• 1.

    Keysary A, Strenger C, 1997. Use of enzyme-linked immunosorbent assay techniques with cross-reacting human sera in diagnosis of murine typhus and spotted fever. J Clin Microbiol 35: 10341035.

    • Search Google Scholar
    • Export Citation
  • 2.

    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.

    • Search Google Scholar
    • Export Citation
  • 3.

    Leitner M, Yitzhaki S, Rzotkiewicz S, Keysary A, 2002. Polymerase chain reaction-based diagnosis of Mediterranean spotted fever in serum and tissue samples. Am J Trop Med Hyg 67: 166169.

    • Search Google Scholar
    • Export Citation
  • 4.

    Basnyat B, 2016. Typhoid versus typhus fever in post-earthquake Nepal. Lancet Glob Health 4: e516e517.

  • 5.

    Murdoch DR, Woods CW, Zimmerman MD, Dull PM, Belbase RH, Keenan AJ, Scott RM, Basnyat B, Archibald LK, Reller LB, 2004. The etiology of febrile illness in adults presenting to Patan hospital in Kathmandu, Nepal. Am J Trop Med Hyg 70: 670675.

    • Search Google Scholar
    • Export Citation
  • 6.

    Premaratna R, Nawasiwatte BM, Niriella MA, Chandrasena TG, Bandara NK, Rajapakse RP, de Silva HJ, 2010. Scrub typhus mimicking enteric fever; a report of three patients. Trans R Soc Trop Med Hyg 104: 309310.

    • Search Google Scholar
    • Export Citation
  • 7.

    Adejumo A, Olabige O, Sivapalan V, 2009. Fatal dual infection with Salmonella and Mycobacterium avium complex infection in a patient with advanced acquired immunodeficiency syndrome: a case report. Cases J 2: 6773.

    • Search Google Scholar
    • Export Citation
  • 8.

    Nogueras MM, Roson B, Lario S, Sanfeliu I, Pons I, Anton E, Casanovas A, Segura F, 2015. Coinfection with “Rickettsia sibirica subsp. mongolotimonae” and Rickettsia conorii in a human patient: a challenge for molecular diagnosis tools. J Clin Microbiol 53: 30573062.

    • Search Google Scholar
    • Export Citation
  • 9.

    Rolain JM, Gouriet F, Brouqui P, Larrey D, Janbon F, Vene S, Jarnestrom V, Raoult D, 2005. Concomitant or consecutive infection with Coxiella burnetii and tickborne diseases. Clin Infect Dis 40: 8288.

    • Search Google Scholar
    • Export Citation
  • 10.

    Sexton DJ 1998. Dual infection with Ehrlichia chaffeensis and a spotted fever group Rickettsia: a case report. Emerg Infect Dis 4: 311316.

    • Search Google Scholar
    • Export Citation
  • 11.

    Grynik A, Shaukat S, Htut EE, Karas JA, 2012. An unusual dual infection with Salmonella bredeney, including bacteraemia, and enterohaemorrhagic Escherichia coli O157 that posed a therapeutic dilemma. J Med Microbiol 61: 14801482.

    • Search Google Scholar
    • Export Citation
  • 12.

    Chowdhury G, Sarkar A, Pazhani GP, Mukhopadhyay AK, Bhattacharya MK, Ramamurthy T, 2013. An outbreak of foodborne gastroenteritis caused by dual pathogens, Salmonella enterica serovar Weltevreden and Vibrio fluvialis in Kolkata, India. Foodborne Pathog Dis 10: 904906.

    • Search Google Scholar
    • Export Citation
  • 13.

    Adhikary R, Joshi S, 2011. Dual Salmonella typhi infection. Indian J Pathol Microbiol 54: 849850.

  • 14.

    Sow A 2016. Concurrent malaria and arbovirus infections in Kedougou, southeastern Senegal. Malar J 15: 47.

  • 15.

    Parker TM, Murray CK, Richards AL, Samir A, Ismail T, Fadeel MA, Jiang J, Wasfy MO, Pimentel G, 2007. Concurrent infections in acute febrile illness patients in Egypt. Am J Trop Med Hyg 77: 390392.

    • Search Google Scholar
    • Export Citation
  • 16.

    Mahajan SK, Kaushik M, Raina R, Thakur P, 2014. Scrub typhus and malaria co-infection causing severe sepsis. Trop Doct 44: 4345.

