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Abstract
Background: Murine typhus, caused by Rickettsia typhi, is a zoonotic infection transmitted to humans via fleas. It typically begins with nonspecific symptoms such as fever, headache, and nausea. Most cases resolve without complications after a 7–14-day incubation period. The primary reservoirs are rats, opossums, cats, and dogs. This case highlights an atypical presentation of murine typhus in an immunosuppressed patient in South Texas.
Case Presentation: 34-year-old female with ankylosing spondylitis treated recently with secukinumab presented to her Primary Care Physician (PCP) due to fevers. PCP ordered laboratory workup which was unrevealing. Four days later, the patient went to the Emergency Department (ED) because her symptoms progressed to weakness, nausea, vomiting, a headache and myalgias, predominantly on her thighs and back. The laboratory workup didn’t reveal leukocytosis or alarming findings from the ED physician perspective, and she was discharged. Six days after she started experiencing fever, the patient also developed neck stiffness, a maculopapular rash in her arms and legs, and small blisters in her right inguinal area. Subsequently, she went back to the ED again, where she received acetaminophen, doxycycline, ketorolac, acyclovir, and a 2L of Lactated Ringer’s (LR) solution bolus. The patient was admitted for further evaluation.
On admission, the patient’s vital signs were the following: Temperature - 101.3F, Pulse - 108 bpm, Blood Pressure - 143/101, and pulse oximetry - 98%. Physical exam revealed the following significant findings: Mild distress due to pain from headache, neck was tender to palpation with limited range of motion when turning head laterally, a maculopapular rash of the extremities noted on the distal arms and proximal thighs, pain was also elicited when shrugging shoulders, she had mild nystagmus that could be overcome on horizontal gaze bilaterally, normal finger-to-nose testing, negative Brudzinski sign, and positive Kernig sign. Additionally, laboratory workup showed elevated transaminase levels: ALT – 112, AST -84. Lastly, extensive history revealed that the patient had dogs and cats at home, and that she had been recently bitten by fleas. CSF findings were unrevealing.
Serology testing for Rickettsia typhi was ordered which came back negative. However, serology for Ricketsia Typhi may be non-diagnostic early in the course of the illness due to the need of a more than 14-day presentation for titers to develop when comparing an acute and convalescent phase of them. In our patient, given the local epidemiology, the clinical manifestation of a cold-like illness to a meningitis-like-syndrome without pleocytosis or other significant abnormalities, and the rapid response to doxycycline, the diagnosis of murine typhus for this patient is highly supported.
Conclusion: Overall, this case underscores the broad clinical spectrum of murine typhus, especially in immunosuppressed individuals, it emphasizes the potential for misdiagnosis (e.g meningitis, encephalitis), and it highlights the importance of considering this diagnosis in endemic areas. Furthermore, this case shows the need for a high index of suspicion and illustrates the diagnostic limitations of serology early in the disease course. These lessons can help clinicians achieve an early diagnosis and initiate appropriate antibiotic therapy, ultimately improving patient outcomes.
Presentation Type
Poster
Recommended Citation
Mora, Johanna; Stein, Kirhyn; Guanajuato, Hernan; Memon, Sobia; Garcia, Laura; and Campo Maldonado, Jose, "Atypical Clinical Presentation of Murine Typhus Infection in Relative Immunosuppressed Patient in South Texas" (2024). Research Colloquium. 12.
https://scholarworks.utrgv.edu/colloquium/2024/posters/12
Included in
Atypical Clinical Presentation of Murine Typhus Infection in Relative Immunosuppressed Patient in South Texas
Background: Murine typhus, caused by Rickettsia typhi, is a zoonotic infection transmitted to humans via fleas. It typically begins with nonspecific symptoms such as fever, headache, and nausea. Most cases resolve without complications after a 7–14-day incubation period. The primary reservoirs are rats, opossums, cats, and dogs. This case highlights an atypical presentation of murine typhus in an immunosuppressed patient in South Texas.
Case Presentation: 34-year-old female with ankylosing spondylitis treated recently with secukinumab presented to her Primary Care Physician (PCP) due to fevers. PCP ordered laboratory workup which was unrevealing. Four days later, the patient went to the Emergency Department (ED) because her symptoms progressed to weakness, nausea, vomiting, a headache and myalgias, predominantly on her thighs and back. The laboratory workup didn’t reveal leukocytosis or alarming findings from the ED physician perspective, and she was discharged. Six days after she started experiencing fever, the patient also developed neck stiffness, a maculopapular rash in her arms and legs, and small blisters in her right inguinal area. Subsequently, she went back to the ED again, where she received acetaminophen, doxycycline, ketorolac, acyclovir, and a 2L of Lactated Ringer’s (LR) solution bolus. The patient was admitted for further evaluation.
On admission, the patient’s vital signs were the following: Temperature - 101.3F, Pulse - 108 bpm, Blood Pressure - 143/101, and pulse oximetry - 98%. Physical exam revealed the following significant findings: Mild distress due to pain from headache, neck was tender to palpation with limited range of motion when turning head laterally, a maculopapular rash of the extremities noted on the distal arms and proximal thighs, pain was also elicited when shrugging shoulders, she had mild nystagmus that could be overcome on horizontal gaze bilaterally, normal finger-to-nose testing, negative Brudzinski sign, and positive Kernig sign. Additionally, laboratory workup showed elevated transaminase levels: ALT – 112, AST -84. Lastly, extensive history revealed that the patient had dogs and cats at home, and that she had been recently bitten by fleas. CSF findings were unrevealing.
Serology testing for Rickettsia typhi was ordered which came back negative. However, serology for Ricketsia Typhi may be non-diagnostic early in the course of the illness due to the need of a more than 14-day presentation for titers to develop when comparing an acute and convalescent phase of them. In our patient, given the local epidemiology, the clinical manifestation of a cold-like illness to a meningitis-like-syndrome without pleocytosis or other significant abnormalities, and the rapid response to doxycycline, the diagnosis of murine typhus for this patient is highly supported.
Conclusion: Overall, this case underscores the broad clinical spectrum of murine typhus, especially in immunosuppressed individuals, it emphasizes the potential for misdiagnosis (e.g meningitis, encephalitis), and it highlights the importance of considering this diagnosis in endemic areas. Furthermore, this case shows the need for a high index of suspicion and illustrates the diagnostic limitations of serology early in the disease course. These lessons can help clinicians achieve an early diagnosis and initiate appropriate antibiotic therapy, ultimately improving patient outcomes.