A pilgrim's progress: severe Rickettsia conorii infection complicated by gangrene

Abstract

A 47-year-old Australian man of Vietnamese origin presented to hospital 3 days after returning from a 2-week pilgrimage to Nepal and India in January 2012 with a 10-day history of fever and myalgia. He had developed high-grade fever with chills and rigors associated with myalgia 7 days after arriving in Nepal. Two days later, he developed nausea and vomiting. He had been vaccinated for hepatitis B and cholera before travel. He was not taking prophylactic antibiotics. He travelled with a group of 10 others who remained well. He recalled receiving a few mosquito bites, and noted rodent infestation and stray dogs in some of the temples he visited. A doctor in the group treated him empirically with oseltamivir after his initial symptoms began. A rash developed 2 days before his admission and 9 days after the onset of symptoms.The main fi ndings of an examination on admission were a high fever (40°C), a macular erythematous rash over his trunk and extremities sparing his palms and soles, and facial fl ushing. There were no eschars.Laboratory investigations on admission showed a platelet count of 44 10 9 /L (reference interval [RI], 150-450 4 Raoult D, Weiller PJ, Chagnon A, et al. Mediterranean spotted fever: clinical, laboratory and epidemiological features of 199 cases. Am J Trop Med Hyg 1986; 35: 845-850. 5 Cascio A, Dones P, Romano A, Titone L. Clinical and laboratory fi ndings of boutonneuse fever in Sicilian children. Eur J Pediatr 1998; 157: 482-486. 6 Walker DH. Rickettsiae and rickettsial infections: the current state of knowledge. Clin Infect Dis 2007; 45 Suppl 1: S39-S44. 7 Lee N, Ip M, Wong B, et al. Risk factors associated with life-threatening rickettsial infections. Am J Trop Med Hyg 2008; 78: 973-978. 8 Cascio A, Colomba C, Di Rosa D, et al. Effi cacy and safety of clarithromycin as treatment for Mediterranean spotted fever in children: a randomized controlled trial. Clin Infect Dis 2001; 33: 409-411. 9 Breitschwerdt EB, Davidson MG, Hegarty BC, et al. Prednisolone at anti-infl ammatory or immunosuppressive dosages in conjunction with doxycycline does not potentiate the severity of Rickettsia rickettsii infection in dogs.

Rickettsioses and Q fever in travelers (2004–2013)

“…Indian tick typhus also differs from MSF, in that the rash is often purpuric, and an inoculation eschar at the bite site is seldom identified [1]. In 2013, Punj et al [55] reported a case of R. conorii infection with a rapidly evolving petechial rash and digital gangrene in a traveler returning from North India.…”

Laboratory diagnosis of human infections transmitted by ticks, fleas, mites and lice in Australia

“…(2) Mediterranean Spotted Fever, seen mainly in persons returning from the Indian sub-continent. This tick-transmitted infection is caused by Rickettsia conorii 24,25 . 3 Microbiology laboratory techniques used for the diagnosis of human infections transmitted by ticks, fleas, mites and lice…”