Case Presentation: A 41-year-old male with a history of amphetamine use and an inguinal hernia presented with epigastric abdominal pain with associated subjective fevers, and non-bloody, non-bilious emesis. On presentation, he was tachycardic, febrile to 39.8 degrees Fahrenheit, and hypotensive with a mean arterial pressure (MAP) of 57. An infectious work-up was performed with his initial blood tests significant for bandemia with >24% bands, elevated alkaline phosphatase (AP) 184, AST 109, ALT 82, bilirubin 3.4, direct bilirubin 3.1, but negative lipase, CK and troponin. Intravenous fluids and broad-spectrum antibiotics with ceftriaxone, metronidazole, and vancomycin were initiated. He was unresponsive to fluids and required vasopressor support and was admitted to the medical intensive care unit (MICU). He continued to decline clinically and developed respiratory distress that required intubation. Despite broad-spectrum antibiotics, he continued to have fevers to 39 degrees Celsius, as well as an increase in liver function tests, high ferritin, hypertriglyceridemia, a new leukocytosis with WBC >16, continued bandemia of >24% bands, worsening kidney functions, and worsening platelet count of 20,000 from 80,000 on presentation. His imaging was notable for the left inguinal hernia with non-obstructive bowel and mild splenomegaly. Due to his acute decompensation, unknown etiology for his shock, and continued fevers, doxycycline was initiated due to concerns for endemic typhus while his send-out laboratory tests were pending. After initiation of the doxycycline, the patient defervesced, his blood pressure normalized, and he was extubated and stable for transfer to the medicine floor. The Typhus IgM laboratory test later in the admission resulted in a positive test before his discharge home.
Discussion: Endemic typhus, or murine typhus, is a flea-born disease caused by Rickettsia typhi. It classically presents as a mild illness with non-specific symptoms, including the classic triad of fever, headache, and rash (35-49% of patients). Gastrointestinal symptoms such as nausea, vomiting, and abdominal pain may also be present. Like our patient, severe disease can also occur, although less commonly. If left untreated, it can affect multiple organ systems, including the kidneys, lungs, eyes, heart, and spleen as seen in our patient who required CRRT, was intubated, and had evidence of splenomegaly. Due to the non-specific nature of the symptoms, the laboratory tests, and the diagnostics, the diagnosis of endemic typhus is difficult. A broad work-up is necessary. Our patient did not show improvement despite several interventions, including continued high fevers. A decision was made to empirically treat with doxycycline due to our high clinical suspicion of typhus while the send-out laboratory tests were pending.
Conclusions: Due to its non-specific symptoms, laboratory tests, and diagnostics, diagnosis of endemic typhus can be difficult. Although rare, mild symptoms can progress to severe manifestations of endemic typhus. It is important to have prompt treatment with doxycycline to avoid the progression of the disease with a recommendation for empiric treatment if there is a high suspicion due to the risk of shock and possible death.