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Dear Sir, An 11-year-old boy presented to the Sultan Qaboos University Hospital (SQUH), Muscat, Oman, in 2016 with a one-week history of scattered nodular-like erythematous lesions over the arms, petechial rashes over the dorsa of both feet and itchy maculopapular urticarial rashes over both thighs [Figure 1]. He had a high-grade fever which reached 39.5 °C as well as a headache, generalised body pain and swelling around the joints. The patient lived in Muscat and had no known history of tick bites, travel or contact with animals. A systemic examination revealed hepatomegaly and splenomegaly (both organs enlarged to 3 cm below the costal margin) as well as generalised body tenderness, myalgia and meningism. The bilateral knee and ankle joints were swollen with some restriction in movement, mainly flexion with partial extension. All vital signs were stable and normal, except for the persistent high-grade fever, which responded only partially to antipyretic medications. Initial investigations showed mild proteinuria (700 mg/dL over a 24-hour period) and microscopic haematuria (1+). A complete blood count revealed normal amounts of haemoglobin cells and platelets; however, the patient had leukocytosis (white blood cell count: 24,000/m3) and neutrophilia (absolute neutrophil count: 21,400/m3). His coagulation profile was normal. Further investigations indicated high C-reactive protein levels (125 mg/L), a high erythrocyte sedimentation rate (58 mm/hour), persistent unexplained low sodium levels (128 mmol/L), low chloride levels (89 mmol/L), very high creatine kinase levels (781 U/L), low serum albumin levels (29 g/L), normal renal function, normal complement levels, elevated alanine aminotransferase levels (190 IU/L) and elevated aspartate aminotransferase levels (250 U/L). An initial chest X-ray, ultrasound of the abdomen and gallium scan were normal. Autoimmune causes, including vasculitis, immune deficiency, malignancy and pyrexia of unknown origin, were ruled out with various investigations, including antinuclear antibody, anti-double-stranded DNA, antineutrophil cytoplasmic autoantibody, antimyeloperoxidase antibody and antiproteinase 3 antibody tests, skin and bone marrow aspirate biopsies, cultures and lumbar punctures. However, the patient had persistently high inflammatory markers. Serology screening for Brucella, Leishmania, Mycoplasma, malaria and Leptospira infections was negative. A bronchoalveolar lavage for tuberculosis resulted in a negative acid-fast bacilli smear with normal cytology and negative cultures. Virology screening was negative for cytomegalovirus, Epstein-Barr virus and acute hepatitis infections. Virology screening of nasopharyngeal aspirate was negative for influenza A and B viruses and subtype A H1N1 as well as enteroviruses, Coxsackieviruses, human immunodeficiency virus and Coxiella burnetii bacteria. The patient was treated with several combinations of antibiotics, including ceftriaxone and piperacillin/ tazobactam, vancomycin and meropenem, vancomycin and erythromycin as well as ciprofloxacin and gentamicin. However, he did not respond to these treatments. At this point, his fever had persisted for 35 days. A funduscopic letter to the editor Sultan Qaboos University Med J, November 2016, Vol. 16, Iss. 4, pp. e529–530, Epub. 30 Nov 16 Submitted 4 Jul 16 Revision Req. 4 Aug 16; Revision Recd. 18 Aug 16 Accepted 25 Aug 16 doi: 10.18295/squmj.2016.16.04.025

Rickettsial Infection Diagnosed in a Clinical Context in Oman