Real-Time PCR studies regarding the borrelia burgdorferi, francisella tularensis, tick borne encephalitis virus (TBEv) and crimeean congo hemorrhagic fever virus (CCHFv) occurrence in the Romanian ticks

Background: Epidemic typhus is due to R. prowazekii. In India the endemic spot is Kashmir. Infection is transmitted when the contaminated louse faces is rubbed through the minute abrasions caused by scratching. Occasionally, infection may also be transmitted by aerosols of dried louse faces through inhalation or through the conjunctiva. Incubation period is 5 15 days. They infect the vascular endothelium and reticuloendothelial cells with 40%case fatality. A characteristic rash sparing the face, palms and soles. Towards the second week, the patient becomes stuporous and delirious. Thrombocytopenia is observed in more than half of the patients. Methods & Materials: A 17 years old male patient, residing in hostel, complained of high grade fever since 9 days and after 4 days of fever, rashes appeared first on trunk which spread over limbs but sparing face, palm and sole and consequently changed into purpura fulminans. On day 6th patient had syncope with seizure. On day 9th patient was admitted in ICU because of altered sensorium with left facial paralysis without neck rigidity. Immediately empirical treatment was started with cephaperazone-sulbactum, doxycycline and acyclovir and de-escalated subsequently. Investigation showed Hb 13.6 gm/dl, WBC 14900 /mm3 (Neutrophil 79%) and platelet 26000/mm3. CSF and other blood examination done were normal. Weil-Felix test was positive (by tube agglutination, to proteus antigen OX19 (1:640); OXK (1:640); OX2 (negative)). CT and further MRI brain were normal. Results: The case appears atypical because suspected encephalitis resolved fast in one day without any sequel. Patient had high grade fever till day 17,which responded to12 days of doxycycline. Initial presentation of case was like acute stroke andreview of literature also sparsely reported this butinvestigations did not support this. Suspected neurorickettsioses disappeared rapidly, is also very atypical in pathogenesis of vasculitis. Prolonged high grade fever till day 17, was investigated for malaria and tuberculous meningitis. Weil-Felix Test report was high with equal titresin 0X19 & OXK which is also atypical. Conclusion: For rare organisms, clinical presentation and investigation reports can be vague. Lack of facility to confirm rickettsioses is the biggest limitation.In current scenario Rickettsioses is diagnosed by relevant clinical findings and Weil-Felix test positivity.