  • 17.

    Epelboin L, Hanf M, Dussart P, Ouar-Epelboin S, Djossou F, Nacher M, Carme B, 2012. Is dengue and malaria co-infection more severe than single infections? A retrospective matched-pair study in French Guiana. Malar J 11: 142.

    • Search Google Scholar
    • Export Citation
  • 18.

    Blacksell SD, Sharma NP, Phumratanaprapin W, Jenjaroen K, Peacock SJ, White NJ, Pukrittayakamee S, Day NP, 2007. Serological and blood culture investigations of Nepalese fever patients. Trans R Soc Trop Med Hyg 101: 686690.

    • Search Google Scholar
    • Export Citation
  • 19.

    Sharma Y, Arya V, Jain S, Kumar M, Deka L, Mathur A, 2014. Dengue and typhoid co-infection—study from a government hospital in north Delhi. J Clin Diagn Res 8: DC09DC11.

    • Search Google Scholar
    • Export Citation
  • 20.

    Kamath SR, Ranjit S, 2006. Clinical features, complications and atypical manifestations of children with severe forms of dengue hemorrhagic fever in south India. Indian J Pediatr 73: 889895.

    • Search Google Scholar
    • Export Citation
  • 21.

    Seow CW, Logarajah V, Tan NWH, 2017. Typhoid and scrub typhus coinfection in a returned traveler. Glob Pediatr Health 4: 2333794X17726941.

  • 22.

    Mazumder RN, Pietroni MA, Mosabbir N, Salam MA, 2009. Typhus fever: an overlooked diagnosis. J Health Popul Nutr 27: 419421.

  • 23.

    Ormsbee R, Peacock M, Philip R, Casper E, Plorde J, Gabre-Kidan T, Wright L, 1978. Antigenic relationships between the typhus and spotted fever groups of rickettsiae. Am J Epidemiol 108: 5359.

    • Search Google Scholar
    • Export Citation
  • 24.

    Sompolinsky D, Boldur I, Goldwasser RA, Kahana H, Kazak R, Keysary A, Pik A, 1986. Serological cross-reactions between Rickettsia typhi, Proteus vulgaris OX19, and Legionella bozemanii in a series of febrile patients. Isr J Med Sci 22: 745752.

    • Search Google Scholar
    • Export Citation
  • 25.

    Breitschwerdt EB, Davidson MG, Aucoin DP, Levy MG, Szabados NS, Hegarty BC, Kuehne AL, James RL, 1991. Efficacy of chloramphenicol, enrofloxacin, and tetracycline for treatment of experimental Rocky Mountain spotted fever in dogs. Antimicrob Agents Chemother 35: 23752381.

    • Search Google Scholar
    • Export Citation

 

 

 

 

Case Report: Typhoid Fever and Spotted Fever Group Rickettsiosis Presenting Concomitantly in an Indian Immigrant

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  • 1 Infectious Diseases Unit, Sanz Medical Center, Laniado Hospital, Netanya, Israel;
  • 2 The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel;
  • 3 Intensive Care Unit, Sanz Medical Center, Laniado Hospital, Netanya, Israel;
  • 4 Department of Infectious Diseases, The Israel Institute for Biological Research, Ness-Ziona, Israel

We present a rare case of an Indian immigrant suffering from concomitant infection of Salmonella typhi and spotted fever group Rickettsia. We discuss the scarce reports of dual infections from the developing world and the related diagnostic challenges.

CASE PRESENTATION

A 26-year-old Indian female was admitted to our intensive care unit (ICU) because of fever, severe diarrhea, dehydration, and suspected disseminated intravascular coagulation. She was a previously healthy, certified nurse, who emigrated from India 7 days before her admission to work in Israel. Her past medical history included past infection with chikungunya virus. She originally lived in Kerala, but for 2 months before her emigration, she stayed in poor conditions in New Delhi. She recalled being bitten by “bed bugs” 2 weeks before arriving in Israel. One year earlier, she received a typhoid fever vaccine. She was human immunodeficiency virus negative.

Two days before her departure from India, she became ill with high fever, chills, severe diarrhea, recurrent vomiting, headache, abdominal pain, backache, and severe weakness. Cough was noted on the day before admission. She recalled similar symptoms a month earlier while in New Delhi, then she was treated with amoxicillin and metronidazole for 7 days with clinical improvement.

