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

Abstract

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. Case reportA 58-year-old retired and previously healthy man presented himself at a peripheral hospital in northern Greece with a sudden onset of chest pain at rest and headache. Clinical, laboratory and imaging investigation, including electrocardiogram, troponin T test, stress test and echocardiogram, showed no pathological findings; the chest pain receded spontaneously and the patient was released after 2 days. One day later, at home, the patient developed high fever (39 uC) with persisting headache and diffuse myalgia. He received amoxycillin-clavulanic acid orally, and showed only a slight improvement of his symptoms. Additionally, a facial and upper limb maculopapular rash occurred 2 days later, which was considered to be an allergic side effect of the antibiotic therapy. The antibiotics were discontinued and the patient received antihistamines. He still complained of headache, myalgia and subfebrile temperatures. The next day (6 days after disease onset) the patient suddenly developed confusion, for which reason he was transferred to our department immediately. Clinical examination at admission revealed an axillary body temperature of 37?8 uC and a fading diffuse macupapular rash with no signs of lymphadenopathy. Neurological examination of the patient showed confusion, ataxia and dysarthria without neck stiffness or any focal neurological findings. Although a history of tick exposure was denied, a black necrotic scabbed lesion of 5 mm in diameter was found on the patient's left thumb. ). Blood-gas analysis revealed hypoxaemia (pO 2 60 mm Hg, pCO 2 35 mm Hg, pH 7?4). The cerebrospinal fluid showed a slight pleocytosis (12 cells mm 23 , 90 % polymorphonuclear) and an increased level of protein (53 mg dl 21 ). A CT (computed tomography) scan and ultrasound of the abdomen showed mild enlargement of liver and spleen without lymphadenopathy. Chest X-ray, CT scan and magnetic resonance imaging of the head, as well as an encephalogram, were normal.The patient remained haemodynamically stable, but deteriorated neurologically within the first 24 h after admission, in spite of additional intravenous therapy with dexamethasone and mannitol. Due to clinical findings (diffuse macupapular rash, fever, headache, myalgia, inoculation eschar) and laboratory findings (thrombocytopenia, elevated alanine and aspartate aminotransferase) a rickettsial infection was suggested, so antibiotic therapy with doxycycline (200 mg per day, orally) was started on the eighth...

A case series of spotted fever rickettsiosis with neurological manifestations in Sri Lanka

“…10 However, neurological manifestations of Mediterranean spotted fever are limited to case reports, and common neurological problems in these cases have been alterations of the level of consciousness, headache, and CSF abnormalities such as pleocytosis and increased protein levels suggestive of meningoencephalitis. [11][12][13] Some have reported ataxia and dysarthria. Similarly, a case of meningitis has been reported due to Japanese spotted fever.…”

“…Similar manifestations have been reported in the published cases of spotted fever with neurological manifestations. [11][12][13][14] This evidence suggests that involvement of the nervous system in spotted fever is not an isolated event and it may occur with the other clinical manifestations of rickettsiosis. Susceptibility to cerebral involvement in spotted fever was not clear in this study, however most of our patients were over the middle age.…”

Fatal Mediterranean spotted fever in Greece

“…MSF cases have been reported in Greece, and R. conorii has been isolated both from patients and ticks [5][6][7][8][9]. However, the disease is likely to be underestimated in this country and diagnosis is based mainly on clinical symptoms or only on serology.…”

Update on Tick-Borne Rickettsioses around the World: a Geographic Approach

“…In recent years, atypical and serious life-threatening presentations of MSF in Mediterranean countries were reported, with cardiac symptoms (ectasia of the coronary arteries, myocarditis, and atrial fibrillation) (231-233), ocular symptoms (uveitis, retinopathy, and retinal vasculitis) (177,(234)(235)(236), neurological symptoms (cerebral infarct, meningoencephalitis, sensorineural hearing loss, acute quadriplegia secondary to an axonal polyneuropathy, and motor and sensory polyneuritis) (228,(236)(237)(238)(239)(240)(241), pancreatic involvements (242,243), splenic rupture (244), acute renal failure (245), and the presence of hemophagocytic syndrome (246). In addition to the classical risk factors for malignant MSF (advanced age, immunocompromised situations, chronic alcoholism, glucose-6-phosphate dehydrogenase [G6PD] deficiency, prior prescription of an inappropriate antibiotic, and delay of treatment) (209), alcoholism was definitively confirmed as a risk factor (218), and fluoroquinolone treatment was shown to be associated with increased MSF disease severity and longer hospital stays (238).…”