Family outbreak of Rickettsia conorii infection.

To the Editor: Over a 15-day period, three young siblings were separately taken to an emergency room in Israel, with symptoms suggesting a contagious viral illness (fever, maculopapular rash, hepatosplenomegaly, lymphadenopathy, neutropenia, and thrombocytopenia). None of the children had been in direct contact with animals. Specific immunoglobulin (IgM) immunofluorescence assay (IFA) 7 to 8 days after admission of each child confirmed the diagnosis of Rickettsia conorii infection.

Spotted fever is the generic name given to a variety of tickborne rickettsial diseases distributed worldwide. In Mediterranean countries, including Israel, spotted fever is caused by members of the R. conorii complex. Spotted fever has been endemic in Israel for more than 40 years, with several hundred cases reported annually. In 1997, two fatal cases were reported (1). Spotted fever is caused by a variant member of R. conorii, which is transmitted by the dog tick Rhipicephalus sanguineous (2,3). The disease has a broad spectrum of clinical signs, from asymptomatic to fatal (4,5). Symptoms and signs include fever, headache, vomiting, myalgia, conjunctivitis, and a typical maculopapular or purpuric rash. The tache noir at the site of the tick bite, which is found in patients in Europe, is seldom, if ever, seen in Israel.

The first patient, a 6-year-old boy, was taken to the pediatric emergency room with high fever and a diffuse rash, approximately I week after visiting a cousin who had similar complaints. Physical examination showed temperature of 40 [degrees] C, chills, diffuse maculopapular rash all over the body, including the hands and feet, hepatosplenomegaly, and lymphadenopathy. Blood tests showed neutropenia, thrombocytopenia, and hyponatremia. Because Rickettsia was included in the differential diagnosis, immunofluorescent assay (IFA) for Rickettsia was performed and intravenous doxycycline (2 mg/kg/day) was initiated. One week later, the boy's 8-month-old sister was brought to the emergency room with similar complaints, and 2 days afterwards his 2-year-old sister began to have the same symptoms. A detailed history revealed that all children had played on a lawn frequented by dogs.

All three siblings had fever, chills, and diffuse maculopapular rash all over the body, including the hands and feet. An IgM IFA test for R. conorii from the first child was negative on the day of admission and became positive 8 days later. On the day of the boy's hospital discharge, his 8-month-old sister was taken to the emergency room. Her serology test was negative on admission but became positive 7 days later. The third (2-year-old) sibling's first blood test was negative, and the family did not agree to a second blood test. All three children responded well to doxycycline (2 mg/kg/day, with a double dose the first day) for 5 to 7 days. Most symptoms subsided within 48 hours.

Spotted fever is usually a sporadic illness and is not spread from person to person. Clusters of cases have been reported. Yagupsky reported spotted fever in Israel in a few children living near each other in an agricultural settlement (6). A report from the Delaware Division of Public Health described a group of children who had been camping together where contact with ticks was likely (7). This case illustrates that spotted fever may be acquired even without direct contact with animals, through exposure to ticks in places frequented by infected animals. Our report suggests that Rickettsial illness should be considered in the differential diagnosis of fever with rash in disease-endemic areas, even if the timing of similar complaints in several family members suggests a contagious viral illness.

References

(1.) Spotted fever. Jerusalem, Israel: Ministry of Health, Department of Epidemiology; 1997.

(2.) Goldwasser RA, Steiman Y, Klinberg W, Swartz TA, YJingberg MA. The isolation of strains of Rickettsiae of the spotted fever group in Israel and their differentiation from other members of the group by immunofluorescence methods. Scand J Infect Dis 1974;6:53-62.

(3.) Manor E, Ighbarieh J, Sarov B, Kassis 1, Regnery R. Human and tick spotted fever group rickettsia isolated from Israel: a genotypic analysis. J Clin Microbiol 1992;30:2653-6.

(4.) Wolach B, Franci S, Bogger-Goren S, Drucker M, Goldwasser RA, Sadan N, et al. Clinical and laboratory findings of spotted fever in Israeli children. Pediatr Infect Dis J 1989;8:152-5.

(5.) Yagupsky P, Wolach B. Fatal Israeli spotted fever in children. Clin Infect Dis 1993;17:850-3.

(6.) Agupsky P, Sarov B, Sarov I. A cluster of cases of spotted fever in a kibbutz in southern Israel. Scand J Infect Dis 1989;21:155-60.

(7.) Rotz L, Callejas L, McKechnie D, Wolfe D, Gaw E, Hathcock L, et al. An epidemiologic and entomologic investigation of a cluster of Rocky Mountain spotted fever cases in Delaware. Del Med J 1998;70:285-91.

G. Shazberg, J. Moise, N. Terespolsky, and H. Hurvitz

Bikur Cholim General Hospital, Jerusalem, Israel