[A case from practice (358). Rickettsia coronii infection (Mediterranean spotted fever, boutonneuse fever)].
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Antibodies, Bacterial↗
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[Fever and exanthema after trip to the Mediterranean area--Mediterranean spotted fever (Boutonneuse fever)].
HISTORY AND CLINICAL FINDINGS: In connection with a period of residence in the Mediterranean basin (Portugal, Spain, Sicily) one woman and two men (age: 28, 31 and 40 years) got sick with fever in August and in the midst of October. In addition, they complained about headache in two cases and myalgias, arthralgia and vomiting in one case, respectively. Two of the vacationers (cases 2 and 3) had been accompanied by their dogs. One of them (case 2) was bitten of a tick. The woman (case 3) removed few days after vacation-beginning ticks from her dogs. Patients 1 and 2 appeared severely ill and presented with high fever and generalized maculopapular rash which included also the soles and palms. Patients 2 and 3 had a primarily-lesion ("eschar"). In patient 3 the eschar was pustular and associated with regional lymphadenitis. INVESTIGATIONS: All three patients showed an increased erythrocyte sedimentation rate and elevated liver enzymes. Cases 1 and 2 presented with a significantly elevated activity of lactate dehydrogenase, leukocyturia and microhematuria. Indirect immunofluorescent assay for specific antibodies directed against Rickettsia conorii revealed titers between 1:40 and 1:640 (normal: negative). DIAGNOSIS, TREATMENT AND COURSE: Diagnosis was based on the triad fever, rash and eschar as well as on epidemiological data which include a recent period of residence in the Mediterranean basin during the summer and contact with a dog. In case 1 diagnosis was difficult because of the absence of an eschar. This patient had been treated with penicillin for two days without success. Only the parenteral administration of ciprofloxacin caused complete defervescence and clinical improvement within two days. A complete defervescence within two days was reached with doxycycline also in case 2. In comparison to these cases, the course in the third patient was mild, and the patient defervesced spontaneously. CONCLUSION: Mediterranean spotted fever should be considered in the case of unclear fever and rash following a period of residence in the Mediterranean basin during summer time. An eschar may confirm this diagnosis, and early start of therapy may shorten the course of the disease and prevent complications.
Adult↗
[Occurrence of extracapillary glomerulonephritis during Mediterranean boutonneuse fever].
Boutonneuse spotted fever is a summer and late spring infection caused by Rickettsia Conorii mainly in Middle East countries adjacent to the mediterranean coast (1). Malignant forms have been described in debilitated patients associated with prerenal azotemia, acute tubular necrosis or renal vasculitis (2, 3). We report for the first time to our knowledge, the association of an extracapillary glomerulonephritis with a Boutonneuse spotted fever. This observation suggest that Rickettsia Conorii, as other bacteria, could participate to the development of glomerulonephritis.
Aged↗
[Medical terminology: high fever; guaco; boutonneuse fever].
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Boutonneuse Fever↗
[Seroimmunologic studies in boutonneuse fever. I. Evaluation of a commercial micro-immunofluorescence kit in the serodiagnosis of boutonneuse fever].
The diagnosis of Boutonneuse Fever usually depends on clinical evidence (summer occurrence, fever, tache noire at the site of the tick bite, in 30-70% of cases, erythemato -papular rash, prompt response to chloramphenicol or tetracycline treatment). Serological confirmation is difficult since the only diagnostic procedure currently feasible, the Weil-Felix test, is not specific. Other more specific diagnostic procedures (agglutination, complement fixation, ELISA, indirect immunofluorescence tests) are beyond the possibilities of most laboratories (antigens are not available from the market). In the present paper, results obtained with a new commercially produced kit for indirect immunofluorescence are reported. Sera from patients with infectious and non infectious diseases as well as Boutonneuse Fever (at various stages of illness, from 6 days to 12 months) were examined. Sera from blood donors were also included. Specificity and sensitivity were satisfactory as well as reproducibility of results. Some apparently false positivities must be related to the present epidemiological pattern in western Sicily, and namely to the incidence of asymptomatic cases of Boutonneuse Fever, as demonstrated by recent works.
Antibodies, Bacterial↗
[Liver involvement in Q fever and Mediterranean boutonneuse fever. Comparative study].
Rickettsia spp. infections produce hepatic damage with transaminases elevation and biological signs of cholostasis. Classical biochemical tests of hepatic function were analyzed and compared in 8 patients with Q Fever (QF) and 7 with Boutonneuse Mediterranean Fever (BMF). Liver enlargement was detected in 75% of the QF group of patients as compared with the 57% of the BMF group. Transaminases were raised in 75% of the patients of the QF group and in 85, 7% of the BMF patients. Only one patient in the QF group showed manifest clinical jaundice. Statistically significant differences were found between the values of AST, ALT, alkaline phosphatase and GGT, which were higher in the QF group. Liver involvement is more important in patients with QF than in FBM. There is a large percentage of clinically silent involvement in both diseases. Liver function tests should be carried out in infections by Rickettsia spp.
