Annals of Tropical Paediatrics International Child Health
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Spotted fever in Hong Kong R. Y. M. Tseng, A. K. C. Ho, C. K. Li, J. S. L. Tam, S. F. Mo, B. Leung & S. J. Oppenheimer To cite this article: R. Y. M. Tseng, A. K. C. Ho, C. K. Li, J. S. L. Tam, S. F. Mo, B. Leung & S. J. Oppenheimer (1992) Spotted fever in Hong Kong, Annals of Tropical Paediatrics, 12:3, 255-257, DOI: 10.1080/02724936.1992.11747581 To link to this article: http://dx.doi.org/10.1080/02724936.1992.11747581
Published online: 13 Jul 2016.
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Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19 Download by: [Australian Catholic University]
Date: 06 August 2017, At: 22:38
Annals of Tropz"cal Paediatn"cs (1992) 12,255-257
Spotted fever in Hong Kong R. Y. M. TSENG, A. K. C. HO*, C. K. LI, J. S. L. TAM*, S. F. MO**, B. LEUNG & S. J. OPPENHEIMER
Downloaded by [Australian Catholic University] at 22:38 06 August 2017
Departments of Paediatrics and* Microbiology, Prince of Wales Hospital, Shatin, Hong Kong, and** Department of Biology, Chinese University of Hong Kong (Received 17 September 1991)
Summary A previously healthy 7-year-old Hong Kong-born Caucasian child developed sudden onset fever, followed by a generalized rash and systemic symptoms of rigor and prostration, mucous membrane involvement (conjuctivitis) and arthralgia. He lives in a rural area of Hong Kong and has been in contact with various domestic animals-rodents, dogs and cows. Chloramphenicol 50 mg/kg/ day was given on day 4 with rapid response. Subsequent Weil-Felix test and specific serology suggested the diagnosis of rickettsial infection of the spotted fever group. To our knowledge, this is the first confirmed case of spotted fever reported in Hong Kong.
Introduction
Case report
The spotted fevers represent a group of diseases caused by closely related Rickettsiae. They are transmitted by species of ixodid ticks from animal reservoirs. The prototype disease follows a fairly characteristic clinical picture at presentation, irrespective of the type of rickettsial infection. However, the severity and outcome depends to a large extent on early diagnosis and treatment. 1 Previously reported cases of suspected rickettsial infection in Hong Kong have been identified, with two exceptions/•3 as scrub typhus. 4 ' 5 This affected mainly Caucasian adults. Mortality quoted in standard textbooks in untreated cases has been high.' We describe our recent experience of spotted fever in a child in Hong Kong.
A 7-year-old Caucasian boy was referred from a private hospital with a 3-day history of fever and malaise. The onset of fever was accompanied by symptoms of joint pains involving upper and lower limbs and the neck. A generalized maculo-papular rash began on the 2nd day of his illness, starting from the periphery and spreading centrally. The boy related his illness to a scratch on his shin by a tick-infested dog which took place a week earlier. In addition to tick-infested dogs in the household, other domestic animals in the neighbourhood included cows, mice, puppies and kittens. None of these animals had been noted to be ill. In spite of systemic cefuroxime and erythromycin for 3 days, there was a steady deterioration, with high swinging fever up to 40°C. During the fever, the child became delirious and prostrated but during afebrile periods he was fully conscious. Physical examination revealed a wellnourished European boy with a generalized,
Reprint requests to: Dr R. Y. M. Tseng, Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Kong.
256
R. Y. M. Tseng et al.
Downloaded by [Australian Catholic University] at 22:38 06 August 2017
Treatment and outcome In view of the clinical deterioration and a history of close contact with tick-infected animals, we started chloramphenicol 50 mg/ kg/day intravenously empirically on day 4 to cover the possibility of spotted fever. There was rapid improvement in symptoms. The delirious spells ceased before a gradual fall of temperature by lysis in the ensuing 48 hours. During this period, some of the maculopapular erythematous rash faded, but in other areas purpuric spots developed. Chloramphenicol was given for a further 7 days. The child remained well at 7 months.
