Fatal spotted fever group rickettsiosis due to Rickettsia conorii conorii mimicking a hemorrhagic viral fever in a South African traveler in Brazil

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Author's personal copy
Ticks and Tick-borne Diseases 1 (2010) 149–150
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Ticks and Tick-borne Diseases
journal homepage: www.elsevier.de/ttbdis
Short communication
Fatal spotted fever group rickettsiosis due to Rickettsia conorii conorii
mimicking a hemorrhagic viral fever in a South African traveler in Brazil
Daniele N. de Almeidaa, Alexsandra R. Favachoa, Tatiana Rozentala, Halime Barcauib,
Alexandro Guterresa, Raphael Gomesa, Silvana Levisd, Janice Coelhoc, Alberto Chebabob,
Ligia C. Costae, Salete Andreaf, Paulo F. Barrosob, Elba R.S. de Lemosa,∗
a Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Rio de Janeiro, Brazil
b Hospital Universitário Clementino Fraga Filho – School of Medicine/UFRJ, Rio de Janeiro, Rio de Janeiro, Brazil
c Instituto Nacional de Enfermedades Virales Humanas, Pergamino, Argentina
d Instituto de Pesquisa Evandro Chagas, FIOCRUZ, Rio de Janeiro, Rio de Janeiro, Brazil
e Secretaria de Vigilância em Saúde/Ministério da Saúde, Brasília, Distrito Federal, Brazil
f Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
a r t i c l e i n f o
Article history:
Received 21 January 2010
Received in revised form 29 April 2010
Accepted 10 May 2010
Available online 25 June 2010
Keywords:
Fatal spotted fever
Rickettsia conorii conorii
South African traveler
Brazil
a b s t r a c t
The authors present a fatal case of spotted fever group rickettsiosis (SFGR) caused by Rickettsia conorii
conorii mimicking a hemorrhagic viral fever in a South African male on a business trip in Brazil. SFGR was
confirmed by molecular and immunohistochemical analyses.
© 2010 Published by Elsevier GmbH.
1. Introduction
A wide spectrum of rickettsioses has been recognized in international
travelers in the last 2 decades (Freedman et al., 2006;
Gautret et al., 2009; Jensenius et al., 2004, 2009; Kun-Hsien et al.,
2009; Wilson et al., 2007). Tick-borne spotted fever is increasingly
being diagnosed among international travelers, and most cases are
acquired in sub-Saharan Africa, mainly in South Africa, where spotted
fever group rickettsioses (SFGR) are secondary only to malaria
as the most frequent febrile disease in travelers reported to the
GeoSentinel Surveillance Network (Jensenius et al., 2009; Kun-
Hsien et al., 2009). We report a fatal case of SFGR due to R. conorii
conorii,mimicking a hemorrhagic viral fever, in a South Africanman
on a business trip to Brazil.
2. The case
On November 27, 2008, a white 53-year-old South African male
engineer on a business trip, 2 days after arriving in Brazil, reported
∗ Corresponding author at: Pavilhão Hélio Peggy Pereira, Sala B116, FIOCRUZ,
Avenida Brasil, 4365 Rio de Janeiro, Rio de Janeiro 22040-900, Brazil,
Tel.: +55 2125621712; fax: +55 2125621897.
E-mail address: elemos@ioc.fiocruz.br (E.R.S. de Lemos).
headache, fever, chills, sore throat, asthenia, and hematuria. He
was medicated with symptomatic drugs, without improvement.
Four days later, he was admitted to a private hospital in Rio de
Janeiro with worsening of his clinical picture and the appearance
of a generalized maculopapular rash, hepatosplenomegaly, and
vomiting. There was no eschar. Antimicrobial therapy directed to
arenaviruses, community sepsis, and rickettsiosis was initiated, but
he developed renal and respiratory failure. Laboratory examination
revealed anemia, white blood cells with 50% band forms, and
thrombocytopenia (platelet count 69×109/L).