Adult↗
[A prospective study of 57 cases of Mediterranean boutonneuse fever].
Mediterranean boutonneuse fever (MBF) is an uncommon acute infective disease characterized by the development of an inoculation lesion followed by fever and maculo-papular erythematous rash. In the present study we have evaluated the epidemiological, clinical and laboratory abnormalities of 57 cases of MBF diagnosed in our Hospital during a 2-year period. Although incidence does not appear to increase, our series shows that MBF is a common disease in our area. On the whole, MBF is a benign condition; however, torpid forms are increasingly reported. Therefore, a rational therapeutic approach questioning the validity of single therapeutic doses is required, particularly for adults.
Adolescent↗
[5 cases of Mediterranean boutonneuse fever in Switzerland].
The Boutonneuse Fever also called Marseilles or Eruptive Mediterranean Fever is an common disease in mediterranean area, in Africa and Indien. Rickettsia conorii is the microorganism involved and Rhipicephalus sanguineus is the most common vector. In Switzerland, this dog's tick don't exist in the nature, but it may be introduced by a dog contaminated elsewhere outside of the country and remain alive in our houses. It the reason why this disease is very uncommon in Switzerland. However, it may be observed in people coming back from vacation or in patients in contact with imported Rhipicephalus. In this paper, five cases of Boutonneuse Fever diagnosed between 1980 and 1985 are reported. The epidemiological relationships between four of these cases are of special interest. The clinical picture of the disease is presented with the different serological tests useful in confirming the diagnosis. Prevention and treatment are discussed.
Adult↗
[Hepatic involvement in boutonneuse fever (author's transl)].
Boutonneuse fever is a rickettsioses which is endemic in the Mediterranean countries. Since 1972 we have had the chance to study eight observations os this disease (6 in the last year) and our attention has been drawn by the constant hepatic involvement. This was biological in all cases and histopathologic in the five patients submitted to a liver biopsy. Functional liver tests showed an elevation of SGOT and SGPT in six patients, as well as of the alkaline phosphatase and/or gamma-GT in five. No signs of hepatocellular insufficiency were detected and posterior controls demonstrated a complete normalization of the analytical parameters. As regards the histopathologic findings the most important was the fibrous enlargement of the porta spaces with slight infiltration by round cells, hyperplasia of the Kupffer's cells, and accumulations of histiocytes and lymphocytes. In no patient did we observed epithelioid granulomas. The authors conclude that the hepatic involvement in boutonneuse fever is benign but very constant, which means that it ought to be known about and that it has no defined histopathologic patterns.
Alanine Transaminase↗
[FROM MEDITERRANEAN BOUTONNEUSE FEVER TO THE SPOTTED BOUTONNEUSE GROUP].
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Animals↗
[A severe form of Mediterranean boutonneuse fever].
A severe case of boutonneuse fever was reported which was only diagnosed after death. The infectious syndrome and cutaneous eruption were associated with meningitis, encephalitis, hypoxaemia and thrombocytopaenia. The absence of an initial lesion ("tache noire") and the notion of recent German measles contamination explained the late diagnosis. Serious cases of boutonneuse fever were usually rare; they were better known as Rocky Mountain spotted fever, a rickettsial infection of the same group, the clinical symptoms of which were very similar and which gave the same proteus agglutination reactions as with boutonneuse fever. An earlier diagnosis, now possible thanks to immunofluorescent techniques using skin biopsies, should enable earlier treatment.
Acute Disease↗
A recombinant Rickettsia conorii vaccine protects guinea pigs from experimental boutonneuse fever and Rocky Mountain spotted fever.
There are no vaccines against boutonneuse fever and Rocky Mountain spotted fever. Previous studies have identified a Rickettsia rickettsii surface protein as a vaccine candidate and shown that an antigenically related protein is present in R. conorii, which causes boutonneuse fever. The gene encoding the R. rickettsii protein has been cloned and expressed in Escherichia coli. We confirmed by 7.5% sodium dodecyl sulfate-polyacrylamide gel electrophoresis of rickettsial lysates followed by immunoblotting with a monoclonal antibody raised against the R. rickettsii protein that an analogous protein exists in R. conorii. Although these proteins were previously called 155-kilodalton (kDa) proteins, we found that their apparent molecular masses were 198 kDa for R. conorii Kenya tick typhus and 190 kDa for R. rickettsii R. Using the R. rickettsii gene probe, we cloned and expressed a 5.5-kilobase HindIII fragment from R. conorii Kenya tick typhus genomic DNA in E. coli JM107. The expressed recombinant product was recognized by a monospecific polyclonal rabbit antiserum prepared against the 198-kDa protein. Guinea pigs immunized with sonic lysates of the E. coli strain expressing the recombinant gene product developed antibodies recognizing R. conorii when tested by a microimmunofluorescence antibody assay. Upon immunoblotting of rickettsial lysates, those antisera specifically recognized the 198-kDa R. conorii protein and its 190-kDa analog in R. rickettsii. Guinea pigs immunized with sonic lysates of the recombinant E. coli expressing the 198-kDa protein were protected from experimental infections with the homologous R. conorii strain and partially protected from experimental infections with a strain of the heterologous species R. rickettsii. These findings show that the 198-kDa R. conorii protein is a candidate for a vaccine against boutonneuse fever.
