title: [Clinical features of four atypical pediatric cases of endemic typhus with pneumonia].
abstract: OBJECTIVE
  To analyze clinical manifestations, treatment and prognosis of 4 cases with endemic typhus.
  
  
  METHODS
  The clinical data of four endemic typhus patients in prognosis were retrospectively analyzed. These four atypical cases of endemic typhus with pneumonia were treated in our department from October 2011 to March 2012. They were all male, with an age range of 15 months to 7 years. The four patients had long history, mild respiratory symptom and no improvement was found after treatment with cephalosporins. There were no evidences of bacterial, viral, or fungal infections and we thought they might have infection with other pathogen. Three were from rural areas. Routine blood tests, Weil-Felix reaction, blood smear (Giemsa staining) , and indirect immunofluorescence assay were performed.
  
  
  RESULTS
  Blood smear and IFA tests showed evidences for endemic typhus. The clinical presentations were atypical, the patients had no headache, but all had fever, rash, and pneumonia of varying severity. None of the patients had a severe cough, but bronchial casts were observed in one case. Recurrent fever was reported in three cases. Physical examinations showed no eschars, but one patient had a subconjunctival hemorrhage, and one had skin scratches, cervical lymphadenopathy, pleural effusion, pericardial effusion, and cardiac dilatation. Two patients had remarkably increased peripheral blood leukocyte counts; both these patients also had high alanine aminotransferase (ALT) levels and one had a high C-reactive protein (CRP) level. Weil-Felix testing was negative or the OX19 titer was low. The peripheral blood smear (Giemsa stain) showed intracellular pathogens in all four cases. After combined therapy with doxycycline and macrolide antibiotics, all four patients recovered well.
  
  
  CONCLUSIONS
  The endemic typhus children often come from rural areas. The clinical presentations were atypical, they usually have no headache, but have fever (often Periodic fever) , rash, and pneumonia of varying severity in these four cases. Combined therapy with doxycycline and macrolide antibiotics was effective in all four patients.
authors.affiliation: Respiratory and Infectious Diseases Center,Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China.
authors.forename: Jin-rong
authors.initials: JR
authors.lastname: Liu
authors.forename: Bao-ping
authors.initials: BP
authors.lastname: Xu
authors.forename: Shao-gang
authors.initials: SG
authors.lastname: Li
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.forename: Bao-lin
authors.initials: BL
authors.lastname: Tian
authors.affiliation: Email: zhaoshunying 2001@163.com.
authors.forename: Shun-ying
authors.initials: SY
authors.lastname: Zhao
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004318:Doxycycline / Q000627:therapeutic use; D005334:Fever / Q000175:diagnosis / Q000188:drug therapy / Q000473:pathology; D019084:Fluorescent Antibody Technique, Indirect; D006801:Humans; D007223:Infant; D007958:Leukocyte Count; D008168:Lung / Q000000981:diagnostic imaging / Q000473:pathology; D018942:Macrolides / Q000627:therapeutic use; D008297:Male; D011014:Pneumonia / Q000175:diagnosis / Q000188:drug therapy / Q000473:pathology; D011859:Radiography; D012189:Retrospective Studies; D013194:Staining and Labeling / Q000379:methods; D014437:Typhus, Endemic Flea-Borne / Q000175:diagnosis* / Q000188:drug therapy* / Q000473:pathology
chemical_list: D000900:Anti-Bacterial Agents; D018942:Macrolides; D004318:Doxycycline