring in North Africa. However, there are only a few fragmentary reports on the epidemiology and clinical aspects of rickettsioses in North Africa, and cases are still rarely documented. We report herein a prospective study conducted in Oran, the second largest city in Algeria. This disease has not been properly described in Oran or in other Algerian cities. METHODS: A total of 167 cases of Mediterranean spotted fever were documented for the first time by the use of reference methods including immunofluorescence serology and Western blot and absorption studies, including isolation in culture by the shell-vial techniques, and molecular tools. RESULTS: Although some aspects of MSF were found to be in accordance with the general epidemiology of the disease, uncommon aspects were found, including increased incidence and the presence of multiple inoculation eschars in 12% of patients. The role of climatic changes in alterations of host-seeking and feeding behaviors of the vectors, including the brown dog tick Rhipicephalus sanguineus, is discussed. Also, 49% of patients were hospitalized with a severe form. The global death rate was 3.6%, but it was 54.5% in patients hospitalized with major neurological manifestations and multiorgan involvement. CONCLUSIONS: The present report gives a unique panel of clinical aspects of MSF as well as new trends in this disease. Entomological, climatic, and molecular studies are needed to better understand both epidemiological and clinical aspects of MSF.

Host- and microbe-related risk factors for and pathophysiology of fatal Rickettsia conorii infection in Portuguese patients.

BACKGROUND: The pathophysiologic mechanisms that determine the severity of Mediterranean spotted fever (MSF) and the host-related and microbe-related risk factors for a fatal outcome are incompletely understood. METHODS: This prospective study used univariate and multivariate analyses to determine the risk factors for a fatal outcome for 140 patients with Rickettsia conorii infection admitted to 13 Portuguese hospitals during 1994-2006 with documented identification of the rickettsial strain causing their infection. RESULTS: A total of 71 patients (51%) were infected with the Malish strain of Rickettsia conorii, and 69 (49%) were infected with the Israeli spotted fever (ISF) strain. Patients were admitted to the intensive care unit (40 [29%]), hospitalized as routine inpatients (95[67%]), or managed as outpatients (5[4%]). Death occurred in 29 adults (21%). A fatal outcome was significantly more likely for patients infected with the ISF strain, and alcoholism was a risk factor. The pathophysiology of a fatal outcome involved significantly greater incidence of petechial rash, gastrointestinal symptoms, obtundation and/or confusion, dehydration, tachypnea, hepatomegaly, leukocytosis, coagulopathy, azotemia, hyperbilirubinemia, and elevated levels of hepatic enzymes and creatine kinase. Some, but not all, of these findings were observed more often in ISF strain-infected patients. CONCLUSIONS: Although fatalities and similar clinical manifestations occurred among both groups of patients, the ISF strain was more virulent than the Malish strain. Multivariate analysis revealed that acute renal failure and hyperbilirubinemia were most strongly associated with a fatal outcome.

Epidemiological features of Mediterranean spotted fever, murine typhus, and Q fever in Split-Dalmatia County (Croatia), 1982-2002.

We determined the epidemiological features of three zoonoses in hospitalized patients in southern Croatia. Patients were diagnosed by serological testing. Clinical and epidemiological data were also collected. Between 1982 and 2002, Mediterranean spotted fever (MSF) was diagnosed in 126 (incidence rate 1.27/100,000 per year), murine typhus (MT), in 57 (incidence rate 0.57/100,000 per year), and Q fever in 170 (incidence rate 1.7/100,000 per year) patients. MSF and Q fever were characterized by a marked seasonality. Incidences of Q fever and of MSF were higher for males than for females (P<0.0001 and P=0.0024, respectively). The most frequent of the three zoonoses in children was MSF. Q fever and MT cases were mostly seen in the 21-50 years age group. We found no statistically significant differences between season- and gender-specific incidence rates of MT. Whereas infections due to rickettsiae decreased, the incidence of Q fever increased over the last 12 years of the study.

[Abnormal liver function in Mediterranean spotted fever]. / Interessamento epatico in corso di febbre bottonosa del Mediterraneo.

In this study we retrospectively assessed the prevalence of impaired liver function in all 49 patients suffering from Mediterranean Spotted Fever (MSF) consecutively admitted to our department over the last four years. The main parameters of liver function and ultrasound of upper abdomen were performed at entry and at the end of treatment. At admission mean values of transaminases were above the normal limits and significantly higher when compared to mean serum levels at recovery. 55% and 51% of patients had serum values of GOT and GPT, respectively, above the normal limits versus 1% and 2% at the end of treatment. Mean serum values of alkaline phosphatase (AP) were within the normal limits at entry in hospital, but 22 of them had serum values above the normal limits. The same proportion was seen for gamma glutamiltranspeptidase values. Eighteen patients (36.7%) had both transaminases and AP above the normal limits. There were no significant differences among serum values of albumin, bilirubin and gamma globulin before and after therapy. Platelet count, on the contrary, was significantly reduced at admission (p < 0.0001). At ultrasound half of the patients showed hepatomegaly with a hepatitis-like pattern and 39% of patients had splenomegaly. In conclusion, this study confirms previous data from the literature showing a high frequency of liver impairment during the course of MSF, which is usually mild-moderate. In a few cases, however, the increase of transaminases could be serious and the recovery delayed, but never, in our experience, has there been progression toward chronic liver disease.

