A RARE CASE OF TYPHUS FEVER PRESENTING IN TEXAS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Typhus Fever is a rare bacterial infection (R. prowazekii and P. human capitis) commonly transmitted via louse vectors on humans. While rare in the US, there have been cases located east of the Mississippi River. We will describe a case of typhus fever in an elderly male located in Dallas, Texas. CASE PRESENTATION: A 73-year-old man with Parkinson Disease and hearing impairment developed acutely progressing weakness and encephalopathy. At baseline he was oriented to self and others and could ambulate with a walker. Now he was unable to ambulate, sit up in a chair and required a sitter due to disorientation. Initial labs were unremarkable save thrombocytopenia. He was admitted for progressing Parkinson vs infectious meningitis. The next day, he was less responsive and aphasic with a fever of 102.1F. An infectious work up and empiric antibiotics were started. By day 3, fever remained with negative cultures prompting an Infectious Disease consult. Head CT was unrevealing (cochlear implants precluded MRI). EEG revealed diffuse encephalopathy without epileptiform discharges. Lumbar puncture was deemed unsafe (thrombocytopenia). Repeat blood cultures, viral respiratory panel, COVID testing, strep pneumoniae, legionella and mycoplasma serologies, HIV, and a myriad of serologies for atypical sources of fever were drawn – all negative. Empiric treatment was broadened to include CNS dosing. On day 8, he required intubation for respiratory failure. Post platelet transfusion an LP was done, ultimately negative. On day 11, serologic Typhus Fever antibodies (IgM) resulted. At the time of diagnosis he had become ventilator dependent and prognosis was grim. Family withdrew life sustaining measures on day 13. DISCUSSION: Typhus fever occurs via louse feces which are highly infectious with Rickettsia and infect the host via injured skin or mucous membranes. Symptoms include fever, chills, headache, myalgia, fatigue, and rash. Neurologic manifestations include confusion, drowsiness, seizures, and coma. Diagnosis is made via serologic studies;immunofluorescent antibody tests or immunoblots. Treatment varies from days to weeks of doxycycline or chloramphenicol. Prognosis is dependent on patient demographics. Mortality is higher in males and increases with age. Prior to the development of antibiotics, prognosis was poor and mortality was high. With modern efficiency of testing and antibiotics, mortality has modestly improved (10-40%). CONCLUSIONS: While rare, Typhus fever is an important diagnosis to consider in patients presenting with encephalopathy regardless of location. Prognosis is fair in those promptly treated. Thus, high suspicion combined with early testing and empiric treatment is crucial for recovery. REFERENCE #1: Anderson, JO. Andersson, SG. A century of typhus, lice and Rickettsia. Research in Microbiology. 2000 Mar;151(2):143-50. REFERENCE #2: Houhamdi, L. Fournier, PE. Fang, R. Lepidi, H. Raoult, D. An experimental model of human body louse infection with Rickettsia prowazekii. J Infect Dis. 2002;186(11):1639. REFERENCE #3: Raoult, D. Roux, V. Ndihokubwayo, JB. Bise, G. Baudon, D. Marte, G. Birtles, R. Jail fever (epidemic typhus) outbreak in Burundi. Emerg Infect Dis. 1997;3(3):357. DISCLOSURES: No relevant relationships by christopher bettacchi, source=Web Response No relevant relationships by Adan (Adam) Mora, source=Web Response No relevant relationships by Ciara Wisecup, source=Web Response