Two weeks later, IF serology demonstrated an IgG titer of 1/1,280 against R conorii. A protein C deficiency was also diagnosed.

A 61-year-old Moroccan living in Belgium was repatriated from Morocco in September 2007 and admitted in the University Hospital of Antwerp, Belgium because of multi organ failure. He was visiting his family in Tetouan and in Nador (Mediterranean coast of Morocco) when he became abruptly ill. He was hospitalized in an intensive care unit in Morocco with high fever, jaundice, severe upper intestinal bleeding, and septic shock. Blood results showed at that time elevated white blood cells count (17,600/µL, comprising 95% of neutrophils), a low platelet count (48,000/µL), an elevated CRP level (20 mg/dL), a kidney failure (level of creatinine: 2.5 mg/dL), and liver test disturbances (ALT: 102 buy PLX4032 IU/L, total bilirubin 6.3 mg/dL, conjugated

bilirubin 4.4 mg/dL). Fluid resuscitation, inotropic agents, hemodialysis, proton-pump inhibitors, and amoxicillin–clavulanate were administered and the patient was transferred to our institution 10 days later. At admission he had no more fever (37.2°C), was hemodynamically stable and cognitively fine. Patient was too weak to stand alone, but no focal neurological defect was found. Jaundice and a slight purpuric rash were noticed. Doxycycline was added to the ongoing treatment. A gastroscopy revealed a large gastric ulceration with stigma of recent bleeding. Z-VAD-FMK manufacturer Clinical and laboratory evolution was quickly favorable thereafter. On admission in our institution IF assay was positive for R conorii (IgG titer: 1/640) and R typhi (1/320). Paired serology 2 weeks later confirmed a more than fourfold

increase of the titer against R conorii (>1/2,560), but not against R typhi (1/640). The three reported cases of MSF acquired in Morocco presented with very different malignant courses: the first one with meningoencephalitis, the second one with lung embolism, and the third one with septic shock and multi-organ failure. No fatality occurred but the first patient experienced prolonged and serious neurological impairment. In historical series before antibiotic use, mortality rate of MSF was below 1% and severe forms were described very sporadically.2 Since the eighties however, complicated cases have been increasingly reported. Chloroambucil Table 1 summarizes the main findings of the largest published series.5–15 This overview has however several limitations. First, comparisons between studies are impossible because they differ widely in terms of location, setting (mostly hospital-based), design (mostly retrospective), study participants (adults and/or children), recruitment bias, diagnostic criteria for MSF (clinical—classic immunofluorescence serology—newer reference methods), and case definitions of severe course. This last definition is particularly variable between series, ranging from “hospital admission”13 to “severe organ involvement”8,12 or “admission in intensive care.