If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Baylor College of Medicine Houston, TexBlanton Eye Institute, Houston Methodist Hospital Houston, TexThe Houston Methodist Research Institute, Houston Methodist Hospital Houston, TexWeill Cornell Medicine New York, NYWeill Cornell Medicine New York, NYUniversity of Texas Medical Branch Galveston, TexUniversity of Texas MD Anderson Cancer Center Houston, TexTexas A and M College of Medicine Bryan, TexThe University of Iowa Hospitals and Clinics Iowa City, Iowa
Murine typhus is an acute infection transmitted by rodent or cat fleas carrying gram-negative, obligate intracellular bacteria, Rickettsia typhi. This vector for transmission is most often carried on rodents, but opossums are thought to be a reservoir in suburban settings.
Symptoms of murine typhus can be nonspecific, and they typically appear 7–14 days after infection. Patients most often present with recurrent fever, maculopapular rash, and headache, but arthralgia, cough, and abdominal pain can also be present.
We present a rare case of intracranial hypertension, papilledema, and visual disturbance secondary to Rickettsia typhi infection. To our knowledge, only three cases of this nature have been reported to date.
A 31-year-old African American woman presented with acute, painless, binocular loss of vision. She also had a ten day history of acute intractable vomiting with nausea, chills, recurrent fevers up to 103°F, neck stiffness, myalgias, diarrhea, and left-upper-quadrant abdominal pain. She reported headaches behind the left eye with radiation to the left occipital region, which was noticeably different from her usual migraine pattern. On examination, neck pain was elicited in the occipital area, but there was no neck stiffness or Brudzinski sign. Past medical history was significant for hypertension, diabetes mellitus type II, migraines, and obesity (body mass index 34.3). She had no recent travel, animal exposure, or sick contacts.
Cranial magnetic resonance imaging (MRI) of the head and magnetic resonance venography with contrast were normal (Fig. 1, Fig. 2). MRI of the spine was normal. Laboratory testing revealed an elevated C-reactive protein of 19.96 (normal <8 mg/dL), an erythrocyte sedimentation rate of 27 mm/h (normal 0–20 mm/hr), and elevated liver enzymes (alkaline phosphatase of 410 U/L (normal 35–104 U/L), aspartate transaminase of 117 U/L (normal 10–35 U/L), and alanine transaminase of 126 U/L (normal 5–50 U/L). Blood and sputum cultures showed no growth. Lumbar puncture revealed an elevated opening pressure of 34 cmH2O (normal 7–18 cmH2O), but cerebrospinal fluid composition was normal. Ophthalmic examination showed visual acuity of 20/20 in the OD and OS. She had reactive pupils with no anisocoria or relative afferent pupillary defect. The anterior segment was within normal limits, and intraocular pressures were 15 OD and 16 OS. Automated perimetry 24-2 Humphrey visual field testing showed a superior arcuate defect and inferior nasal step OD and snonspecific scatter OS. Dilated fundus exam showed Frisen grade 1 disc edema bilaterally (OU) (Fig. 3), which was confirmed with optical coherence tomography (Fig. 4).
Diagnostic studies for Rickettsial IgG and IgM antibodies were elevated at IgG 1:1024 and IgM >1:1024 specific for Rickettsia typhi, and IgG 1:64 and IgM 1:256 for Rickettsia rickettsii. The patient was thus found to be positive for Rickettsia typhi. She was treated with acetazolamide 500 mg twice a day and doxycycline 100 mg twice a day with resolution of her symptoms.
Murine typhus is uncommon but the prevalence may be rising
. To our knowledge, this is only the fourth case describing papilledema and pseudotumor cerebri secondary to Rickettsia typhi infection. Although the symptoms and signs may mimic idiopathic intracranial hypertension, patients with murine typhus have symptoms that are not related to increased intracranial pressure (e.g., fever, myalgias, and constitutional symptoms) and abnormal laboratory studies (e.g., elevated acute phase reactants and liver function studies).
Patients presenting with recurrent fever, headache, abdominal pain, and/or a rash should be evaluated for arthropod-borne illnesses, including murine typhus. Ophthalmologists should inquire about fever, rash, and stiff neck in cases of possible pseudotumor cerebri because the imaging and the cerebrospinal fluid, as in our case, can be consistent with idiopathic intracranial hypertension.
Footnotes and Disclosures
The authors have no proprietary or commercial interest in any materials discussed in this article.
Typhus group Rickettsiosis, Texas, USA, 2003–2013.