Fleaborne Typhus–Associated Deaths — Los Angeles County... - CDC

Results

Case Series

Patient A. In June 2022, a man identifying as Hispanic^¶ aged 68 years was evaluated in an emergency department (ED) for a 3-day history of fever and progressive lower extremity weakness (Table). Medical history included diffuse lymphadenopathy, obesity, hypertension, diabetes mellitus type 2, and peripheral vascular disease complicated by a chronic left foot ulcer. He had anemia and elevated liver enzymes and was admitted to the hospital with a diagnosis of sepsis and treated with broad-spectrum antibiotics. His mental status deteriorated, and he became difficult to rouse. On hospital day 8, he experienced hypotension and atrial fibrillation with rapid ventricular response and was transferred to the intensive care unit. The next day, he experienced hypoxemic respiratory failure and was placed on mechanical ventilation; the day after, he required vasopressor support and was given stress-dose steroids. On hospital day 9, a bone marrow biopsy was notable for scattered hemophagocytosis (histiocytic phagocytosis of red blood cells, white blood cells, platelets, and their precursors), and on hospital day 16, he received a diagnosis of hemophagocytic lymphohistiocytosis (HLH), a rare immune system disease, for which he received chemotherapy and infection prophylaxis as indicated by HLH-2004 protocol (8). He received doxycycline on hospital day 18, after receiving a positive Karius test** result for R. typhi. On hospital day 24, he no longer required mechanical ventilation, was extubated, and remained minimally responsive. On hospital day 29, he experienced multiorgan failure and transitioned to comfort care; he died on hospital day 30. Death was attributed to fleaborne typhus–induced HLH and septic shock. Potential exposure to rodents and fleas included proximity of the patient's home to a highway and litter.

Patient B. In August 2022, a woman identifying as Hispanic aged 49 years was evaluated at an urgent care facility for a 2-day history of headache and fever. Medical history included obesity, hypertension, hyperlipidemia, and diabetes mellitus type 2. During that visit she received a negative SARS-CoV-2 test result and was given a prescription for antihistamines and nasal steroids to treat presumed allergic rhinitis. Five days later, she visited an ED with fever, chills, night sweats, headache, and back pain. She received intravenous fluids and was discharged after symptomatic improvement. She returned to the ED the next day where she was found to be thrombocytopenic, hypokalemic, and had elevated liver enzymes; she was admitted to the hospital with a diagnosis of sepsis; treatment with broad-spectrum antibiotics was initiated. On hospital day 2, she experienced supraventricular tachycardia and two episodes of cardiac arrest with successful resuscitation. Cardiac catheterization found stress cardiomyopathy and no coronary artery disease. In light of the patient's headache, fever and elevated transaminases, an infectious diseases physician recommended treatment with doxycycline, which was started on hospital day 2, for possible fleaborne typhus. The patient subsequently experienced multiorgan failure and died on hospital day 3. Autopsy confirmed myocarditis as a proximate cause of death. Immunohistochemistry evaluation for typhus group Rickettsia demonstrated rare, multifocal staining of rickettsial antigens in endothelial cells in small blood vessels of the heart and less frequently in endothelial cells lining the sinusoidal spaces of the liver (Supplementary Figure, https://stacks.cdc.gov/view/cdc/131262). Potential flea exposure included stray kittens living in the patient's backyard.

Patient C. In October 2022, a man identifying as Hispanic aged 71 years who was experiencing homelessness and had a history of alcohol use disorder was brought to an ED by ambulance after having been observed lying in the same place on the ground for 24 hours. He was febrile, disoriented, hypotensive, tachypneic, and experiencing atrial fibrillation with rapid ventricular response. He had anemia, thrombocytopenia, and a low white blood cell count with a predominance of immature neutrophils, in addition to lactic acidosis and elevated liver enzymes. He had a petechial rash on his legs and torso. Treatment for suspected meningitis, fleaborne typhus, and neurosyphilis was initiated. On hospital day 2, the patient became hypoxemic, and on hospital day 4, experienced hypoxemic respiratory failure and was placed on mechanical ventilation. He experienced worsening multiorgan failure and disseminated intravascular coagulation and transitioned to comfort care; he died on hospital day 5. Causes of death listed on the death certificate were septic shock associated with shock liver, hyperkalemia, and lactic acidosis. The patient might have also been exposed to fleas and rodents at the encampment where he lived.

Adblock test (Why?)