Murine typhus (MT) is a flea-borne infection caused by Rickettsia typhi.1 It is typically a nonspecific febrile illness without complications. Fever, headache, rash, chills, malaise, myalgias, and anorexia are the most common presenting signs and symptoms. Elevated transaminase levels, hyponatremia, thrombocytopenia, and anemia are commonly associated laboratory abnormalities.2,3 A systematic review found 26.1% of patients had complications of organ failure or required hospitalization; however, intensive care unit admission and death were rare.3 Three thousand and forty-eight confirmed or probable cases of MT were reported in Texas from 1985 to 2015, with 11 fatalities.4 However, the specific causes of death were not detailed for these 11 fatal cases. If progress is to be made in preventing complications and death during the course of MT, a better understanding of the pathogenesis of severe illness for this infection is necessary. Herein, we report a case of a middle-aged male with MT who presented with septic shock, renal failure, and status epilepticus, who suffered a fatal course. An autopsy was obtained. The findings were compared with other published autopsy cases of MT and with other neurologic presentations of MT (NPMT).
Afzal Z, Kallumadanda S, Wang F, Hemmige V, Musher D, 2013. Acute febrile illness and complications due to murine typhus, Texas, USA. Emerg Infect Dis 23: 1268–1273.
Tsioutis C, Zafeiri M, Avramopoulos A, Prousali E, Miligkos M, Karageorgos SA, 2017. Clinical and laboratory characteristics, epidemiology, and outcomes of murine typhus: a systematic review. Acta Trop 166: 16–24.
Pieracci EG, Evert N, Drexler NA, Mayes B, Vilcins I, Huang P, Campbell J, Behravesh CB, Paddock CD, 2017. Fatal flea-borne typhus in Texas: a retrospective case series, 1985–2015. Am J Trop Med Hyg 96: 1088–1093.
Murray KO, Evert N, Mayes B, Fonken E, Erickson T, Garcia MN, Sidwa T, 2017. Typhus group rickettsiosis, Texas, USA, 2003–2013. Emerg Infect Dis 23: 645.
California Department of Health, 2018. Human Flea-Borne Typhus Cases in California. Available at: www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Flea-borneTyphusCaseCounts.pdf. Accessed January 24, 2018.
Walker DH, Parks FM, Betz TG, Taylor JP, Muehlberger JW, 1989. Histopathology and immunohistologic demonstration of the distribution of Rickettsia typhi in fatal murine typhus. Am J Clin Pathol 91: 720–724.
Angelakis E, Botelho E, Socolovschi C, Sobas CR, Piketty C, Parola P, Raoult D, 2010. Murine typhus as a cause of fever in travelers from Tunisia and Mediterranean areas. J Travel Med 17: 310–315.
Regan JJ 2015. Risk factors for fatal outcome from rocky mountain spotted fever in a highly endemic area—Arizona, 2002–2011. Clin Infect Dis 60: 1659–1666.
de Sousa R 2008. Host- and microbe-related risk factors for and pathophysiology of fatal Rickettsia conorii infection in Portuguese patients. J Infect Dis 198: 576–585.
Walker DH, Hawkins HK, Hudson P, 1983. Fulminant Rocky Mountain spotted fever. Its pathologic characteristics associated with glucose-6-phosphate dehydrogenase deficiency. Arch Pathol Lab Med 107: 121–125.
Kim IH, Lee HB, Hwang JH, Kwon KS, Lee CS, 2010. Scrub typhus in patients with liver cirrhosis: a preliminary study. Clin Microbiol Infect 16: 419–424.
Molina DK, DiMaio VJ, 2012. Normal organ weights in men: part II-the brain, lungs, liver, spleen, and kidneys. Am J Forensic Med Pathol 33: 368–372.
Kirkland KB, Marcom PK, Sexton DJ, Dumler JS, Walker DH, 1993. Rocky Mountain spotted fever complicated by gangrene: report of six cases and review. Clin Infect Dis 16: 629–634.
Carr SB, Bergamo DF, Emmanuel PJ, Ferreira JA, 2014. Murine typhus as a cause of cognitive impairment: case report and a review of the literature. Pediatr Neurol 50: 265–268.
Drevets DA, Leenen PJ, Greenfield RA, 2004. Invasion of the central nervous system by intracellular bacteria. Clin Microbiol Rev 17: 323–347.