Animals↗
[Boutonneuse fever in clinical practice].
Boutonneuse fever has become endemic in some parts of Sicily and the Italian mainland over the last five years. An account is given of the features assisting its clinical recognition and serological verification. The main nosographical aspects of the disease are described. The conditions required for certain, probable and presumed diagnosis are stated, stress being laid on the prime importance of timely clinical assessment, and the possibility of serological ascertainment when the disease is waning, or even later. Serum diagnosis via complement fixation or microagglutination will be positive in the second half of the second seven-day period of fever. It is specific with Rickettsia conorii antigens, though these have not been easy to find so far. The Weil-Felix reaction with Proteus OX19 and OX2 is significantly positive in advanced coalescence. While this is always a practical possibility, it is of indicative, and usually retrospective, value only.
Antibody Formation↗
Frequent occurrence of hepatic lesions in boutonneuse fever.
Seven consecutive Sicilian patients with boutonneuse fever but without clinical symptoms of hepatic disease underwent hepatic biopsy and had similar hepatic lesions. Foci of hepatocellular necrosis were infiltrated with predominantly mononuclear leukocytes. No intact Rickettsia conorii were identified in the tissues by immunofluorescence. The apparent high frequency of viscerotropism in boutonneuse fever conforms to the recent observations of severe illness in what had often been described previously as a benign rickettsiosis.
Adult↗
[Mixed cryoglobulinemia secondary to Mediterranean boutonneuse fever].
A clinical case of Mediterranean Boutonneuse Fever (MBF) with circulating cryoglobulins during the acute phase, with no clinical symptoms is described and considered an epiphenomenon of the infection. The possible relationship between the infection and the cryoglobulinemia are discussed. The patient is also added to the increasing list of patients reported of Boutonneuse Fever in the Mediterranean area during the observation period.
Aged↗
Familial cases of boutonneuse fever.
Pairs of cases of Boutonneuse Fever (BF) occurred in three families. The illness appeared almost simultaneously in both members of each family, but was generally more serious in one as judged by clinical and laboratory parameters. The possibility of a "bed rickettsiosis", that is reactivation of rickettsiae by the blood meal obtained from the first individual by the same tick which fed upon the second individual, could be excluded in two of the three pairs of cases. In only one of the case pairs were the individuals sharing the same bed. The differences in severity of symptoms may be related to the different immunological pattern observed in these patients. Previous rickettsial infection may have provided partial immune protection, as is repeatedly reported in the literature. In one couple, the more seriously ill patient had antibodies of the IgM class, suggesting that this was his first exposure to Rickettsia conorii. The less severely ill patient had antibodies of the IgG class only, presumably as the result of re-exposure after previous asymptomatic infection with spotted-fever-group rickettsia.
Adult↗
Differential up-regulation of circulating soluble selectins and endothelial adhesion molecules in Sicilian patients with Boutonneuse fever.
In 150 patients with Boutonneuse fever (BF), caused by Rickettsia conorii, we studied the plasma levels of soluble L-selectin (sL-selectin), vascular cell adhesion molecule-1 (sVCAM-1), intercellular adhesion molecule-1 (sICAM-1) and E-selectin (sE-selectin) in various phases of disease to clarify their role in disease evolution. Results indicate that during the acute phase of BF there is a significant increase in the serum levels of sL-selectin, sE-selectin, sVCAM-1 and sICAM-1. sL-selectin and sVCAM-1 returned to normal levels in the third week of disease, whereas sE-selectin and sICAM-1 persisted at significantly high levels even after the third week. The secretion of these soluble CAMs in BF is mainly the result of leucocyte expression and endothelial cell activation, but secretion also appears to mediate anti-inflammatory activities, moderating leucocyte adhesion and reducing in particular lymphocyte and monocyte infiltration. Only sL-selectin serum levels were found to correlate with the acute phase of infection characterized by fever.
Adult↗
[Complications of boutonneuse fever].
Complications are rare in boutonneuse fever. This is clear from the brief review offered of the relevant literature. Reference is made to the clinical records of a personal series collected in Sicily during the current endemo-epidemic expansion of the disease through some regions of Italy. Primary complications appear in the form of cutaneous vesicles, a pyramidally located psychosensorial syndrome, transient atrial fibrillation and myocardial ischaemia, anuria with hyperazotaemia and another severe renal impairment. Careful clinical investigation of cases with unusual symptoms is recommended, coupled with systematic pathogenetic examination along modern lines.
Boutonneuse Fever↗