Cases reported "Boutonneuse Fever"

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1/18. Isolation of a rickettsia related to Astrakhan fever rickettsia from a patient in chad.

    We isolated a novel spotted fever group rickettsia from a patient coming back from chad with fever and a maculopapulous rash. In africa, only six pathogenic spotted fever group rickettsiae have been identified, R. conorii, R. africae, R. akari, R. aeschlimannii, "R. mongolotimonae," and R. felis. Our isolate was identified by PCR amplification and sequencing of the 16S rRNA (16S rDNA), citrate synthase (gltA), and rOmpA (ompA) encoding genes. The 16S rDNA, gltA, and ompA sequences of the isolate were found to be 99.7, 99.6, and 99.5% identical with that of Astrakhan fever rickettsia, respectively. This rickettsia is endemic in the Caspian sea area and has also recently been identified in kosovo. Using mouse serotyping, the currently accepted method for the identification of spotted fever group rickettsiae, the chad isolate exhibited a specificity difference of 2 when compared to Astrakhan fever rickettsia and at least 4 when compared with other members of the R. conorii complex. The chad isolate should be considered a variant of Astrakhan fever rickettsia. This is the first description of Astrakhan fever rickettsia outside europe and the bacterium may be responsible for cases of spotted fever in chad. Although Astrakhan fever rickettsia is transmitted by rhipicephalus ticks in europe, further studies are indicated to identify its vector in africa where these ticks are also prevalent.
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2/18. 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.
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3/18. boutonneuse fever in a child: a case report and overview.

    A five and half year-old boy presented with an acute febrile illness associated with abdominal pain, generalised myalgia, arthralgia and skin rash. An elder sibling had a similar illness and had expired three days back. Initially crystalline penicillin and chloramphenicol were started. Investigations to diagnose the cause of fever viz, peripheral blood smear for malarial parasite, blood and urine cultures, Widal test and dot-ELISA for leptospirosis were negative. Weil-Felix test revealed a positive OX-2 titre of 1:100. Retrospectively, a history of close contact with dogs was elicited and a tick bite mark on the hand detected. Within five days of antibiotic therapy the fever resolved. chloramphenicol was given totally for two weeks and the child recovered fully. Rickettsial infection should be considered in a child presenting with an acute febrile illness with skin rash since the response to specific antimicrobial therapy is dramatic and life saving.
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4/18. Laboratory-confirmed Mediterranean spotted fever in a Japanese traveler to kenya.

    A Japanese traveler returning from kenya became ill, presenting with fever and a prominent, generalized rash without an eschar. Results of the immunofluorescence antibody assay of the patient's sera performed in japan were compatible with illness due to a spotted fever group (SFG) rickettsia, and a presumptive diagnosis of African SFG rickettsiosis, probably either Mediterranean spotted fever (MSF) or African tick-bite fever (ATBF), was rendered. To further define the disease diagnosis, sera were examined in france by Western immunoblotting combined with cross-adsorption, which confirmed the diagnosis of MSF but not of ATBF. Because of the need to further characterize the epidemiologic and clinical features of the two African SFG rickettsioses, clinicians are encouraged to contact a specialized laboratory when encountering such cases.
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5/18. Rickettsia: an unusual cause of sepsis in the emergency department.

    Mediterranean spotted fever (caused by rickettsia conorii) is one of the tick-borne rickettsioses. It is prevalent in southern europe, africa and central asia and may also be seen in travellers returning from these areas. It presents with various non-specific symptoms, including fever, maculopapular rash, headache, myalgia or diarrhoea and vomiting. A visible eschar at the site of the tick bite is characteristic but not present in all cases. There is no test that reliably confirms the disease in its early stages and diagnosis is often made on clinical grounds. Delay in diagnosis and in providing correct antibiotic treatment increases the mortality rate of this condition. Emergency clinicians should be aware of the possible diagnosis in travellers returning from endemic areas in order to start the correct treatment as early as possible and minimise subsequent complications and mortality.
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6/18. Mechanism of upper gastrointestinal hemorrhage in Mediterranean spotted fever.

