The Salamanca Province of Spain is an endemic zone for Mediterranean spotted fever. In this area, only one case of Q fever has been reported and typhus group rickettsial diseases have never been diagnosed. To obtain a panoramic view of the presence of antibodies to the most ubiquitous rickettsial agents, 400 sera specimens from a statistically representative sample of the human population of Salamanca City and its surrounding province were subjected to indirect microimmunofluorescent test for antibodies against Rickettsia conorii, Coxiella burnetti, phase II, and Rickettsia typhi antigens. Titers greater than or equal to 1:40 to R. conorii were found in 73.5% of the sera. Positivity was more common in subjects who reported closer contact with the natural environment and/or with domestic animals. Seropositivity to C. burnetti, phase II, was detected in 50.2% of sera. These positive cases were related to rural environmental factors and to previous contact with animals. The frequency of antibodies increased with age showing a progressive exposure to the rickettsial antigen. The prevalence of antibodies to R. conorii and C. burnetii in the human population of Salamanca Province is higher than that reported from any other geographic zone. The study of antibodies to R. typhi showed that 12.5% of the sera had titers greater than or equal to 1:40. According to our results, seropositivity to this rickettsial antigen cannot be related to any particular group of population nor interpreted totally as cross reactivity with R. conorii. Our data show a wide distribution of R. conorii and C. burnetii antigens in Salamanca Province, and also indicate the presence of R. typhi antigens in this area.

The authors studied the incidence, type and systemic relationship of the retinal findings observed by ophthalmoscopy in Mediterranean spotted fever (MSF) in a consecutive series of 34 cases. It is found that retinal vasculitits either arterial and/or, more frequently, venous is present in 55.9% of the cases. Branch vein retinal thrombosis appeared as complication of such small vessel vasculitis in 1 case. Although frequent, the retinal findings were asymptomatic in all cases but the retinal vein thrombosis one, and were not significatively related to or were predicted by other systemic parameters of severity of the disease. Because of its frequency, retinal vasculitis might be considered as an important clinical sign of MSF in endemic areas.

A 77-year-old woman from rural Spain had a febrile summertime disease develop with rash, eschar, and pulmonary, abdominal, and neurologic signs and symptoms. Mediterranean spotted fever (MSF) was diagnosed late in the course, and antirickettsial treatment was given only during the last 30 hours of life. Clinical manifestations of severe disseminated vascular injury included thrombocytopenia, hypoalbuminemia, edema of the lungs and legs, and severe prerenal azotemia. The diagnosis was documented by specific serology. Necropsy revealed vascular injury with perivascular lymphohistiocytic infiltrates suggestive of rickettsiosis in the central nervous system, lung, heart, kidneys, esophagus, stomach, colon, pancreas, spleen, and thyroid. Gastric hemorrhage and acute pneumonia contributed to the patient's death on day 18 of illness. Antimicrobial treatment and host defenses apparently reduced rickettsiae to an undetectable quantity. MSF has increased in incidence in the Mediterranean basin and has been reported in travelers returning to the United States.

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