Brill-Zinsser Disease in Moroccan Man, France, 2011

To the Editor: Epidemic typhus is caused by Rickettsia prowazekii and transmitted by human body lice. 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. A 69-year-old man living in France sought care from his general practitioner on March 7, 2011, after 2 days of high-grade fever (40°C) associated with headache, myalgia, fatigue, and mild cough. 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. Blood test results were as follows: C-reactive protein 111 mg/L (reference 0–8 mg/L); procalcitonin 0.49 ng/mL (reference 0.1–0.4 ng/mL), lymphocyte count 0.7 × 10 3 cells/μL (reference 1–4 × 10 3 cells/μL), platelet count 92 × 10 3 cells/μL (reference 150–450 × 10 3 cells/μL), and lactate dehydrogenase 376 U/L (reference 94–246 U/L). Chest radiograph results were normal. Results of 5 blood cultures and a urine culture were negative. Stupor developed on March 11. Cerebrospinal fl uid 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 13. 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 and Chlamydia spp. infections. Acute-phase and convalescent-phase serum samples were positive for typhus-group rickettsiae by the microimmunofl uorescence assay at the World Health Organization Collaborative Center for Rickettsioses and Other Arthropod-Borne Bacterial Diseases (Marseille, France). A microimmunofl uorescence assay showed titers of 100 for IgM and 6,400 for IgG. Western blot analyses and cross-adsorption studies strongly suggested R. prowazekii as the cause of the man's illness. Quantitative PCR result on DNA extracted from the acute-phase serum was negative (2). 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. …