Tropical Medicine and Infectious Disease Article Spotted Fever Rickettsiosis in a Wildlife Researcher in Sabah, Malaysia: A Case Study Milena Salgado Lynn 1,2,3,4, Timothy William 5 ID , Ampai Tanganuchitcharnchai 6, Suthatip Jintaworn 7, Janjira Thaipadungpanit 7, Mei Ho Lee 8, Cyrlen Jalius 1,3, Peter Daszak 8 ID , Benoît Goossens 1,2,4,9, Tom Hughes 8 and Stuart D. Blacksell 6,7,* ID 1 Danau Girang Field Centre, c/o Sabah Wildlife Department, Sandakan, Sabah 90009, Malaysia; [email protected] (M.S.L.); fi[email protected] (C.J.); [email protected] (B.G.) 2 School of Biosciences, Cardiff University, Cardiff CF10 3AX, UK 3 Wildlife Health, Genetic and Forensic Laboratory, c/o Sabah Wildlife Department, Kota Kinabalu, Sabah 88100, Malaysia 4 Sustainable Places Research Institute, Cardiff University, Cardiff CF10 3BA, UK 5 Jesselton Medical Centre, Kota Kinabalu, Sabah 88300, Malaysia; [email protected] 6 Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford OX3 7FZ, UK; [email protected] 7 Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; [email protected] (S.J.); [email protected] (J.T.) 8 EcoHealth Alliance, New York, NY 10001-2320, USA; [email protected] (M.H.L.); [email protected] (P.D.); [email protected] (T.H.) 9 Sabah Wildlife Department, Kota Kinabalu, Sabah 88100, Malaysia * Correspondence: [email protected]; Tel.: +66-2-2036-3333 Received: 12 December 2017; Accepted: 28 February 2018; Published: 6 March 2018 Abstract: We present evidence for a case of spotted fever rickettsiosis with severe complications in a young adult male. Although spotted fever group rickettsiae (SFGR) have been reported as the most prevalent cause of rickettsiosis in rural areas of Sabah, Malaysia since the 1980s, this is the first detailed case report of suspected SFGR in the state. Current data on the prevalence, type, and thorough clinical reports on complications of SFGR and other rickettsioses in Sabah is lacking and required to raise the awareness of such diseases. There is a need to emphasize the screening of rickettsioses to medical personnel and to encourage the use of appropriate antibiotics as early treatment for nonspecific febrile illnesses in this region. Suspected rickettsioses need to be considered as one of the differential diagnoses for patients presenting with acute febrile illness for laboratory investigations, and early treatment instituted. Keywords: rickettsiae; Malaysia; diagnosis 1. Introduction Over the past 25 years, there has been an increase in the knowledge of rickettsial pathogens worldwide [1]. Nevertheless, there are still geographical areas where little information on rickettsioses is available regarding the clinical cases, the pathogens and the vectors [1–4]. Yet in Southeast Asia, and in travellers returning from this region, rickettsial diseases are among the leading causes of treatable acute febrile illnesses [5,6]. The clinical symptoms of rickettsioses may vary depending on the rickettsial species involved, and therefore diagnosis can be challenging even for experienced physicians [1]. Moreover, the specific laboratory methods for the diagnosis of infections are seldom available in remote areas, and even in large cities, in Southeast Asia [1,5,7]. In addition, the management of the disease could also be challenging given the (lack of) availability of the most commonly used antibiotics, the possible resistance to them, and the alternatives to such antibiotics [8,9]. Trop. Med. Infect. Dis. 2018, 3, 29; doi:10.3390/tropicalmed3010029 www.mdpi.com/journal/tropicalmed Trop. Med. Infect. Dis. 2018, 3, x FOR PEER REVIEW 2 of 8 commonlyTrop. Med. Infect. used Dis. antibiotics,2018, 3, 29 the possible resistance to them, and the alternatives to such antibiotics2 of 8 [8,9]. Rickettsioses are considered endemic in Malaysia and mostly associated with rural/estate areas [10,11]Rickettsioses though current are data considered on the prevalence endemic in and Malaysia type of rickettsioses and mostly are associated scarce [12–16]. with rural/estate Reports of thisareas disease [10,11 in] thoughSabah are current limited data to two on retrospective the prevalence serological and type studies of rickettsioses in the early are 2000s scarce [13,14], [12 –one16]. cross-sectionalReports of this survey disease in in1986 Sabah [17], areand limitedone prospect to twoive retrospective study in 2017 serological [18]. In this studies report, inwe the present early evidence2000s [13 ,for14], a one case cross-sectional of spotted fever survey rickettsioses in 1986 [17], in and a onewildlife prospective researcher study in inSabah, 2017 [18Malaysia,]. In this highlightingreport, we present the need evidence for increased for a case awareness of spotted of ricke feverttsioses rickettsioses as a cause in a of wildlife acute febrile researcher illness in in Sabah, this region.Malaysia, highlighting the need for increased awareness of rickettsioses as a cause of acute febrile illness in this region. 