Fatal Mediterranean spotted fever in Greece

Abstract

Forty-five days after the first confirmed and fatal Crimean-Congo haemorrhagic fever (CCHF) case in Greece in 2008, a female patient with similar signs and symptoms (high fever, thrombocytopaenia) and resident of the same area, was admitted to the University General Hospital of Alexandroupolis. Before admission, she had visited a local hospital where a cephalosporin was prescribed. A rash manifested over subsequent days, which was misdiagnosed as an allergy to the drug. Upon admission to the University Hospital, she was given further antibiotics, including doxycycline; a few hours later, ribavirin was added because CCHF was suspected. After the patient's death, rickettsiosis caused by Rickettsia conorii conorii (Meditteranean spotted fever; MSF) was diagnosed. Extremely high values of interleukin (IL)-1ra, IL-6, interferon-gamma-inducible protein-10, monocyte chemoattractant protein-1 and an absence of tumour necrosis factor-alpha were observed. MSF is a potentially severe and even fatal disease resembling viral haemorrhagic fevers that has to be included in the differential diagnosis of febrile syndromes combined with thrombocytopaenia, even when a tick bite is not reported, and an eschar is absent. Physicians have to be aware of MSF in patients with severe disease who are returning from the Mediterranean area.

Update on Tick-Borne Rickettsioses around the World: a Geographic Approach

“…Recently, the mortality rate in Portugal reached 13% (9/71) of patients with MSF, including many patients with confusion and obtundation (67%), and a multivariate analysis revealed the following independent predictors associated with fatal outcome: hyperbilirubinemia, acute renal failure, and the absence of rash (226). Other fatal cases were reported in France, Greece, Bulgaria, and Turkey (213,229,240,247). Rickettsia conorii subsp.…”

Rickettsia species in human-parasitizing ticks in Greece

“…In a previous study using two target genes (17-kDa antigen gene and ompA gene) in a clinical sample both PCRs were positive (R. conorii). 7 The fact that R. conorii was not detected in the present study is likely due to its pathogenicity for ticks, since it was shown that exposure of Rh. sanguineus to R. conorii strain Malish produces lasting harmful effects on their survival.…”

“…2 Four tick-borne Rickettsiae have been currently identified in humans in Greece: R. conorii, R. aeschlimannii, R. sibirica mongolotimonae and R. slovaca, while R. massiliae and R. rhipicephali were identified only in ticks. [3][4][5][6][7][8][9] Unusual increased tick aggressiveness was observed in summer 2008 in northeastern Greece resulting in increased number of persons bitten by ticks, and two fatal cases, one caused by R. conorii and one by Crimean-Congo hemorrhagic fever virus (the first and only report in Greece). 7,10 As a result, many residents of the region sought medical advice in the emergency departments of the regional hospitals.…”

“…[3][4][5][6][7][8][9] Unusual increased tick aggressiveness was observed in summer 2008 in northeastern Greece resulting in increased number of persons bitten by ticks, and two fatal cases, one caused by R. conorii and one by Crimean-Congo hemorrhagic fever virus (the first and only report in Greece). 7,10 As a result, many residents of the region sought medical advice in the emergency departments of the regional hospitals. A study conducted in the two main hospitals (in Alexandroupolis and Komotini) during July-September 2008 showed that the majority of the 537 removed ticks were Rh.…”

Murine Typhus with Marked Thrombocytopenia in a Child in Northern Greece and Literature Review

“…Murine typhus is generally underdiagnosed in childhood (5). Although there are reports on infections caused by R. conorii (13,14), there is not any study on murine typhus from northern Greece. A seroprevalence study conducted in 2000 in various prefectures of northern Greece showed that IgG antibodies against R. conorii and R. typhi were detected in 1% and 2% of the population in Kavala prefecture, respectively (15).…”