Volume 92, Issue 3
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Patients with rickettsial infection may present with encephalitis or meningitis but neurologic involvement is rare in murine typhus. Here, we report two patients with meningitis who presented with cranial neuropathy, presumably caused by two distinct disease processes. Recognition of the disease manifestations is important because rickettsial infections are potentially associated with significant morbidity. Simple effective treatments are available.


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  1. Gillespie JJ, Williams K, Shukla M, Snyder EE, Nordberg EK, Ceraul SM, Dharmanolla C, Rainey D, Soneja J, Shallom JM, Vishnubhat ND, Wattam R, Purkayastha A, Czar M, Crasta O, Setubal JC, Azad AF, Sobral BS, , 2008. Rickettsia phylogenomics: unwinding the intricacies of obligate intracellular life. PLoS ONE 3: e2018.[Crossref] [Google Scholar]
  2. Civen R, Ngo V, , 2008. Murine typhus: an unrecognized suburban vectorborne disease. Clin Infect Dis 46: 913918.[Crossref] [Google Scholar]
  3. Ong AK, Tambyah PA, Ooi S, Kumarasinghe G, Chow C, , 2001. Endemic typhus in Singapore: a re-emerging infectious disease? Singapore Med J 42: 549552. [Google Scholar]
  4. Chen MI, Chua JK, Lee CC, Leo YS, Kumarasinghe G, , 2001. Epidemiological, clinical and laboratory characteristics of 19 serologically confirmed rickettsial disease in Singapore. Singapore Med J 42: 553558. [Google Scholar]
  5. Loh KC, Leo YS, Heng MK, Goh BC, , 1996. Murine typhus: a forgotten cause of febrile illness in Singapore. Singapore Med J 37: 3943. [Google Scholar]
  6. Dumler JS, Taylor JP, Walker DH, , 1991. Clinical and laboratory features of murine typhus in south Texas, 1980 through 1987. JAMA 266: 13651370.[Crossref] [Google Scholar]
  7. Carter CN, Ronald NC, Steele JH, Young E, Taylor JP, Russell LH, Jr Eugster AK, West JE, , 1997. Knowledge-based patient screening for rare and emerging infectious/parasitic diseases: a case study of brucellosis and murine typhus. Emerg Infect Dis 3: 7376.[Crossref] [Google Scholar]
  8. Austin SM, Smith SM, Co B, Coppel IG, Johnson JE, , 1987. Serologic evidence of acute murine typhus infection in a patient with culture-negative endocarditis. Am J Med Sci 293: 320323.[Crossref] [Google Scholar]
  9. Buchs AE, Zimlichman R, Sikuler E, Goldfarb B, , 1992. Murine typhus endocarditis. South Med J 85: 751753.[Crossref] [Google Scholar]
  10. Fergie J, Purcell K, , 2004. Spontaneous splenic rupture in a child with murine typhus. Pediatr Infect Dis J 23: 11711172. [Google Scholar]
  11. McKelvey SD, Braidly PC, Stansby GP, Weir WR, , 1991. Spontaneous splenic rupture associated with murine typhus. J Infect 22: 296297.[Crossref] [Google Scholar]
  12. Raoult D, Scheld WM, Whitley RJ, Marra CM, , 2004. Rickettsioses, Ehrlichiosis, and Q Fever. , eds. Infections of the Central Nervous System. Third edition. Philadelphia, PA: Lippincott Williams & Wilkins, 423439. [Google Scholar]
  13. Stuart B, Pullen R, , 1945. Endemic (murine) typhus fever: clinical observations of 180 cases. Ann Intern Med 23: 520536.[Crossref] [Google Scholar]
  14. Harrell GT, , 1953. Rickettsial involvement of the nervous system. Med Clin North Am 37: 395422.[Crossref] [Google Scholar]
  15. Bleck TP, , 1999. Central nervous system involvement in rickettsial diseases. Neurol Clin 17: 801812.[Crossref] [Google Scholar]
  16. Masalha R, Merkin-Zaborsky H, Matar M, Zirkin HJ, Wirguin I, Herishanu YO, , 1998. Murine typhus presenting as subacute meningoencephalitis. J Neurol 245: 665668.[Crossref] [Google Scholar]
  17. Vallejo-Maroto I, Garcia-Morillo S, Wittel MB, Stiefel P, Miranda M, Pamies E, Aparicio R, Carneado J, , 2002. Aseptic meningitis as a delayed neurologic complication of murine typhus. Clin Microbiol Infect 8: 826827.[Crossref] [Google Scholar]
  18. Manor E, Politi F, Marmor A, Cohn DF, , 1977. Papilledema in endemic typhus. Am J Ophthalmol 84: 559562.[Crossref] [Google Scholar]
  19. Vander T, Medvedovsky M, Valdman S, Herishanu Y, , 2003. Facial paralysis and meningitis caused by Rickettsia typhi infection. Scand J Infect Dis 35: 886887.[Crossref] [Google Scholar]
  20. Kato CY, Chung IH, Robinson LK, Austin AL, Dasch GA, Massung RF, , 2013. Assessment of real-time PCR assay for detection of Rickettsia spp. and Rickettsia rickettsii in banked clinical samples. J Clin Microbiol 51: 314317.[Crossref] [Google Scholar]
  21. Brodsky MC, Vaphiades M, , 1998. Magnetic resonance imaging in pseudotumor cerebri. Ophthalmology 105: 16861693.[Crossref] [Google Scholar]
  22. Larner AJ, , 2003. False localizing signs. J Neurol Neurosurg Psychiatry 74: 415418.[Crossref] [Google Scholar]
  23. Murthy JM, , 2005. Management of intracranial pressure in tuberculous meningitis. Neurocrit Care 2: 306312.[Crossref] [Google Scholar]