Laboratory results
I. Generalized maculo-papular erythematous rash, becoming purpuric (vasculitic) in nature during convalescence. FIG.
maculo-papular erythematous rash with well defined margins measuring 1-5 mm in diameter, with a centripetal distribution (Fig. 1). Multiple warts also were noted on the trunk and proximal parts of the upper limb. A malar flush was noted in addition to a healed scratch mark on the shin. There was bilateral cervical lymphadenopathy and conjunctivitis. Other mucous membranes were spared. He complained of pain on passive movements of the knees and ankles but there was no evidence of arthropathy or periarticular inflammation. There was no meningism. The other systems, on examination, were normal and urine, on microscopy, was also normal. Our initial differential diagnosis included viral illness, muco-cutaneous syndrome, auto-immune disease, mycoplasma infection and drug reaction. However, the rash was quite unlike that of the common infectious exanthemata, nor was it typical of Kawasaki or Stevens-Johnson syndromes.
Serial samples of serum taken from this patient were stored at -70°C. Weil-Felix tests showed a marked risk of OX2 (1/20 to 1/2560), no significant change in OX19 (1/80 to 1/160), and no rise in OXK ( 1/20) between days 3 and 15 of his illness. In addition, specific antibodies (IgG, IgM) to Rickettsia siberica, R. typhi and R. tsutsugamushi were assayed by immunoperoxidase tests. Specific peroxidase-tagged reagents were used to detect specific antibodies, employing a modification of Suto's method. 6 (Kits were obtained by courtesy of the US Armed Forces Research Institute of Medical Sciences in Bangkok.) R. siberica IgG and IgM titres were selectively elevated: IgM titres were 1/800, and IgG fell from 1/800 to 1/200 between days 3 and 7 of his illness, whilst IgG and IgM titres against R. typhi and R. tsutsugamushi were less than 1/10. The results of other investigations included ESR 69 mm/h, haemoglobin 11.4 g/dl, WCC 5.5 x 109 /1 and platelets 141 x 109 /1; prothrombin and partial thromboplastin times and the results of renal and liver function screening were all normal. Screening for infection included blood culture and malaria slides. The results of serological tests for Salmonella typhi (Widal), brucella, rubella, Epstein Barr virus and Mycoplasma infections were all negative.
Spotted fever in Hong Kong TABLE I. Serology results
Downloaded by [Australian Catholic University] at 22:38 06 August 2017
Day3 Weil-Felix OXK 800 lgM >800 R. tsutsugamushi lgG
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Spotted fever in Hong Kong R. Y. M. Tseng, A. K. C. Ho, C. K. Li, J. S. L. Tam, S. F. Mo, B. Leung & S. J. Oppenheimer To cite this article: R. Y. M. Tseng, A. K. C. Ho, C. K. Li, J. S. L. Tam, S. F. Mo, B. Leung & S. J. Oppenheimer (1992) Spotted fever in Hong Kong, Annals of Tropical Paediatrics, 12:3, 255-257, DOI: 10.1080/02724936.1992.11747581 To link to this article: http://dx.doi.org/10.1080/02724936.1992.11747581
Published online: 13 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19 Download by: [Australian Catholic University]
Date: 06 August 2017, At: 22:38
Annals of Tropz"cal Paediatn"cs (1992) 12,255-257
Spotted fever in Hong Kong R. Y. M. TSENG, A. K. C. HO*, C. K. LI, J. S. L. TAM*, S. F. MO**, B. LEUNG & S. J. OPPENHEIMER
Downloaded by [Australian Catholic University] at 22:38 06 August 2017
Departments of Paediatrics and* Microbiology, Prince of Wales Hospital, Shatin, Hong Kong, and** Department of Biology, Chinese University of Hong Kong (Received 17 September 1991)
Summary A previously healthy 7-year-old Hong Kong-born Caucasian child developed sudden onset fever, followed by a generalized rash and systemic symptoms of rigor and prostration, mucous membrane involvement (conjuctivitis) and arthralgia. He lives in a rural area of Hong Kong and has been in contact with various domestic animals-rodents, dogs and cows. Chloramphenicol 50 mg/kg/ day was given on day 4 with rapid response. Subsequent Weil-Felix test and specific serology suggested the diagnosis of rickettsial infection of the spotted fever group. To our knowledge, this is the first confirmed case of spotted fever reported in Hong Kong.