On her admission, she had a fever of 37.4°C, heart rate of 104 per minute, blood pressure of 97/64 mm of Hg, and oxygen saturation of 98% on room air. She looked ill, dehydrated, and stuporous. There was no dyspnea or confusion. Physical examination showed dry mucous membranes and a strawberry tongue. There were crepitations over both lung bases, heart sounds were normal, and there were no murmurs. Her abdomen was tender and distended with no organomegaly. There were no signs of rash, insect bites, eschar, or lymphadenopathy.

Laboratory results showed pancytopenia (white blood cell count of 2,600 cells/mL, hematocrit of 31.9%, and severe thrombocytopenia of 39,000 cells/mL), mild hyponatremia (131 mmol/L), hypokalemia (2.7 mmol/L), mildly elevated transaminases (aspartate transaminase 241 IU/L and alanine transaminase 89 IU/L), and lactic dehydrogenase of 1974 IU/L. Prothrombin time was only mildly increased (14.6 seconds), D-dimer levels were > 20 mcg/mL, and fibrinogen was 311 mg/dL. Schistocytes were not seen in the blood smear. The chest X-ray was normal.

Initial treatment with ceftriaxone, azithromycin, and metronidazole was commenced in the emergency room. She was admitted to the ICU with a clinical picture of septic shock and multi-organ failure and required inotropic support. The initial differential diagnosis included imported viral diseases (including dengue virus, chikungunya virus, Epstein–Barr virus [EBV], cytomegalovirus [CMV], and other viruses), typhoid fever, malaria, Clostridium difficile colitis, hemophagocytic lymphohistiocytosis, and rickettsial diseases.

After 1 day in the ICU, four of six blood cultures were reported as positive, and Gram-negative bacilli were consequently identified as Salmonella typhi, sensitive to ampicillin, ceftriaxone, and trimethoprim/sulfamethoxazole but resistant to azithromycin and to ciprofloxacin. Stool culture was also positive for S. typhi. Stool antigen for C. difficile was negative, as well as serology for EBV, hepatitis A virus, hepatitis C virus, and Coxiella burnetii. Real-time polymerase chain reaction (PCR) tests for dengue (whole blood) and for enterovirus (stool) were negative. Malaria antigen (CareStart Malaria [Pan], RAPYDTEST, manufactured by APACOR, Wokingham, United Kingdom) was negative and CMV serology showed evidence of past infection. Initial Rickettsia serology for Rickettsia typhi and Rickettsia conorii was suspected to be positive and the serum was sent for confirmation to the Israeli reference laboratory for Rickettsia at the Israel Institute for Biological Research (IIBR). At the IIBR, serologic diagnosis was performed using the immunofluorescence assay method, as previously described,1 and was found negative.

During the first 2 days, she improved clinically: the fever abated, she became more alert, and the abdominal pain and tenderness improved. The pancytopenia was also resolving and all antibiotic therapy apart from ampicillin was stopped. However, on her third day in the ICU, she developed acute respiratory distress syndrome and needed mechanical ventilation. Her temperature increased to 39.9°C. There were no signs of intestinal perforation on imaging. The antibiotic coverage was broadened again to include ertapenem, ampicillin, doxycycline, and metronidazole. A repeat malaria antigen test was negative. She also received nitric oxide, furosemide, and corticosteroids and gradually improved. After 5 days of mechanical ventilation, she was extubated and subsequently discharged from the ICU.

As stated, the first serology for Rickettsia spp. came back negative from the IIBR. Serum samples 11 days and 4 weeks later were borderline for R. typhi (typhus group [TG]) and for R. conorii (of the spotted fever group [SFG]) rickettsiosis. Because we still highly suspected a rickettsial disease, and the serology failed to show a conclusive 4-fold increase in the titers, all the samples were sent to the Centers of Disease Control (CDC) for PCR testing and for repeated serologic tests to include also Orientia tsutsugamushi and other Rickettsia. At the CDC, nested PCR was performed, as previously described2 and was found to be positive for SFG Rickettsia. This test was repeated at the IIBR, using the same methods, and the positive nested PCR sample was further analyzed using the restriction fragment length polymorphism test,3 receiving the same results. Sequencing to the exact species was unsuccessful. Still, coupled sera, 4 weeks apart failed to show seroconversion for R. typhi, Rickettsia prowazekii, R. conorii, and for O. tsutsugamushi in both laboratories.