Severe case of Mediterranean spotted fever in Greece with predominantly neurological features.

Rickettsia conorii is endemic in Greece, though only a few cases of infection have been published to date. The case of a 58-year-old man from northern Greece with a severe form of Mediterranean spotted fever and rapid neurological deterioration is presented here. The patient received antibiotic treatment with doxycycline, showing immediate clinical and laboratory improvement. Diagnosis was confirmed later, during the second week after disease onset, by detection of elevated titres of IgM and IgG antibodies against R. conorii using an indirect immunofluorescence assay.

Rickettsial infections around the world, part 1: pathophysiology and the spotted fever group.

BACKGROUND: The rickettsial diseases are an important group of infectious agents that have dermatological manifestations. These diseases are important to consider in endemic areas, but in certain suspicious cases, possible acts of bioterrorism should warrant prompt notification of the appropriate authorities. OBJECTIVE: In this two part review article, we review these diverse diseases by examining established and up-to-date information about the pathophysiology, epidemiology, clinical manifestations, and treatment of the ricksettsiae. METHODS: Using PubMed to search for relevant articles, we browsed over 500 articles to compose a clinically based review article. RESULTS: Part one focuses on pathophysiology of the rickettsial diseases and the clinical aspects of the spotted fever group. CONCLUSIONS: At the completion of part one of this learning activity, participants should be able to discuss all of the clinical manifestations and treatments of the sported fever group. Participants should also be familiar with the pathophysiology of the rickettsial diseases.

Acute spotted fever rickettsiosis among febrile patients, Cameroon.

Although potential arthropod vectors are abundant in Cameroon, acute febrile illnesses are rarely evaluated for arboviral or rickettsial infections. Serum samples from 234 acutely febrile patients at clinics in Tiko and Buea, Cameroon, were examined for antibodies to Rickettsia africae and African alphaviruses and flaviviruses. These serum samples did not contain antibodies against typhoid, and blood malarial parasites were not detected. Serum samples of 32% contained immunoglobulin M antibodies reactive with R. africae by immunofluorescence assay and were reactive with outer membrane proteins A and B of R. africae by immunoblotting. These findings established a diagnosis of acute rickettsiosis, most likely African tick-bite fever. Hemagglutination inhibition testing of the serum samples also detected antibodies to Chikungunya virus (47%) and flaviviruses (47%). High prevalence of antibodies to arboviruses may represent a major, previously unrecognized public health problem in an area where endemic malaria and typhoid fever have been the principal diagnostic considerations.

Rickettsial disease: classical and modern aspects.

Rickettsial diseases have been reassessed in recent years since they represent an important field in today's medicine. New agents have been described: some are non-pathogenic agents and the others are associated with well-defined or peculiar clinical patterns. In addition, different species of rickettsiosis are found in relation to the geographic areas of the world. Some agents may be defined as variants of older diseases whereas most of the newly described forms of rickettsiosis represent distinct entities with unique epidemiologial and clinical features. Probably the main news regards the group of the spotted fevers. An additional new aspect is linked to the medicine of travellers and tourists. However, this aspect may not be significant for the rickettsial diseases in relation to other human illnesses, such as malaria. Therefore, an investigation into the geographical origin of patients has to enter our routine medical work.

Report of eight cases of fatal and severe Mediterranean spotted fever in Portugal.

Mediterranean spotted fever (MSF), endemically present, is associated with a low mortality and morbidity in Portugal. Etiological agents are Malish and Israeli tick typhus strains of Rickettsia conorii. In the last few years severe forms of MSF have emerged, with patients presenting atypical symptoms, major neurological manifestations, and multiorgan involvement, who have required intensive care facilities. Advanced age, underlying chronic disease, and delay of appropriate treatment are bad prognostic factors. In the acute phase of diagnosis, serological studies are delayed, inconclusive, and often unhelpful. A definitive diagnosis can only be made using isolation or molecular biology which can establish and clearly identify agents. Using evidence-based case reports, clinical and laboratory data were evaluated from patients with severe or fatal MSF observed in Garcia da Orta Hospital-Almada. Of the eight reference cases, four died, three in an acute fulminant stage. Of the survivors, four presented atypical involvement: ocular inoculation, massive gastric hemorrhage, acute respiratory disease (ARDS), and necrotizing vasculitis. Diagnosis by isolation of the agent was made in two cases, by immunohistochemistry in three, and by the indirect fluorescent antibody test (IFA) in three others. Israeli tick typhus and Malish R. conorii strains were isolated once each in fatal cases. In early stages, diagnosis continues to be clinical and patients should start appropriate therapy without delay if clinical suspicion of rickettsiosis arises to prevent poor outcome. Patients ranged in age from 39 to 71 years (mean 60), APACHE II ranged from 15 to 38 points and TISS 28 was between 24 and 46 points. In reported cases severity of disease was not obviously related to the usual comorbidities. Accelerated clinical course may not suggest classical MSF. Another relevant factor was prior prescription of an inappropriate antibiotic that contributed to misleading clinical features. The reported complications and atypical manifestations illustrate well the diversity of this disease.

Japanese spotted fever involving the central nervous system: two case reports and a literature review.

Japanese spotted fever (JSF), first reported in 1984, is a rickettsial disease caused by Rickettsia japonica. Until now, affliction of the central nervous system has been rarely reported. Here we report two cases of JSF associated with a central nervous system disorder such as meningoencephalitis.