Case Reports
Oklahoma. In late May, a female child aged 7 years was taken
to an emergency department (ED) with 2 days of fever (102.7º
F [39.3º C]), malaise, abdominal pain, nausea, and vomiting.
Viral gastroenteritis was diagnosed, and the patient was released. Four
days later, the patient reported to a second ED with persistent fever,
anorexia, irritability, photophobia, cough, diffuse myalgias, nausea,
and vomiting. Physical examination showed hepatosplenomegaly and an
erythematous papular rash with scattered petechiae on the trunk, arms,
legs, palms, and soles. Laboratory results included an elevated white
blood cell (WBC) count of 11.4 x 109 cells/L (normal range:
3.0-9.1 x 109 cells/L), thrombocytopenia (19 x 109
platelets/L [normal range: 150-350 x 109 platelets/L]),
elevated aspartate aminotransferase (AST) of 279 U/L (normal: </=42
U/L), and elevated alanine aminotransferase (ALT) of 77 U/L (normal:
</=48 U/L). In the ED, the patient was treated with intravenous (IV)
doxycycline for suspected RMSF and transferred to a pediatric intensive
care unit at a tertiary care medical center, where she had declining
mental status, metabolic acidosis, and respiratory failure; the patient
died 6 days after initially seeking treatment. IgG antibodies reactive
with R. rickettsii at a reciprocal titer of 128 were demonstrated
by using an indirect immunofluorescence antibody (IFA) assay in a serum
specimen collected 2 days before death. Spotted fever group rickettsiae
(SFGR) were detected by immunohistochemical (IHC) staining at CDC in
autopsy specimens from the brain, skin, heart, lung, spleen, and kidney.
On June 1, the child's sister, aged 3 years, had fever, headache,
myalgias, and vomiting; on the following day, she had an erythematous
maculopapular rash on the trunk, extremities, palms, and soles. RMSF was
diagnosed, and the child was treated with doxycycline; she recovered.
Seroconversion of IgG antibodies reactive with R. rickettsii was
demonstrated in acute and convalescent phase serum specimens obtained
during illness and 5 months later. Both children played frequently in
grassy areas near their home. No history of tick bite was reported,
although ticks were frequently observed on the family's pet dogs and
often were manually removed by members of the household.
Kentucky. In early August, a male child aged 2 years was taken
to a pediatrician after 1 day of fever (101.0º F [38.3º
C]) with a papular rash on his legs, arms, trunk, and back. An
unspecified viral syndrome was diagnosed, and the child was treated with
nonsteroidal anti-inflammatory drugs. During the next 2 days, the child
continued to have fevers, spiking to 102.0º F-103.0º
F (38.9º C-39.4º C), and variable rash. The child
was examined in an ED and discharged with a diagnosis of viral
infection. Four days after initial treatment, the child was again
evaluated by a pediatrician because of lethargy and refusal to walk.
Laboratory tests showed thrombocytopenia (42 x 109
platelets/L), a WBC count of 3.3 x 109 cells/L, anemia
(hemoglobin 10.4 g/dL [normal range: 13.8-17.2 g/dL]), and hyponatremia
(134 mmol sodium/L [normal range: 135-145 mmol sodium/L]). The next day,
the child was admitted and treated with IV ceftriaxone and
methylprednisolone. Two days later, the child was transferred to a
tertiary care hospital. Physical examination at admission revealed a
fine petechial rash on the groin, trunk, ankles, and palms. The patient
was treated with IV vancomycin, cefotaxime, and doxycycline. His
condition continued to deteriorate; 8 days after initial treatment, he
died from multiple system failure. A serum specimen collected 2 days
earlier tested positive by enzyme immunoassay for IgM antibodies
reactive with R. rickettsii at 9.4 index value units (index
values >2.0 were considered reactive by the testing laboratory). SFGR
were detected by IHC stain in autopsy specimens of the brain, skin,
heart, lung, spleen, kidney, lung, and adrenal gland.
The child's mother, aged 40 years, was hospitalized 2 days before her
son's death with 2 days of diplopia, dizziness, headache, and fever.
Oral doxycycline and IV ceftriaxone were administered; she was
discharged after 5 days. Seroconversion of IgG antibodies reactive with
R. rickettsii was demonstrated in acute and convalescent phase
serum specimens obtained during illness and 2 weeks later. The family
lived near a lake with woods. The mother did not recall any recent tick
bites, travel, or participation in outdoor activities, by herself or her
son prior to illness onset.
Arizona. In mid-August, a male child aged 14 months was taken
to a community health clinic after 1 day of fever (103.7º F
[39.8º C]), with a maculopapular rash, including the palms
and soles, and thick white exudates on the tongue. Chest radiographic
evaluation showed a possible right lower lobe infiltrate. The child was
treated with intramuscular cefotaxime, acetominophen, and antifungal
medication for presumptive thrush. The next day, the child visited the
clinic with nausea, vomiting, anorexia, and dehydration. The patient was
transferred to a referral hospital for treatment of pneumonia, roseola
infantum, and thrush; on admission, the patient had a temperature of
105.7º F (41º C). After 3 days, he was transferred
to a tertiary care hospital with a diagnosis of sepsis and disseminated
intravascular coagulopathy. The patient was treated with IV ceftazidime
and vancomycin. Laboratory findings included an elevated WBC count (16.2
x 109 cells/L), thrombocytopenia (46 x 109
platelets/L), and elevated levels of AST (291 U/L) and ALT (99 U/L). Six
days after initial treatment, the child died of pulmonary hemorrhage; an
autopsy was not performed. A serum specimen obtained 5 days before the
child's death tested negative by IFA for IgM and IgG antibodies reactive
with R. rickettsii; however, R. rickettsii DNA was
amplified from serum by polymerase chain reaction (PCR) assay. A serum
specimen obtained from a brother, aged 5 years, showed IgM and IgG
antibodies reactive to R. rickettsii, indicating recent exposure.
The children lived in a rural environment with low shrubs and grasses
and frequently interacted with free-roaming dogs with ticks; however,
neither child had a history of recent tick bite.
Reported by: C Levy, MS, J Burnside, MS, T Tso, Arizona
Dept of Health Svcs. S Englender, MD, M Auslander, DVM, S Billings, DVM,
Div of Epidemiology and Health Planning, Kentucky Dept for Public
Health. K Bradley, DVM, J Bos, MPH, L Burnsed, MPH, Div Communicable
Diseases, Oklahoma Dept of Health. J Brown, MD, D Mahoney, MD, K
Chamberlain, M Porter, C Duncan, B Johnson, R Ethelbah, K Robinson, M
Wessel, S Savoia, MD, C Garcia, J Dickson, D Kvamme, D Yost, MD, M
Traeger, MD, Indian Health Svc. J Krebs, MS, C Paddock, MD, W Shieh, MD,
J Guarner, MD, S Zaki, MD, D Swerdlow, MD, J McQuiston, DVM, WL
Nicholson, PhD, Div of Viral and Rickettsial Diseases, National Center
for Infectious Diseases; L Demma, PhD, EIS Officer, CDC