2. Clinical History 2. Clinical History A previously-healthy 23-year-old British male presented to Jesselton Medical Centre (JMC), Kota A previously-healthy 23-year-old British male presented to Jesselton Medical Centre (JMC), Kinabalu, Sabah, Malaysia, with an acute febrile illness. The patient had been in Sabah for a period Kota Kinabalu, Sabah, Malaysia, with an acute febrile illness. The patient had been in Sabah for a of three months prior to becoming ill. Earlier on the day of admittance at JMC the patient had period of three months prior to becoming ill. Earlier on the day of admittance at JMC the patient had attended a clinic from where he was discharged to wait two days for the results of diagnostic tests attended a clinic from where he was discharged to wait two days for the results of diagnostic tests (dengue and malaria), evidently not recognising the severity of his symptoms. Upon admission to (dengue and malaria), evidently not recognising the severity of his symptoms. Upon admission to JMC JMC (day 1, D1), the patient reported onset of symptoms four days prior, having high fever (over◦ 39 °C),(day headache, 1, D1), the dry patient cough, reported sweating, onset diarrhoea, of symptoms joint four and days muscular prior, having pain, highappetite fever loss, (over nausea, 39 C), confusionheadache, and dry cough,light-headedness. sweating, diarrhoea, Physical examination joint and muscular indicated pain, a mild appetite rash loss, of small, nausea, undefined, confusion scatteredand light-headedness. red dots on the Physical limbs and examination abdomen indicatedand mild haemoptysis, a mild rash of at small, which undefined, point he was scattered admitted red todots the on theintensive limbs andcare abdomen unit (ICU). and mild Haematology haemoptysis, and at which biochemistry point he was results admitted indicated to the intensive severe thrombocytopenia,care unit (ICU). Haematology leukopenia, and biochemistrylymphopenia, results and indicated a mild severe cholestasis thrombocytopenia, (Table 1). leukopenia,He was haemodynamicallylymphopenia, and astable, mild cholestasishis lungs were (Table clear,1). He and was there haemodynamically was no evident stable,hepatosplenomegaly. his lungs were Followingclear, and thereadmission, was no the evident patient’s hepatosplenomegaly. condition rapidly deteriorated. Following admission, The admission the patient’s chest X-ray condition was normal,rapidly but deteriorated. a repeat X-ray The admissionthe following chest day X-ray showed was clear normal, pleural but aeffusion repeat X-ray(Figure the 1). following On D3 post- day admission,showed clear the pleural patient effusion went into (Figure hypotensive1). On D3 sh post-admission,ock (BP 70-80/30-40). the patient CT wentscans intoshowed hypotensive pleural effusionshock (BP in 70-80/30-40).the right lung CT as scanswell as showed ground-glass pleural effusionopacities in in the the right dependent lung as portion well as ground-glassof the lungs, bilaterallyopacities in (Figure the dependent 1). Additionally, portion of the lungs,liver an bilaterallyd the spleen (Figure were1). Additionally, enlarged at the21 liverand and15 cm, the respectively.spleen were enlargedSigns of atabnormal 21 and 15 liver cm, respectively.function became Signs evident of abnormal on D5 liver post-admission function became and evident were persistenton D5 post-admission for more than andtwo wereweeks persistent (Table 1). forAntibiotic more than therapy two commenced weeks (Table with1). Antibioticceftriaxone therapy 2 g o.d. andcommenced doxycycline with 100 ceftriaxone mg b.d., 2with g o.d. the and former doxycycline discontinued 100 mg after b.d., the with hypotensive the former shock discontinued on D3 post- after admission,the hypotensive and the shock latter on on D3 D7 post-admission, post-admission. and Due the to latter the patient’s on D7 post-admission. inability to take Due oral to medication, the patient’s theinability lack toof takediagnosis, oral medication, and to ensure the lack a ofbroad diagnosis, coverage and of to illnesses, ensure a broadmeropenem coverage 1 ofg illnesses,tds and azithromycinmeropenem 1IV g tds500 and mg azithromycino.d. were started IV 500 on mg D3 o.d. and were D4 post-admission started on D3 and for D4four post-admission and seven days for respectively;four and seven intravenous days