P3881 - Typhus in Texas: Rickettsial Infection as a Cause of Elevated Liver Enzymes

Valerie Quach, BSc¹, Anni Chowdhury, DO², Ashlynn Joseph, BSc¹, Kian Abdul-Baki, DO², Raakhi Menon, DO², Jordan Malone, DO², Giri Movva, MD², Jaison S. John, MD², Gabriel Reep, MD^2
1John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX; ²University of Texas Medical Branch, Galveston, TX

Introduction: Murine Typhus is a flea-transmitted infection caused by Rickettsia typhi and is often found in rodent carriers. Diagnosis of murine typhus is typically made based on clinical presentation, but symptoms are non-specific. We describe the case of a patient presenting with elevated liver enzymes secondary to rickettsial infection.

Case Description/Methods: A 51-year-old male with no significant past medical history presented to the ED with a 12-day history of fever of unknown origin (101 degrees F), worsening epigastric pain, and diarrhea. Labs revealed WBC 26, platelets 47,000, creatinine 1.92, bilirubin 1.3, alkaline phosphatase (ALP) 99, alanine aminotransferase (ALT) 63, and aspartate aminotransferase (AST) of 119. 4 days after admission the ALT peaked at 400 and the AST at 341. Clostridioides difficile toxin, as well as PCR of stool and respiratory samples were negative. Workup for CMV, EBV, hepatitis A, COVID-19, influenza, blood cultures, as well as drug screens were negative. CT abdomen/pelvis and abdominal ultrasound revealed mild splenomegaly with spleen measuring up to 14 cm. The patient was questioned for exposure to animals, and revealed he had a domestic cat and two dogs. He had spent significant amount of time outdoors prior to admission. The patient was started on doxycycline empirically for suspected typhus and had subjective improvement with abatement of fevers. His typhus IgM antibody titer returned at >1:1024. He completed the course of antibiotics, and was discharged uneventfully. Patient had follow up liver enzymes measured 2 weeks after discharge, which had returned to normal.

Discussion: Murine typhus is seen throughout the world; however, it is somewhat common in Texas, California, and Hawaii in the United States. It is typically transmitted from fleas of rodents, although domestic cats have been implicated as hosts as well. Symptoms include typical non-specific viral symptoms such as fevers, headaches, and myalgias. There have been reports of elevation in liver enzymes, however these are typically mild. Our patient presented with similar non-specific viral symptoms and also had liver enzyme elevation nearly 10 times the upper limit of normal. This case highlights the importance of considering rickettsial infections in the differential diagnosis of patient’s presenting with febrile illness with elevated liver enzymes, especially in areas with a higher prevalence of infection.


Disclosures:


Valerie Quach, BSc¹, Anni Chowdhury, DO², Ashlynn Joseph, BSc¹, Kian Abdul-Baki, DO², Raakhi Menon, DO², Jordan Malone, DO², Giri Movva, MD², Jaison S. John, MD², Gabriel Reep, MD². P3881 - Typhus in Texas: Rickettsial Infection as a Cause of Elevated Liver Enzymes, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.