Fever and calf tenderness after travel in Thailand: murine typhus and deep vein thrombosis

A 37-year-old German fell ill with fever and diffuse headaches 3 weeks after flying to Thailand for a holiday. Because of increasing sickness he began his return (13 h by train then 11 h by plane). Besides a temperature of 39.3 degrees C he presented with a unproductive cough and pain in his left calf. On examination there were no other pathological findings than a borderline tachycardia, mild hypotension and signs of dehydration. Laboratory tests showed elevated inflammatory parameters (CRP 77.8 mg/l, ESR 36 mm), normal range of leucocytes with obvious shift to the left, mild thrombocytopenia and elevated liver enzymes. The Weil-Felix-reaction revealed a high antibody titre against OX 19, the IFT for Rickettsia typhi a significant increase of IgM with seroconversion for IgG. Duplex ultrasonography and phlebography confirmed a phlebothrombosis of the left upper thigh. Murine typhus and deep vein thrombosis of the left upper leg. Suspecting typhoid fever with ciprofloxacin was started. In less then 2 days the patient became afebrile and recovered. The deep vein thrombosis was treated with low-molecular-weight heparin (Tinzaparin) overlapping with phenprocoumon. In patients with fever after travel to tropical or subtropical areas (including southern Europe) the diagnosis of murine typhus should be considered, especially if concomitant with thromboembolic events. The Weil-Felix-reaction is a helpful screening test supplemented by Rickettsia specific serologic tests. Overall a higher risk of thrombosis should be taken into account after long sedentary travel.