Murine Typhus as a Cause of Fever in Travelers From Tunisia and Mediterranean Areas

Background. Travelers are exposed to a variety of health risks in unfamiliar environments and fever is a common problem in patients returning from travel abroad. Rickettsial diseases are increasingly frequently being reported among international travelers. Here we present cases of Rickettsia typhi infection, the agent of murine typhus, that were identified in our laboratory the last year, in travelers from Tunisia. Methods. For each patient we tested an acute-phase serum sample and for one patient we tested a convalescent-phase serum sample. IgG and IgM antibody titers were estimated with use of the microimmunofluorescence (MIF) assay. Western blot (WB) assay was performed for all the patients. Results. We identified three cases of murine typhus after a travel in Tunisia. All cases were observed during late summer and early autumn and patients were suffering by persistent fever. None of them presented rash or inoculation eschar. MIF was positive for Rickettsia sp. in the acute-phase serum samples of two patients. In one patient, two acute-phase serum samples were Rickettsia sp. negative whereas a third convalescent-phase serum sample that was obtained 2 weeks after was Rickettsia sp. positive. By WB assay we identified infection by R typhi. A treatment was immediately started and patients became apyretic. Conclusions. In the countries of North Europe, although autochthones cases of murine typhus have not been described, sporadic cases of R typhi infection are identified in travelers who visited murine typhus endemic areas. Murine typhus should be considered in the diagnosis of febrile illness without rash in travelers returning from disease endemic areas, like the south Mediterranean area.