Dittrich S 2015. Orientia, rickettsia, and leptospira pathogens as causes of CNS infections in Laos: a prospective study. Lancet Glob Health 3: e104–e112.
Tsioutis C, Chaliotis G, Kokkini S, Doukakis S, Tselentis Y, Psaroulaki A, Gikas A, 2014. Murine typhus in elderly patients: a prospective study of 49 patients. Scand J Infect Dis 46: 779–782.
Masalha R, Merkin-Zaborsky H, Matar M, Zirkin HJ, Wirguin I, Herishanu YO, 1998. Murine typhus presenting as subacute meningoencephalitis. J Neurol 245: 665–668.
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: 652–654.
Galanakis E, Gikas A, Bitsori M, Sbyrakis S, 2002. Rickettsia typhi infection presenting as subacute meningitis. J Child Neurol 17: 156–157.
Silpapojakul K, Chayakul P, Krisanapan S, Silpapojakul K, 1993. Murine typhus in Thailand: clinical features, diagnosis and treatment. Q J Med 86: 43–47.
Chaliotis G, Kritsotakis EI, Psaroulaki A, Tselenti Y, Gikas A, 2012. Murine typhus in central Greece: epidemiological, clinical, laboratory, and therapeutic-response features of 90 cases. Int J Infect Dis 16: e591–e596.
Lew HL, Lane B, Zeiner H, 2005. Neuroimaging and clinical manifestations of bilateral temporal encephalopathy secondary to murine typhus infection. Am J Phys Med Rehabil 84: 310–311.
Aouam A, Toumi A, Brahim HB, Loussaief C, Jelliti B, Romdhane FB, Yahia SB, Khairallah M, Chakroun M, 2015. Epidemiological, clinical and laboratory features of murine typhus in central Tunisia. Med Mal Infect 45: 124–127.
Hernández-Cabrera M, Angel-Moreno A, Santana E, Bolaños M, Francès A, Martín-Sánchez AM, Pérez-Arellano JL, 2004. Murine typhus with renal involvement in Canary Islands, Spain. Emerg Infect Dis 10: 740.
Vallejo‐Maroto I, García‐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: 826–827.
Walker DH, Dumler JS, 1997. Rickettsial infections. Connor DH, Chandler FW, Schwartz DA, Manz HJ, Lack EE, eds. Pathology of Infectious Diseases. Stamford, CT: Appleton & Lange, 789–800.
Dumler JS, Taylor JP, Walker DH, 1991. Clinical and laboratory features of murine typhus in south Texas, 1980 through 1987. JAMA 266: 1365–1370.
Mas Bernard A, 1960. Focal epilepsy, sole revealing clinical manifestation of murine rickettsiosis. Apropos of 2 cases developing in parallel. Presse Med 68: 1656.
Tsiachris D, Deutsch M, Vassilopoulos D, Zafiropoulou R, Archimandritis AJ, 2008. Sensorineural hearing loss complicating severe rickettsial diseases: report of two cases. J Infect 56: 74–76.
Lin SY, Wang YL, Lin HF, Chen TC, Chen YH, Lu PL, 2010. Reversible hearing impairment: delayed complication of murine typhus or adverse reaction to azithromycin? J Med Microbiol 59: 602–606.
Xu Z, Zhu X, Lu Q, Li X, Hu Y, 2015. Misdiagnosed murine typhus in a patient with multiple cerebral infarctions and hemorrhage: a case report. BMC Neurol 15: 121.
Bernabeu-Wittel M, Pachón J, Alarcón A, López-Cortés LF, Viciana P, Jiménez-Mejías ME, Villanueva JL, Torronteras R, Caballero-Granado FJ, 1999. Murine typhus as a common cause of fever of intermediate duration: a 17-year study in the south of Spain. Arch Intern Med 159: 872–876.
Vander T, Medvedovsky M, Valdman S, Herishanu Y, 2003. Facial paralysis and meningitis caused by Rickettsia typhi infection. Scand J Infect Dis 35: 887–888.
Whiteford SF, Taylor JP, Dumler JS, 2001. Clinical, laboratory, and epidemiologic features of murine typhus in 97 Texas children. Arch Pediatr Adolesc Med 155: 396–400.
Rosenblum MJ, Masland RL, Harrell GT, 1952. Residual effects of rickettsial disease on the central nervous system: results of neurologic examinations and electroencephalograms following Rocky Mountain spotted fever. AMA Arch Intern Med 90: 444–455.