  24. Graybill JR, Sobel J, Saag M, van Der Horst C, Powderly W, Cloud G, Riser L, Hamill R, Dismukes W, , 2000. Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis. The NIAID Mycoses Study Group and AIDS Cooperative Treatment Groups. Clin Infect Dis 30: 4754.[Crossref] [Google Scholar]
  25. Lindvall P, Ahlm C, Ericsson M, Gothefors L, Naredi S, Koskinen LO, , 2004. Reducing intracranial pressure may increase survival among patients with bacterial meningitis. Clin Infect Dis 38: 384390.[Crossref] [Google Scholar]
  26. Wenzel RP, Hayden FG, Groschel DH, Salata RA, Young WS, Greenlee JE, Newman S, Miller PJ, Hechemy KE, Burgdorfer W, Peacock M, Rubinstein LJ, , 1986. Acute febrile cerebrovasculitis: a syndrome of unknown, perhaps rickettsial, cause. Ann Intern Med 104: 606615.[Crossref] [Google Scholar]
  27. Simon NG, Cremer PD, Graves SR, , 2011. Murine typhus returns to New South Wales: a case of isolated meningoencephalitis with raised intracranial pressure. Med J Aust 194: 652654. [Google Scholar]
  28. Hsu CH, Hsieh LP, , 2014. Murine typhus with presentation of unilateral abducens nerve palsy: a case report. Journal of Internal Medicine of Taiwan 25: 3640. [Google Scholar]
  29. Lee YH, Yun YJ, Jeong SH, , 2010. Isolated abducens nerve palsy in a patient with scrub typhus. J AAPOS 14: 460461.[Crossref] [Google Scholar]
  30. Rajadhyaksha A, Phatak S, Nolkha N, Pathan Y, Sonawale A, , 2013. Rickettsial fever presenting with isolated third nerve palsy. J Assoc Physicians India 61: 144145. [Google Scholar]
  31. Donegan EA, , 1946. Ocular findings in tropical typhus (Tsutsugamushi or Japanese river fever). Br J Ophthalmol 30: 1119.[Crossref] [Google Scholar]
  32. Doherty MJ, Jayadev S, Watson NF, Konchada RS, Hallam DK, , 2005. Clinical implications of splenium magnetic resonance imaging signal changes. Arch Neurol 62: 433437.[Crossref] [Google Scholar]
  33. Masot L, Sola G, Alcantara J, Friedemann S, Gutierrez S, , 2013. Lesions of the Corpus Callosum: MRI Findings and Differential Diagnosis. Available at: http://dx.doi.org/10.1594/ecr2013/C-0194. Accessed July 28, 2014. [Google Scholar]
  34. Mathew T, Badachi S, Sarma GR, Nadig R, , 2014. “Boomerang sign” in rickettsial encephalitis. Neurol India 62: 336338.[Crossref] [Google Scholar]
  35. Aliaga L, Sanchez-Blazquez P, Rodriguez-Granger J, Sampedro A, Orozco M, Pastor J, , 2009. Mediterranean spotted fever with encephalitis. J Med Microbiol 58: 521525.[Crossref] [Google Scholar]
  36. Allen AC, Spitz S, , 1945. A comparative study of the pathology of scrub typhus (Tsutsugamushi disease) and other rickettsial diseases. Am J Pathol 21: 603681. [Google Scholar]
  37. Silpapojakul K, Ukkachoke C, Krisanapan S, Silpapojakul K, , 1991. Rickettsial meningitis and encephalitis. Arch Intern Med 151: 17531757.[Crossref] [Google Scholar]
  38. Ozdemir D, Sencan I, Yildirim M, Guclu E, Yavuz T, Karabay O, , 2008. Andiscriminated aseptic meningitis case between Rickettsia and leptospiral meningitis. European Journal of General Medicine 5: 5153. [Google Scholar]
  39. Chacko F, Modi M, Lal V, Prabhakar S, Rana S, Arora S, , 2010. Diagnostic efficacy of adenosine deaminase levels in cerebrospinal fluid in patients with tubercular meningitis: a comparison with PCR for Mycobacterium tuberculosis . Ann Neurosci 17: 126130.[Crossref] [Google Scholar]
  40. Tuon FF, Higashino HR, Lopes MI, Litvoc MN, Atomiya AN, Antonangelo L, Leite OM, , 2010. Adenosine deaminase and tuberculous meningitis: a systematic review with meta-analysis. Scand J Infect Dis 42: 198207.[Crossref] [Google Scholar]
  41. Massung RF, Davis LE, Slater K, McKechnie DB, Puerzer M, , 2001. Epidemic typhus meningitis in the southwestern United States. Clin Infect Dis 32: 979982.[Crossref] [Google Scholar]
  42. Pai H, Sohn S, Seong Y, Kee S, Chang WH, Choe KW, , 1997. Central nervous system involvement in patients with scrub typhus. Clin Infect Dis 24: 436440.[Crossref] [Google Scholar]
  43. Centers for Disease Control and Prevention, 2013. Rickettsial (Spotted & Typhus Fevers) & Related Infections (Anaplasmosis & Ehrlichiosis). Available at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/rickettsial-spotted-and-typhus-fevers-and-related-infections-anaplasmosis-and-ehrlichiosis. Accessed July 2, 2014. [Google Scholar]
  44. World Health Organization, 2001. WHO Model Prescribing Information–Drugs Used in Bacterial Infections. Available at: http://apps.who.int/medicinedocs/pdf/s5406e/s5406e.pdf. Accessed July 3, 2014. [Google Scholar]

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  • Received : 04 Sep 2014
  • Accepted : 02 Dec 2014
  • Published online : 04 Mar 2015

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