Murine Typhus Presenting as Septic Acute Cholangitis in a Young Woman From South Texas.

Jeffrey Xia,Sabi Shrestha,James C Saca

doi:10.7759/cureus.19209

Abstract

Murine (endemic) typhus is a zoonotic disease spread by fleas carrying Rickettsia typhi bacteria. Typically, murine typhus presents with mild and nonspecific flu-like symptoms. However, it can manifest with severe systemic complications potentially leading to delayed treatment or unnecessary interventions.We present the case of a young woman from South Texas who presented to the emergency department after 10 days of fever, myalgia, headache, nausea, and right-sided abdominal pain. She was found to be febrile, severely hypotensive, suffering from acute liver injury with a predominantly cholestatic pattern, acute kidney injury, severe thrombocytopenia, and hyponatremia. She was initially managed with broad-spectrum antibiotics for undifferentiated septic shock, and doxycycline was added due to suspicion of a Rickettsial infection. Although radiographic findings showed some evidence of biliary involvement, they were not typical for common biliary diseases. However, due to her severe clinical presentation and findings suggesting possible acute cholangitis, she underwent an endoscopic ultrasound with endoscopic retrograde cholangiopancreatography, which revealed no evidence of acute obstructive biliary disease. Without strong evidence to explain her presentation, an extensive chronic liver disease workup was done, which was negative. The patient ultimately clinically improved with antibiotics alone.This case demonstrates an atypical presentation of murine typhus, presenting with septic shock and masquerading as acute cholangitis. With the rising incidence of murine typhus in endemic areas of the United States, this case reinforces the importance of being cognizant of the typical and atypical presentations of murine typhus, which may allow for early appropriate treatment and potentially avoid unnecessary interventions. Additionally, in this study, we conducted a literature review of murine typhus cases associated with acute biliary dysfunction.

Highlights

Murine typhus is caused by Rickettsia typhi, a gram-negative, intracellular, rod-shaped bacterium transmitted by rat or cat flea vectors
Murine typhus was last a nationally notifiable disease in 1987 with 49 incident cases in the United States; it remains a state-notifiable disease in some states such as Texas and California, where the most reported cases of murine typhus occur in the country [3]
This case exhibits an atypical presentation of murine typhus mimicking acute cholangitis

Summary

Introduction

Murine typhus is caused by Rickettsia typhi, a gram-negative, intracellular, rod-shaped bacterium transmitted by rat or cat flea vectors This condition often presents with nonspecific and mild symptoms such as fever, myalgia, and rash. A 40-year-old Caucasian woman from South Texas with a medical history of hypothyroidism, type 2 diabetes, and hypertension presented to her primary care physician with five days of intermittent fever, chills, headache, cough, myalgia, nausea, and cervical lymphadenopathy in the month of July She was given a methylprednisolone injection and prescriptions for cefdinir and ondansetron for presumed bacterial upper respiratory tract infection and symptomatic management. RUQ ultrasound revealed normal common bile duct (CBD), mild gallbladder wall thickening, and mildly increased liver echogenicity Due to her severe presentation, she was admitted to the intensive care unit (ICU).

Discussion

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Disclosures

Ziessman HA