Mediterranean spotted fever with multiorgan involvement

Abstract

A previously well man in his 50s returned to the UK after a trip to the Mediterranean. The day after returning he developed malaise, fevers, rigors and severe headache. He was hospitalised with sepsis, multiorgan involvement, a maculopapular rash and an eschar on each hip. Serology was positive for Rickettsia spp (spotted fever group) with a rise in titre from 1:64 to 1:1024 eight days later. Blood and tissue PCR were also positive for Rickettsia spp. He had cardiac, pulmonary, renal, ocular and neurological involvement. He completed a 14-day course of doxycycline and recovered well. This is a case of likely Mediterranean spotted fever (MSF) caused by Rickettsia conorii, which is endemic to the Mediterranean basin. We highlight the need for awareness and early treatment to prevent severe complications. This case is also the first to describe Purtscher-like retinopathy in the context of likely MSF.

Keywords: Travel medicine; Tropical medicine (infectious disease).

Figure 1

Examples of the rash and eschars on each hip.

Figure 2

Admission chest X-ray (CXR) showing minor bronchial wall thickening in the left lower lobe which could be due to infection or inflammation. CXR 3 days later showing bilateral moderate size pleural effusions and upper lobe diversion.

Figure 3

Diagnostic criteria for Mediterranean spotted fever (MSF). Reprinted from Clinical Microbiology and Infection, vol 10 edition 12, Brouqui P, Bacellar F, Baranton G, Birtles R, Bjoërsdorff a, Blanco J, et al, Guidelines for the diagnosis of tick-borne bacterial diseases in Europe, Pages 1108–32, Copyright 2004, with permission from Elsevier.

Figure 4

Retinal pictures (retinal zones reprinted from Br J Ophthalmol, Vol 91 edition 11, Agrawal A and McKibbin M, Purtscher’s retinopathy: epidemiology, clinical features and outcome, Pages 1145–6, Copyright 2007, with permission from BMJ.).

Figure 5

Optical coherence tomography.

Figure 6

Human rickettsial diseases.