Ann N Y Acad Sci. 2003 Jun;990:285-94.
Mediterranean spotted fever in Portugal: risk factors for fatal outcome in 105 hospitalized patients.
de Sousa R1, Nóbrega SD, Bacellar F, Torgal J.
1. Centro de Estudos de Vectores e Doenças Infecciosas, Instituto Nacional de Saúde Dr. Ricardo Jorge, Aguas de Moura, Portugal. email@example.com
Mediterranean spotted fever (MSF) is the most important tick-borne disease in Portugal. It is a notifiable disease and during 1989-2000 the annual incidence rate in Portugal was 9.8/10(5) inhabitants. Although recognized as a benign acute disease and treated mainly with ambulatory procedures, some cases are severe and fatalities have increased in the last few years. In 1997, MSF mortality became more evident in Beja, a Portuguese southern district, with a case fatality rate of 32.3% in hospitalized patients. Analysis of 55 variables regarding epidemiologic, clinical, laboratory, and therapeutic data of fatal and nonfatal MSF cases were compared to identify risk factors in 105 patients hospitalized in Beja District Hospital, between 1994 and 1998. It was statistically significant that the patients dying in 1997 were younger than those in other years. The risk of dying is statistically significant in those who presented with diabetes, vomiting, dehydration, and uremia. The interval between the onset of symptoms to administration of anti-rickettsial therapy was the same for all patients. Therapy delay, reported by some authors to be associated with mortality of MSF, was not a risk factor in our study. The patients who died in 1997 died faster than those in other years. The variables studied could not explain the higher mortality rates observed in our study. Although one may speculate that the pathogenic strain of Israeli tick typhus, isolated in 1997, could be responsible for this increase of fatality rate, inherited patient factors might also be strongly associated with mortality.
PMID: 12860641 [PubMed - indexed for MEDLINE]
Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
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Ann N Y Acad Sci. 2003 Jun;990:331-43.
Report of eight cases of fatal and severe Mediterranean spotted fever in Portugal.
Amaro M1, Bacellar F, França A.
1. Hospital Garcia de Orta, 2801-501 Almada, Portugal.
Mediterranean spotted fever (MSF), endemically present, is associated with a low mortality and morbidity in Portugal. Etiological agents are Malish and Israeli tick typhus strains of Rickettsia conorii. In the last few years severe forms of MSF have emerged, with patients presenting atypical symptoms, major neurological manifestations, and multiorgan involvement, who have required intensive care facilities. Advanced age, underlying chronic disease, and delay of appropriate treatment are bad prognostic factors. In the acute phase of diagnosis, serological studies are delayed, inconclusive, and often unhelpful. A definitive diagnosis can only be made using isolation or molecular biology which can establish and clearly identify agents. Using evidence-based case reports, clinical and laboratory data were evaluated from patients with severe or fatal MSF observed in Garcia da Orta Hospital-Almada. Of the eight reference cases, four died, three in an acute fulminant stage. Of the survivors, four presented atypical involvement: ocular inoculation, massive gastric hemorrhage, acute respiratory disease (ARDS), and necrotizing vasculitis. Diagnosis by isolation of the agent was made in two cases, by immunohistochemistry in three, and by the indirect fluorescent antibody test (IFA) in three others. Israeli tick typhus and Malish R. conorii strains were isolated once each in fatal cases. In early stages, diagnosis continues to be clinical and patients should start appropriate therapy without delay if clinical suspicion of rickettsiosis arises to prevent poor outcome. Patients ranged in age from 39 to 71 years (mean 60), APACHE II ranged from 15 to 38 points and TISS 28 was between 24 and 46 points. In reported cases severity of disease was not obviously related to the usual comorbidities. Accelerated clinical course may not suggest classical MSF. Another relevant factor was prior prescription of an inappropriate antibiotic that contributed to misleading clinical features. The reported complications and atypical manifestations illustrate well the diversity of this disease.
PMID: 12860647 [PubMed - indexed for MEDLINE]
Free full text (em português): http://www.actamedicaportuguesa.com/rev ... w/1216/868Acta Med Port. 2003 Nov-Dec;16(6):429-36. Epub 2003 Dec 1.
[Epidemiologic features of Mediterranean spotted fever in Portugal].
[Article in Portuguese]
Sousa Rd1, Nóbrega SD, Bacellar F, Torgal J.
1. Instituto Nacional de Saúde Dr. Ricardo Jorge, CEVDI Aguas de Moura, Lisboa.
Mediterranean spotted fever (MSF) is a tick-borne rickettsial disease. It is endemic in Portugal and Ricardo Jorge recognized it in 1930. Rhipicephalus sanguineus is the main vector and reservoir of the disease. In Portugal the etiologic agents are two strains of Rickettsia conorii complex: R. conorii Malish and "Israeli tick typhus". MSF is clinically characterized by a vasculitis process with the classical clinical triad of fever, rash, and lesion at the site of tick bite. Although the majority MSF cases are considered benign, last years some districts presented more severe cases than expected. The reported incidence of MSF in Portugal for 1989 to 2000 was 9.8/10(5) inhabitants, the highest incidence compared to other mediterranean countries. Alentejo was the region who presents the highest incidence with 31/10(5) inhabitants. Nevertheless, Bragança was the district which appears with greater number of cases, 62/10(5) inhabitants. The highest annual incidence rate reported was among children, peaking in those 1-4 years of age with 60.2/10(5) inhabitants. Observation of mortality rates have shown that Beja district have the highest mortality rates for MSF in Portugal, but in 1997 in this district, mortality have unexpected values with 7.6 deaths per 100,000 inhabitants have occurred. Although is an obligatory notifiable disease, high number of underreported cases are detected.
PMID: 15631855 [PubMed - indexed for MEDLINE]