Faucher, C. Chirouze, L. Hustache-Mathieu, B. Socolovschi, C. Aubry, D. Raoult Corresponding author.
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For centuries, it has been associated with overcrowding, cold weather, and poor hygiene. Brill-Zinsser disease is a recurrent form of epidemic typhus that is unrelated to louse infestation and develops sporadically years after the primary illness. Clinical features are similar to, but milder than, those of epidemic typhus 1. We report a case of Brill-Zinsser disease in a patient who was born in Morocco and had no history of epidemic typhus.
Amoxicillin was prescribed for a putative diagnosis of acute respiratory infection. He was admitted to hospital on March 9 for persistent fever. Physical examination results were unremarkable. Chest radiograph results were normal. Results of 5 blood cultures and a urine culture were negative. Stupor developed on March Cerebrospinal fluid test results were normal. Because the patient lived near a goat farm, Q fever and tularemia were considered plausible hypotheses, and oral doxycycline was introduced on March The patient became afebrile on March 15, and he was discharged from the hospital and remained well.
On the basis of serologic results, the following diagnoses could be ruled out: viral infections HIV, cytomegalovirus, Epstein-Barr virus ; tularemia; Q fever; leptospirosis; salmonellosis; and Legionella, Mycoplasma, and Chlamydia spp. Acute-phase and convalescent-phase serum samples were positive for typhus-group rickettsiae by the microimmunofluorescence assay at the World Health Organization Collaborative Center for Rickettsioses and Other Arthropod-Borne Bacterial Diseases Marseille, France.
A microimmunofluorescence assay showed titers of for IgM and 6, for IgG. Western blot analyses and cross-adsorption studies strongly suggested R. The patient had been raised in Morocco.
At 19 years of age, he emigrated to France, where he lived in a urban area. He subsequently traveled every 3 years to Morocco for 1-month summer holidays, always in urban areas. He had most recently traveled to Morocco in He denied any history of hospitalization for a severe febrile illness and any exposure to louse bites. In the weeks before disease onset, he had not taken any new drug. He had no immunoglobulin deficiency. On the basis of serologic analysis with Western blot, we confirmed R.
In contrast, the patient in our report was living in a hygienic environment, and an autochthonous infection is therefore highly unlikely. Epidemic typhus was endemic to North Africa until the s 4. Subsequently, this region was thought to be free from epidemic typhus, but 2 cases have been reported since in Algeria, where 1 case of Brill-Zinsser disease was observed in a man who had had epidemic typhus in during the Algerian civil war 5 — 7.
Few published data exist about the seroprevalence of R. In Tunisia, no epidemic typhus was found in among 47 febrile patients 8. This finding suggests that R. No recent published data are available from Morocco. Since , reports of only 8 cases of Brill-Zinsser disease have been published 9 , In all cases, known risk factors were present overcrowding, poor hygiene, or contact with flying squirrels. Brill and Zinsser described that stress or waning immunity could reactivate R.
Corticosteroids can trigger recurrence of R. In the case presented here, we found no stress factor, no immunosuppression, and no medical history of epidemic typhus.
The mechanism of R. A recently explored reservoir for silent forms of R. Brill-Zinsser disease should be considered as a possible diagnosis for acute fever in any patient who has lived in an area where epidemic typhus is endemic. Faucher, C. Chirouze, L. Hustache-Mathieu, B.
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Brill-Zinsser Disease in Moroccan Man, France, 2011