Rickettsial Encephalitis: A Case Report

Abstract

Rickettsia infections, being an important cause of pyrexia of unknown origin, is often misdiagnosed and treated without correct diagnosis because of it’s symptoms mimic other causes and lack of confirmatory tests during initial phase of the illness. They are distributed worldwide with foci of endemicity. They are common in southern Europe. In India the cases of rickettsial infections have been documented mainly from South India. The disease presents with a classic triad of fever, rash and eschar. The clinical spectrum varies from a mild febrile illness to potentially life-threatening complication like meningoencephalitis. Definitive diagnosis of rickettsia infection requires the examination of serum for antibodies during the acute and convalescent phase of illness. Weil-Felix test is a non-specific agglutination test which detects anti rickettsial antibodies in patient’s serum. It is easily available, non-expensive and can be performed rapidly. It can be used to confirm a tentative diagnosis of rickettsial fever during acute phase of the disease. Inspite of its low sensitivity, WF test may be the only serological test available in developing countries like India. The rickettsial organisms are constantly susceptible to tetracyclines, thus making doxycycline,the drug of choice. We are reporting a case of encephalitis in a 20-year-old female who presented to hospital ER with 10 days history of fever, headache and seizures.The patient was brought to the ER with status epilepticus. Status epilepticus treatment protocol was given in the ER, patient intubated and admitted to medical intensive care unit. In ICU, the patient was put on mechanical ventilation. Various blood Investigations including Weil Felix test were done. Treatment started with IV antibiotic, IV acyclovir, IV Levetiracetam and tab Doxycycline 100mg BID through RT. Weil-Felix test came positive for spotted fever group with titres being OX2 1:320, OX19 1:640 and OXK 1:20 . Tab doxycycline was given for 10 days. Patient improved gradually and was extubated on 5th day, and shifted to ward on 10th day. Patient was discharged to home after 2 weeks of hospital stay. On follow up in neurology OPD, patient had no complaints and with no neurological sequelae. This case report underlines the importance of a high index of clinical suspicion and the benefits of empirical treatment in setting of compatible epidemiological data for rickettsial infections.