Case Presentation:
The Surviving Sepsis Campaign has defined the best approach to patients with suspected sepsis. The diagnosis of sepsis requires clinical and laboratory findings and a potential source of infection. Therapeutically, the approach focuses on resuscitation and the critical step of empirically selecting appropriate antibiotics. The selections are usually broad and focus on the usual pathogens, with an emphasis on Gram positive and Gram negative organism often based clinical suspicion on organ system involvement. We present a case of sepsis due to Murine Typhus, a cause that is not one of the “usual suspects”.
Discussion:
A 37‐year‐old female presented with fever, chills, and generalized malaise. She had a spontaneous abortion one week prior to admission, and had been seen at another ED, treated with IV ceftriaxone and outpatient antibiotics of cephalexin. On presentation her vital signs were: blood pressure 82/44, heart rate 119, respiration rate 24 and temperature of 102.6. On physical exam she has a diffuse maculopapular rash but no suprapubic or abdominal tenderness. Laboratory studies revealed an AST 232, ALT 161, Alk Phos of 210, WBC of 10.2 and platelet count of 89. In the ED, she received ceftriaxone and vancomycin for clinical suspicion of bacterial meningitis, and gentamicin and clindamycin for suspicion of intra‐uterine infection. A lumbar puncture was negative and a pelvic ultrasound was non‐revealing. Although she had vaginal bleeding the discharge was not purulent. She underwent fluid resuscitation and transferred to the MICU where she was started on empiric antibiotics at time of admission of vancomycin and Zosyn. IV doxycycline was added because of the concern for a Rickettsial disease. She responded and was discharged one week after initial presentation. Her Rickettsial serology, available post discharge, showed R. typhi IgM of 1:256 and IgG of 1:1024 confirming the diagnosis.
Conclusions:
The usual diagnosis of a Rickettsial infection has clinical features of fever, headache, and rash, with laboratory findings of a systemic illness with elevated transaminases, thrombocytopenia and often leukopenia. Rickettsial induced Septic Shock is most unusual and it is often a difficult diagnosis. Rickettsial infections will be culture negative, and requires waiting for serology to confirm diagnosis. Additionally, these infections will have overlapping features such as thrombocytopenia, and transaminase elevation that may be seen in serious sepsis caused by more common etiologies of gram negative and gram‐positive bacteria. This case emphasizes the need to consider clinical clues leading to the diagnosis of uncommon etiologies, which may alter the choice of antibiotics while adhering to the best practices in the treatment of sepsis.