A 22 y.o. returns from Africa with a fever of 103 and a rash. She has a history of autoimmune hepatitis.

What could she have?

A diffuse rash is seen

Our patient remained febrile for seven days.  She initially was treated with ceftriaxone by her PMD and then developed diarrhea.  She was seen in ID clinic and admitted. She was pancytopenic and had mild elevations in liver functions.  AST was 78.  In the hospital she was treated with ceftriaxone and typhoid was the presumed diagnosis. Two days later doxy was added for African tick bite fever.  Her immuran was stopped. The differential for infectious diseases acquired in South Africa is broad.

African tick bite fever was first described in 1931 by Troup and Pijper.   It is transmitted by dog ticks in urban areas and cattle or game in rural areas. The incidence of infection in European visitors is 5% with visitors to game reserves at high risk of infection

Chikungunya

Typhoid fever is most often contracted from exposure to water contaminated with sewage. Since one in twenty  people infected become chronic carriers, it is difficult to eradicate.

Arbovirus diseases are also common in South Africa.  Mosquitoes are the vector for Rift Valley fever, west Nile, dengue  Chikungunya. Ticks are the vector for Crimean-Congo hemorrhagic fever.  This is the most important hemorrhagic fever virus in South Africa.   Retinitis, meningitis and skin bleeds can be seen within two days of contracting the virus. 

typhoid rose spots

When testing for arboviruses, the antibody-based assays may initially test negative as the immune system needs time to mount an immune response. In the case of our pt she had immune suppression from her immuran She was negative for malaria. Tbc, HIV,dengue, chikungunya and strongyloides tests pending at the time of discharge.

She was treated with doxy and Cipro for presumed typhoid fever and African tick bite fever.  She remained febrile although her fever was only 38 on discharge.

Delfos N, Schippers E, Rauoult D, Visser L. Fever and vesicular rash in a traveler returning from South Africa. Oxford Academia South African Fam Pract 2008 Vol 50(2) 33-35.

Prinsloo B. Arboviral diseases in Southern Africa. SA Fam Pract 2006: 48(8). 25-28