Increased transaminases, lactic dehydrogenase, and alkaline
phospatase (>1000 U/L) levels were observed. His clinical state
deteriorated, and he died with multiple organ failure after 7 days
of symptoms. A viral hemorrhagic fever was included in the differential
diagnosis because in October 2008, the patient had had
a possible contact with a fatal illness associated with a new arenavirus
in South Africa (Paweska et al., 2009). Given this possibility,
World Health Organization authorities were notified and local
health authorities implemented recommendations of the International
Sanitary Regulation. Parasitological, bacteriological, and
virological analyses were conducted in blood and post-mortem
liver biopsy samples. Serological tests for SFGR, dengue, yellow
fever, leptospirosis, hantavirus, and arenavirus were all negative.
Blood, urine cultures, and blood smears for malaria and other
1877-959X/$ – see front matter © 2010 Published by Elsevier GmbH.
doi:10.1016/j.ttbdis.2010.05.002
Author's personal copy
150 D.N. de Almeida et al. / Ticks and Tick-borne Diseases 1 (2010) 149–150
parasites were also negative. Blood samples were tested by PCR
for arenavirus, hantavirus, and rickettsiae. Segments of rickettsial
genes htrA (246 bp), ompA (532 bp), ompB (650 bp), and gltA
(381 bp) were amplified (Rozental et al., 2006; Zhu et al., 2005),
and the nucleotide sequences of theompAand gltA amplicons were
analyzed: the nucleotide sequences of the gltA amplicon (325 nt)
and of the ompA amplicon (491 nt) exhibited 100% sequence similarity
to the homologous gltA gene of R. conorii (GenBank accession
no. HM152564) and outer membrane protein A (OmpA) gene fragment
of R. conorii conorii (GenBank accession no. GU256251),
respectively. Biopsy specimens of the liver were tested by immunohistochemical
assay for SFGR using a polyclonal anti-R. rickettsii
antibody (Rozental et al., 2006) and showed SFGR antigens in
perivascular foci inflammation.
3. Discussion
Rickettsiosis is an endemic condition in many areas of the world,
and tick-borne spotted fever rickettsioses have repeatedly been
associated with febrile disease in travelers in the last 2 decades
(Carzola et al., 2008; Font-Creus et al., 1991; Freedman et al., 2006;
Gautret et al., 2009; Jensenius et al., 2004, 2009; Kun-Hsien et al.,
2009; Rovery and Raoult, 2008; Wilson et al., 2007). Although most
cases of international travel-associated rickettsioses acquired in
sub-Saharan Africa, particularly in South Africa and neighboring
countries, are caused by R. africae and R. conorii infections with
unfavorable outcome have also been described in that area (Carzola
et al., 2008; Freedman et al., 2006; Gautret et al., 2009; Wilson et
al., 2007).
Although originally SFGR caused by R. conorii, the causative
agent of the Mediterranean spotted fever, had been recognized as
a benign illness, severe cases associated with renal and respiratory
failure have been reported (Carzola et al., 2008; Font-Creus
et al., 1991; Rovery and Raoult, 2008). This patient had no eschar,
and its absence has been described in 14–40% of cases reported
(Carzola et al., 2008; Font-Creus et al., 1991; Rovery and Raoult,
2008). In this context, the lack of a tick exposure report, the lack
of an eschar, and the late onset of the rash contributed to the lack
of any clinical suspicion possibly leading to the delayed introduction
of a specific antimicrobial therapy and the fatal outcome. The
molecular identification of R. conorii conorii in the clinical samples,
an exotic rickettsia in Brazil, transmitted to humans by the dog tick
Rhipicephalus sanguineus mostly in urban settings, confirms that
the patient was infected in South Africa, where he had lived and
spent more than 6 days before the onset of symptoms (Rovery and
Raoult, 2008).
This case emphasizes the need for a high level of suspicion of
SFGR since travel-related rickettsioses are not rare events. An alert
about the possibility of the occurrence of SFGR in travelers in South
Africa should be considered, and advice for tourists before travel
should include precautions against tick bites and contact with
animals.
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