Repeat stool cultures were negative for Salmonella spp. and she was allowed to continue her work as a nurse in Israel.

DISCUSSION

Salmonella enterica serovar Typhi and Rickettsia are endemic in India. The diseases these microorganisms cause are similar in their clinical presentations and may be practically indistinguishable if one is devoid of access to advanced laboratory tests. Both diseases commonly present as undifferentiated febrile illness. In many developing countries, the approach to fever without localizing features is to treat S. typhi (usually with parenteral ceftriaxone), without rickettsial coverage, occasionally resulting in detrimental outcomes. Consequently, physicians in Patan, Nepal, endorsed the ceftriaxone–doxycycline combination therapy after experiencing a post-earthquake outbreak of scrub typhus in 2015.4 In another cohort from Nepal, 97 patients with undifferentiated fever eventually diagnosed with R. typhi infection had no demographic, clinical, or laboratory features distinguishing them from the other diagnoses in the cohort.5 Scrub typhus may present with severe diarrhea resembling enteric fever.6

Our patient had a dual infection. Physicians typically try to ascribe all symptoms and signs to a single diagnosis, but dual infections occasionally occur. They are typically found among patients with acquired immunodeficiency syndrome,7 in cases in which the same vector transmits more than one pathogen,810 or in food-poisoning outbreaks associated with more than one pathogen.1113 Apart from these situations, mixed infections acquired through different modes of transmissions probably exist (mainly in developing countries) but are under-diagnosed and hence underreported. The diagnosis of concurrent infections is challenging for several reasons. First, naturally and instinctively most physicians suppose there to be a single diagnosis. Second, many infections may have a wide spectrum of clinical manifestations and severities and may be having overlapping signs and symptoms. Third, the confirmation of concurrent infections is dependent on well-equipped microbiology laboratories, which are rare in developing countries. This challenge could be even more difficult with imported diseases that may not be familiar to the local physicians.

There are reports of dual infections, most of them regarding patients with malaria,1417 leptospirosis,5,15,18 and dengue fever18,19 accompanied with other diseases. Concurrent typhoid fever and other infections were reported from Nepal,5,18 India,1921 Bangladesh,22 and Egypt.15 There are only two case reports of concomitant typhoid and typhus (one murine typhus22 and one scrub typhus21), but neither could demonstrate seroconversion, and the diagnosis of typhus relied on the response to doxycycline or on the presence of high immunoglobulin G titers. Other coinfections were reported anecdotally in studies reporting the etiologies of patients presenting with undifferentiated fever. In Kathmandu, Blacksell et al.18 found that of 23 patients presenting with S. typhi or S. Paratyphi A bacteremia, nine also had serologic evidence of scrub typhus, murine typhus, Leptospira, or dengue virus. In only one patient with dual infection (S. typhi/R. typhi), there was evidence of seroconversion. In another study from Nepal, dual infection with S. Paratyphi/R. typhi was reported in three patients.5 In this cohort, all cases of immunoglobulin M-positive murine or scrub typhus were diagnosed initially as enteric fever. In Egypt, Parker et al. studied 1,510 patients presenting with acute febrile illness and found 187 (12%) with concurrent infections, mostly Leptospira spp. with either TG Rickettsia, S. typhi, or Brucella. Only one case of concomitant S. typhi/R. typhi was reported in this cohort. In all the studies reported previously, the acuity of the rickettsial infection could not be confirmed in most cases, because it was based on the detection of IgM antibodies that can persist for months and years after an acute infection.

In our case, given the severe diarrhea on presentation, an enteric infection was promptly suspected and Salmonella bacteremia was not a surprising finding. The clinical and laboratory findings, as well as the response to antimicrobial treatment all fitted the diagnosis of typhoid fever. However, the thrombocytopenia was severe and this is rare in typhoid fever. This, along with the clinical deterioration raised the suspicion of another disease and prompted further diagnostic workup. The rapid clinical response to doxycycline, along with positive PCR for SFG Rickettsia proved the dual infection with Rickettsia.

