Pulmonary Alveolar Proteinosis in a Patient with Severe Flea-Borne Typhus

Flea-borne typhus (FBT) is an infection caused by the bacteria Rickettsia typhi. It is usually an acute undifferentiated febrile illness; however, approximately one-quarter of patients suffer from organ-specific complications. In the present report, the case of a 51-year-old woman who originally presented to the clinic with a febrile illness is described. After being given supportive care with intravenous fluids and antiemetics for presumed viral infection, she returned to the emergency department the next day in a hypotensive state and experiencing respiratory distress, requiring emergent intubation in the context of developing severe acute respiratory distress syndrome (ARDS). An initial chest computed tomography scan revealed diffuse ground-glass opacities with interlobular septal thickening. Bronchoalveolar lavage was performed, revealing acellular eosinophilic aggregates consistent with pulmonary alveolar proteinosis (PAP). The clinical context of her serology strongly supported the diagnosis of FBT. This case illustrates the critical care complexities associated with FBT, in addition to a previously undescribed finding, PAP, in rickettsial infections. The patient's rapid progression of life-threatening ARDS and multiorgan dysfunction highlights the need for the timely diagnosis and treatment of FBT.