Challenges in diagnosis of Mediterranean spotted fever in a patient with aseptic meningitis: A case report from Southeast Iran

Challenges in diagnosis of Mediterranean spotted fever in a patient with aseptic meningitis: A case report from Southeast Iran Dear EditorMediterranean spotted fever (MSF), caused by Rickettsia conorii, is a tick-borne illness found in the Mediterranean, Black, and Caspian Seas, Sub-Saharan Africa, and the Middle East.Its diverse clinical presentation complicates its diagnosis and management [1].After an unnoticed tick bite, patients typically develop fever, maculopapular rash, and eschar within 5-7 days.Although asymptomatic infections are common, symptomatic MSF often includes fever, headache, and myalgia.MSF rarely leads to severe complications such as CNS involvement, including aseptic meningitis, particularly in adults [2].Recent studies have suggested that MSF is endemic in Iran, particularly in southeastern regions [1,3].We report a case of MSF with aseptic meningitis in a patient from Southeast Iran.This case illustrates the complexities of recognizing and managing MSF, particularly in cases complicated by aseptic meningitis.On April 20, 2024, an 85-year-old woman from Jiroft, Kerman Province, Southeast Iran, presented to Afzali Hospital with a weeklong fever, chills, weakness, abdominal pain, diarrhea, vomiting, and headache.She had hypertension, a history of cerebrovascular accident (CVA), and no insect bite recall.Her vital signs were as follows: temperature, 39 C; heart rate 105-130 bpm, blood pressure, 140/85 mmHg; and oxygen saturation, 95 %.A physical examination did not reveal any additional significant findings.At the initial hospitalization, cerebrospinal fluid (CSF) analysis revealed white blood cells (WBC) 108 with 67 % Polymorphonuclear (PMN) and 33 % lymph a protein level of 137 mg/dL (RR: 15-45 mg/dL) and a glucose level of 71 mg/dL (RR: 50-80 mg/dL).Blood and CSF cultures were negative, although the CSF protein levels were elevated.On the first day of hospitalization, a series of diagnostic tests were conducted, including a spiral chest CT scan; ultrasound of the kidneys, urinary tract, abdomen, liver, gallbladder, and spleen; and echocardiography.All results were within the normal limits.Laboratory tests upon admission revealed the following: Hemoglobin: 11.5 g/dL (reference range [RR]: 13.8-17.2g/dL), Leukocyte count: 7500 cells/mm (RR: 4500-11,000 cells/mm), Platelet count: 71 x 10 cells/mm (RR: 150-450 x 10 cells/mm), Serum creatinine: 0.8 mg/dL (RR: 0.8-1.2mg/ dL), Urea: 22 mg/dL (RR: 6-24 mg/dL), Alanine aminotransferase (ALT): 60 U/L (RR: 29-33 U/L), Aspartate aminotransferase (AST): 80 U/L (RR: 8-33 U/L), Alkaline phosphatase (ALP): 220 U/L (RR: 44-147 U/L), Prothrombin Time (PT): 14.9 seconds (RR: 11-13.5 seconds), Partial Thromboplastin Time (PTT): 48 seconds (RR: 25-35 seconds), Lactic acid dehydrogenase (LDH): 302 U/L (RR: 135-214 U/L), Creatine phosphokinase (CPK): 205 U/L (RR: 30-135 U/L), Erythrocyte sedimentation rate (ESR): 37 mm/hr (RR: <30 mm/hr), C-reactive protein (CRP): 80 mg/dL (RR: <0.3 mg/dL).Her platelet count was lower than normal but began to increase during hospitalization and treatment.ALT,