Serologic cross-reactivity is well known between TG and SFG rickettisa,23 as well as with Proteus vulgaris and Legionella bozemanii24 but not with Salmonella spp. We could not differentiate the SFG Rickettsia species infecting this patient, neither by serology nor by molecular methods, but the clinical and therapeutic approach would have been the same for all rickettsial diseases. The abrogated serological reaction, not reaching a 4-fold increase, could be explained by the corticosteroids administration and by the early administration of adequate antibiotic treatment, as was rarely described in an experimental model of Rickettsia rickettsii infection.25 We believe that the patient acquired both diseases while staying in poor conditions in New Delhi, the typhoid being acquired a month previous to presentation with a relapse after an inadequate antibiotic course, and the rickettsial disease acquired just previous to emigration.

To conclude, confirmed dual infection with S. typhi and rickettsial disease is very rarely diagnosed and reported. We were able to delineate between these two concurrent infections because of the clinical deterioration and severe thrombocytopenia. The concept of dual infection must be considered in post-travel patients and in immigrants from developing countries presenting with undifferentiated fever.

REFERENCES

  • 1.

    Keysary A, Strenger C, 1997. Use of enzyme-linked immunosorbent assay techniques with cross-reacting human sera in diagnosis of murine typhus and spotted fever. J Clin Microbiol 35: 10341035.

    • Search Google Scholar
    • Export Citation
  • 2.

    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.

    • Search Google Scholar
    • Export Citation
  • 3.

    Leitner M, Yitzhaki S, Rzotkiewicz S, Keysary A, 2002. Polymerase chain reaction-based diagnosis of Mediterranean spotted fever in serum and tissue samples. Am J Trop Med Hyg 67: 166169.

    • Search Google Scholar
    • Export Citation
  • 4.

    Basnyat B, 2016. Typhoid versus typhus fever in post-earthquake Nepal. Lancet Glob Health 4: e516e517.

  • 5.

    Murdoch DR, Woods CW, Zimmerman MD, Dull PM, Belbase RH, Keenan AJ, Scott RM, Basnyat B, Archibald LK, Reller LB, 2004. The etiology of febrile illness in adults presenting to Patan hospital in Kathmandu, Nepal. Am J Trop Med Hyg 70: 670675.

    • Search Google Scholar
    • Export Citation
  • 6.

    Premaratna R, Nawasiwatte BM, Niriella MA, Chandrasena TG, Bandara NK, Rajapakse RP, de Silva HJ, 2010. Scrub typhus mimicking enteric fever; a report of three patients. Trans R Soc Trop Med Hyg 104: 309310.

    • Search Google Scholar
    • Export Citation
  • 7.

    Adejumo A, Olabige O, Sivapalan V, 2009. Fatal dual infection with Salmonella and Mycobacterium avium complex infection in a patient with advanced acquired immunodeficiency syndrome: a case report. Cases J 2: 6773.

    • Search Google Scholar
    • Export Citation
  • 8.

    Nogueras MM, Roson B, Lario S, Sanfeliu I, Pons I, Anton E, Casanovas A, Segura F, 2015. Coinfection with “Rickettsia sibirica subsp. mongolotimonae” and Rickettsia conorii in a human patient: a challenge for molecular diagnosis tools. J Clin Microbiol 53: 30573062.

    • Search Google Scholar
    • Export Citation
  • 9.

    Rolain JM, Gouriet F, Brouqui P, Larrey D, Janbon F, Vene S, Jarnestrom V, Raoult D, 2005. Concomitant or consecutive infection with Coxiella burnetii and tickborne diseases. Clin Infect Dis 40: 8288.

    • Search Google Scholar
    • Export Citation
  • 10.

    Sexton DJ 1998. Dual infection with Ehrlichia chaffeensis and a spotted fever group Rickettsia: a case report. Emerg Infect Dis 4: 311316.

    • Search Google Scholar
    • Export Citation
  • 11.

    Grynik A, Shaukat S, Htut EE, Karas JA, 2012. An unusual dual infection with Salmonella bredeney, including bacteraemia, and enterohaemorrhagic Escherichia coli O157 that posed a therapeutic dilemma. J Med Microbiol 61: 14801482.

    • Search Google Scholar
    • Export Citation
  • 12.

    Chowdhury G, Sarkar A, Pazhani GP, Mukhopadhyay AK, Bhattacharya MK, Ramamurthy T, 2013. An outbreak of foodborne gastroenteritis caused by dual pathogens, Salmonella enterica serovar Weltevreden and Vibrio fluvialis in Kolkata, India. Foodborne Pathog Dis 10: 904906.

    • Search Google Scholar
    • Export Citation
  • 13.

    Adhikary R, Joshi S, 2011. Dual Salmonella typhi infection. Indian J Pathol Microbiol 54: 849850.