Introduction
Case report
The spotted fevers represent a group of diseases caused by closely related Rickettsiae. They are transmitted by species of ixodid ticks from animal reservoirs. The prototype disease follows a fairly characteristic clinical picture at presentation, irrespective of the type of rickettsial infection. However, the severity and outcome depends to a large extent on early diagnosis and treatment. 1 Previously reported cases of suspected rickettsial infection in Hong Kong have been identified, with two exceptions/•3 as scrub typhus. 4 ' 5 This affected mainly Caucasian adults. Mortality quoted in standard textbooks in untreated cases has been high.' We describe our recent experience of spotted fever in a child in Hong Kong.
A 7-year-old Caucasian boy was referred from a private hospital with a 3-day history of fever and malaise. The onset of fever was accompanied by symptoms of joint pains involving upper and lower limbs and the neck. A generalized maculo-papular rash began on the 2nd day of his illness, starting from the periphery and spreading centrally. The boy related his illness to a scratch on his shin by a tick-infested dog which took place a week earlier. In addition to tick-infested dogs in the household, other domestic animals in the neighbourhood included cows, mice, puppies and kittens. None of these animals had been noted to be ill. In spite of systemic cefuroxime and erythromycin for 3 days, there was a steady deterioration, with high swinging fever up to 40°C. During the fever, the child became delirious and prostrated but during afebrile periods he was fully conscious. Physical examination revealed a wellnourished European boy with a generalized,
Reprint requests to: Dr R. Y. M. Tseng, Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Kong.
256
R. Y. M. Tseng et al.
Downloaded by [Australian Catholic University] at 22:38 06 August 2017
Treatment and outcome In view of the clinical deterioration and a history of close contact with tick-infected animals, we started chloramphenicol 50 mg/ kg/day intravenously empirically on day 4 to cover the possibility of spotted fever. There was rapid improvement in symptoms. The delirious spells ceased before a gradual fall of temperature by lysis in the ensuing 48 hours. During this period, some of the maculopapular erythematous rash faded, but in other areas purpuric spots developed. Chloramphenicol was given for a further 7 days. The child remained well at 7 months.
Laboratory results
I. Generalized maculo-papular erythematous rash, becoming purpuric (vasculitic) in nature during convalescence. FIG.
maculo-papular erythematous rash with well defined margins measuring 1-5 mm in diameter, with a centripetal distribution (Fig. 1). Multiple warts also were noted on the trunk and proximal parts of the upper limb. A malar flush was noted in addition to a healed scratch mark on the shin. There was bilateral cervical lymphadenopathy and conjunctivitis. Other mucous membranes were spared. He complained of pain on passive movements of the knees and ankles but there was no evidence of arthropathy or periarticular inflammation. There was no meningism. The other systems, on examination, were normal and urine, on microscopy, was also normal. Our initial differential diagnosis included viral illness, muco-cutaneous syndrome, auto-immune disease, mycoplasma infection and drug reaction. However, the rash was quite unlike that of the common infectious exanthemata, nor was it typical of Kawasaki or Stevens-Johnson syndromes.
Serial samples of serum taken from this patient were stored at -70°C. Weil-Felix tests showed a marked risk of OX2 (1/20 to 1/2560), no significant change in OX19 (1/80 to 1/160), and no rise in OXK ( 1/20) between days 3 and 15 of his illness. In addition, specific antibodies (IgG, IgM) to Rickettsia siberica, R. typhi and R. tsutsugamushi were assayed by immunoperoxidase tests. Specific peroxidase-tagged reagents were used to detect specific antibodies, employing a modification of Suto's method. 6 (Kits were obtained by courtesy of the US Armed Forces Research Institute of Medical Sciences in Bangkok.) R. siberica IgG and IgM titres were selectively elevated: IgM titres were 1/800, and IgG fell from 1/800 to 1/200 between days 3 and 7 of his illness, whilst IgG and IgM titres against R. typhi and R. tsutsugamushi were less than 1/10. The results of other investigations included ESR 69 mm/h, haemoglobin 11.4 g/dl, WCC 5.5 x 109 /1 and platelets 141 x 109 /1; prothrombin and partial thromboplastin times and the results of renal and liver function screening were all normal. Screening for infection included blood culture and malaria slides. The results of serological tests for Salmonella typhi (Widal), brucella, rubella, Epstein Barr virus and Mycoplasma infections were all negative.
Spotted fever in Hong Kong TABLE I. Serology results
Downloaded by [Australian Catholic University] at 22:38 06 August 2017
Day3 Weil-Felix OXK 800 lgM >800 R. tsutsugamushi lgG
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