CASE REPORT

A previously healthy 33-year-old woman was admitted with a week long history of a progressively painful and inflamed left eye. She had eyelid erythema and swelling, mucopurulent discharge, marked conjunctival hyperaemia, chemosis, and a granulomatous nodule on the lower half of the bulbar conjunctiva. At the 4 o’clock position there was a 1 mm corneal marginal ulcer. Visibly swollen preauricular and submandibular lymph nodes were present on the same side of the eye in question (Parinaud’s oculoglandular syndrome). No other abnormality was detected in the anterior and posterior segments of the eye. Her visual acuity was 6/6.

Conjunctival swabs for bacterial, fungal, and chlamydial cultures collected before starting the treatment were all found to be negative.

Initial therapy consisted of eyedrops containing chloramphenicol (0.4%) and rolitetracycline (0.5%) every 2 hours and 2 g of piperacillin intramuscularly every 12 hours.

The day after her admission, the patient started having fever (38.5°C), headache arthralgia, myalgia, and malaise; within 48 hours the corneal ulcer fully resolved, whereas chemosis and the granulomatous nodule were still present. Blood tests showed an increased erythrocyte sedimentation rate (33 mm after the first hour) and a lower number of white cells (3.52 × 10⁹/l). A computed tomographic scan of the head was normal.

By her third day in hospital, she developed a maculopapular exanthema on her trunk, limbs, and the soles of her feet. After careful questioning, the patient revealed that 2 weeks earlier, while removing ticks from her dog, she accidentally crushed a tick and a jet of blood splashed into her left eye. A blood sample taken on this day was positive to the Weil–Felix test (agglutination of Proteus vulgaris strain OX-19 at 1:80 dilution). On the basis of these data, the diagnosis of Mediterranean spotted fever was made. As a result, piperacillin was discontinued and the patient was given oral doxycycline (100 mg daily). After 2 weeks of treatment, there was a complete resolution of the ocular and systemic disease. A second blood sample, taken during week 2 after the onset of the disease, showed a fourfold rise in OX-19 agglutinins, thus confirming the diagnosis.

COMMENT

Members of the genus Rickettsia are small Gram negative organisms often intimately associated with arthropod tissues.1 2 They may be parasitic in humans and other vertebrates, causing diseases transmitted by arthropods. Species in the genus Rickettsia have been subdivided into three groups of antigenically related organisms: spotted fever, typhus, and scrub typhus.

R conorii, the most ubiquitous Rickettsia of the spotted fever group, is the aetiological agent of Mediterranean spotted fever (also called fièvre boutonneuse) in humans. The brown dog tick, Rhipicephalus sanguineous, is the prevalent vector and the disease is normally transmitted by the bite of the tick. In this report we describe a case of Mediterranean spotted fever acquired through the eye by means of a jet of blood coming from a crushed tick. The disease, which varies in severity but is seldom fatal, is considered endemic during the spring and summer in most of the regions bordering on the Mediterranean and Black seas, in Kenya and other parts of central Africa, South Africa, and certain parts of India. Over the past decade, outbreaks have been reported in Italy3 and Spain.4

When a patient presents with Parinaud’s oculoglandular syndrome in areas where Mediterranean spotted fever is endemic, the possibility that the rickettsial disease may have been acquired through the eye should be kept in mind.