    Gastrointestinal (GI) hemorrhage is not a common complication of Mediterranean spotted fever (MSF). We describe three MSF cases with upper digestive tract bleeding in patients from Salamanca (spain) and the results of the histologic studies performed in two of them. Besides the classical clinical triad of the disease (fever, rash and lesion at the site of tick bite, 'tache noire'), these patients presented purpuric rash and hypoalbuminemia, previously identified in severe forms of the disease. The hemorrhagic complication occurred late in the course of the MSF (between 13 and 20 days after the onset of fever) and was the consequence of multiple acute superficial erosions of the gastric mucosa. The histologic substrate of these lesions was identified as a vasculitic process - characteristically lymphohistiocytic - affecting the small vessels of the gastric wall. Rickettsial vascular injury at this level of the digestive tract is histologically similar to that observed in other organs in patients with MSF and may manifest clinically as digestive tract bleeding.
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7/18. epidemiology of boutonneuse fever in western sicily: accidental laboratory infection with a rickettsial agent isolated from a tick.

    A case is reported of an accidental laboratory infection with a strain of Spotted Fever-Group Rickettsiae freshly isolated from a tick collected in Western sicily. Inoculation into the left thumb of cell-cultured organisms (10(5)/ml) gave rise to clinical signs and symptoms of boutonneuse fever after six days, i.e., a lesion at the point of inoculation, fever, headache, conjunctivitis and myalgias. Rickettsiae were isolated from acute-phase blood samples collected from the infected individual and IgM and IgG response was detected in the patient's serum by indirect immunofluorescence. Complete recovery was obtained after antibiotic treatment. Serologic analysis of the strain, together with analyses of the proteins of the isolate, documented that the isolate was rickettsia conorii and was identical to prototype strain. The relationship of this infection to ongoing studies on the epidemiology of boutonneuse fever in Western sicily is discussed.
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8/18. Mediterranean spotted fever in children returning from france.

    Although the incidence of Mediterranean spotted fever has increased dramatically in parts of europe, africa, and asia, the disease is only rarely seen in travelers. We describe two children who had traveled in southern france and subsequently had rash and lymphadenopathy develop. Both children were treated with doxycycline and had unequivocal serologic evidence of Mediterranean spotted fever develop. Although this disease is usually mild, in the absence of a tick bite the disease can easily be confused with other febrile exanthems. We describe these patients to reemphasize the influence that international travel has brought to pediatrics.
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9/18. Imported rickettsial disease: clinical and epidemiologic features.

    PURPOSE AND methods: The rickettsioses continue to constitute major health problems in many parts of the world. With increasing international travel, recognition of rickettsial diseases by physicians is becoming more important. The clinical features of four cases of rickettsial disease imported into canada over a five-year period are presented; two patients with tick typhus (rickettsia conorii), one patient with scrub typhus (R. tsutsugamushi), and one patient with murine typhus (R. typhi). We also present the North American data over the past 10 years from the Centers for Disease Control (CDC) (Atlanta). RESULTS: Since 1983 in the united states, three cases of imported scrub typhus, all after travel to india, were confirmed, as well as six cases of murine typhus after travel to southeast asia. At the CDC, 67 imported cases of tick typhus have been confirmed by indirect fluorescent antibody test since 1976; most illnesses occurred after travel to africa. CONCLUSION: Rickettsial diseases are underrecognized by physicians, who should consider these diagnoses in travelers returning from endemic areas. Since effective treatment is available, prompt diagnosis and treatment are important. In all cases, specific serologic confirmation should be obtained.
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10/18. Tick-bite fever in pregnancy. A case report.

    Despite the frequency of tick-bite fever in southern africa and its doubtless occurrence in pregnancy, this report documents the first case in a pregnant woman. Consequently, the natural history of tick-bite fever in pregnancy and concomitant placental involvement must be regarded as conjectural. Accordingly a register has been opened by the Department of obstetrics and Gynaecology, University of the Witwatersrand, for recording similar cases. At this stage of our knowledge, erythromycin 500 mg 6-hourly until 3-5 days after defervescence is the therapy of choice for such patients.
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