  • 14.

    Sow A 2016. Concurrent malaria and arbovirus infections in Kedougou, southeastern Senegal. Malar J 15: 47.

  • 15.

    Parker TM, Murray CK, Richards AL, Samir A, Ismail T, Fadeel MA, Jiang J, Wasfy MO, Pimentel G, 2007. Concurrent infections in acute febrile illness patients in Egypt. Am J Trop Med Hyg 77: 390392.

    • Search Google Scholar
    • Export Citation
  • 16.

    Mahajan SK, Kaushik M, Raina R, Thakur P, 2014. Scrub typhus and malaria co-infection causing severe sepsis. Trop Doct 44: 4345.

  • 17.

    Epelboin L, Hanf M, Dussart P, Ouar-Epelboin S, Djossou F, Nacher M, Carme B, 2012. Is dengue and malaria co-infection more severe than single infections? A retrospective matched-pair study in French Guiana. Malar J 11: 142.

    • Search Google Scholar
    • Export Citation
  • 18.

    Blacksell SD, Sharma NP, Phumratanaprapin W, Jenjaroen K, Peacock SJ, White NJ, Pukrittayakamee S, Day NP, 2007. Serological and blood culture investigations of Nepalese fever patients. Trans R Soc Trop Med Hyg 101: 686690.

    • Search Google Scholar
    • Export Citation
  • 19.

    Sharma Y, Arya V, Jain S, Kumar M, Deka L, Mathur A, 2014. Dengue and typhoid co-infection—study from a government hospital in north Delhi. J Clin Diagn Res 8: DC09DC11.

    • Search Google Scholar
    • Export Citation
  • 20.

    Kamath SR, Ranjit S, 2006. Clinical features, complications and atypical manifestations of children with severe forms of dengue hemorrhagic fever in south India. Indian J Pediatr 73: 889895.

    • Search Google Scholar
    • Export Citation
  • 21.

    Seow CW, Logarajah V, Tan NWH, 2017. Typhoid and scrub typhus coinfection in a returned traveler. Glob Pediatr Health 4: 2333794X17726941.

  • 22.

    Mazumder RN, Pietroni MA, Mosabbir N, Salam MA, 2009. Typhus fever: an overlooked diagnosis. J Health Popul Nutr 27: 419421.

  • 23.

    Ormsbee R, Peacock M, Philip R, Casper E, Plorde J, Gabre-Kidan T, Wright L, 1978. Antigenic relationships between the typhus and spotted fever groups of rickettsiae. Am J Epidemiol 108: 5359.

    • Search Google Scholar
    • Export Citation
  • 24.

    Sompolinsky D, Boldur I, Goldwasser RA, Kahana H, Kazak R, Keysary A, Pik A, 1986. Serological cross-reactions between Rickettsia typhi, Proteus vulgaris OX19, and Legionella bozemanii in a series of febrile patients. Isr J Med Sci 22: 745752.

    • Search Google Scholar
    • Export Citation
  • 25.

    Breitschwerdt EB, Davidson MG, Aucoin DP, Levy MG, Szabados NS, Hegarty BC, Kuehne AL, James RL, 1991. Efficacy of chloramphenicol, enrofloxacin, and tetracycline for treatment of experimental Rocky Mountain spotted fever in dogs. Antimicrob Agents Chemother 35: 23752381.

    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to Regev Cohen, Laniado Hospital, Sanz Medical Center, 16 Divrei Haim St., Netanya 4244906, Israel. E-mail: regevc@laniado.org.il

Authors’ addresses: Regev Cohen and Talya Finn, Infectious Diseases Unit, Sanz Medical Center, Laniado Hospital, Netanya, Israel, and Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel, E-mails: regevco@gmail.com and tfinnfried@laniado.org.il. Frida Babushkin, Infectious Diseases Unit, Sanz Medical Center, Laniado Hospital, Netanya, Israel, E-mail: fbabushkin@laniado.org.il. Maurice Shapiro and Martina Uda, Intensive Care Unit, Sanz Medical Center, Laniado Hospital, Netanya, Israel, E-mails: mshapiro@laniado.org.il and m-uda3@web.de. Yafit Atiya-Nasagi, Department of Infectious Diseases, Institute for Biological Research, Ness-Ziona, Israel, E-mail: yafita@iibr.gov.il.

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