Mediterranean Spotted Fever in Central Tunisia.

Abstract

Mediterranean spotted fever (MSF) is a tick-borne rickettsiosis caused by Rickettsia conorii. The disease was first described in Tunisia by Conor and Brush in 1910.’ However, only a few studies suggested the persistence of this disease in Tunisia.2 Edlinger et a13 emphasized the fact that MSF is one of the travel diseases that can be contracted in many Mediterranean countries, including Tunisia. Harris et a1 also reported boutonneuse fever in American traveler^.^ The investigators retrospectively reviewed the charts of 80 patients with MSF observed from January 1984 to December 1991 in the Internal Medicine and Infectious Diseases Units of Sousse and Monastir University Hospitals in Tunisia. In all cases, diagnosis was based on clinical features and epidemiologic data. Serologic confirmation using indirect immunofluorescence reaction was obtained in 54 cases (68%). A fourfold rise in titer was noted in 43 patients, a seroconversion in five and a titer (> 1/256) was noted in a single sample in the six remaining patients. The investigators included 26 cases, despite the absence of serological confirmation. This was because these cases met the criteria gathered in the diagnostic score chart established by Raoult et al’ for the diagnosis of MSF. Indeed, these cases had a score > 25 because all epidemiologic and clinical criteria selected by Raoult diagnostic score were satisfied. Fifty-nine men and 21 women (sex ratio, 2.8:l) were seen in the above-mentioned units from 1984 to 1991 (the mean was 10 cases per year). The mean age was 36 (range was 6 to 70 years). Forty-seven percent of patients were between 20 and 40 years. Sixty-one percent of patients were rural inhabitants. Seventynine cases (99%) were noted in the hot season (from April to October); 68 of them (87%) occurred from July to October. Forty-nine (61%) patients had dogs in their proximity, and 41 of them reported contact with dogs’ ticks, Rhipicephalus sanguineus. As Table 1 demonstrates, fever, headache, weakness, and myalgia were the most frequently reported clinical symptoms. Clinical presentation was typical of MSF in that presence of the characteristic symptomatic triad (i.e., fever, rash, and “tache noire”) was noted in 70 patients (88%). Fever was present in 78 patients (98%) and was higher than 385°C in 80% of cases. Rash was observed in all patients. The rash was macular in 30% of cases, maculopapular in 55%, papular in 10% of cases, and purpuric in one case. The nature of rash was unknown in 4% of cases. Rash appeared on the third day of disease in 63% of cases and between the fourth and seventh days in 25% of patients. The date of appearance of the rash was unknown in 13% of patients. “Tache noire” was noted in 70 patients (88%). It was the sole manifestation in 61 of 70 patients (87%), and multiple (two or three) in the remaining cases. “Tache noire” was located in various sites of the body, especially limbs (36%), trunk (27%), and wrinkles (22%). White blood cell count was normal in 61% of patients as is shown in Table 2 . Various nonspecific abnormalities were noted. Cutaneous biopsy was performed in eight patients. In seven cases, the biopsy showed inflammatory damage of endothelial cells with perivascular reactional lymphohistiocytic crown, which can be considered highly suggestive of the lesions of MSF. Direct immunofluorescence staining was not performed. Forty-four patients ( ~ S ’ % O ) received antibiotics for more than 48 hours before consultation. Antibiotics were appropriate in only two cases (chloramphenicol). Thus, the investigators had the opportunity to note that previously prescribed p-lactam antibiotics (20 cases), trimethoprim-sulfamethoxazole (1 case), erythromycin (8 cases), lincosamine (11 cases), and aminoglycoside (2 cases) were ineffective in the treatment of MSF. Seventy-eight patients were treated in hospital with tetracyclines (500 mg q.i.d. during 10 days). Two received ofloxacin (200 mg b.i.d. during 5 days). Recovery was noted in all patients. In all cases, fever disappeared within the first 48 hours after appropriate therapy. Several complications occurred, including mild gastrointestinal hemorrhage (2 cases), granulomatous hepatitis (1 case), acute reversible renal failure (3 cases), uveitis (1 case), and meningo-encephalitis (1 case). All patients had a favorable outcome. As emphasized by our series, MSF is still present in central Tunisia. Although serologic confirmation is not available in 26 patients, the investigators firmly believe that these patients should not be excluded from this series because all meet the epidemiologic and clinical criteria of the MSF diagnostic score chart established by Raoult et al. Furthermore, the favorable outcome after tretracycline therapy argues strongly for the diagnosis of MSF. Thus, in this series, 80 cases