Suspected Murine Typhus Associated With Neurologic Symptoms and Posterior Reversible Encephalopathy Syndrome (PRES)-Like MRI Abnormalities: A Case Report

Murine typhus, caused by Rickettsia typhi, is a flea-borne zoonosis that typically presents with fever, headache, myalgias, and rash. Central nervous system involvement is uncommon, and neuroimaging findings that mimic posterior reversible encephalopathy syndrome (PRES) are rarely reported. This case highlights a rare neuroinfectious presentation of murine typhus with PRES-like imaging findings in a young woman. A previously healthy woman in her 30s presented with persistent retro-orbital headaches, intermittent fevers, tremors, dysarthria, photophobia, myalgias, progressive weakness, and recurrent syncopal episodes. Initial computed tomography of the head demonstrated age-advanced microvascular ischemic changes versus possible PRES. Brain magnetic resonance imaging later revealed bilateral parietal-predominant fluid-attenuated inversion recovery (FLAIR) hyperintensities in the white matter, concerning for PRES. Cerebrospinal fluid (CSF) analysis was unremarkable, and extensive infectious and autoimmune evaluation was unrevealing. Despite nondiagnostic testing, persistent fevers and neurologic symptoms prompted empiric doxycycline therapy for suspected atypical infection. Within 48 hours, the patient experienced marked clinical improvement with resolution of fever, dysarthria, tremors, photophobia, and severe headache. Post-discharge serology showed a positive Rickettsia typhi IgM with a negative IgG. While these findings were consistent with possible early murine typhus, the absence of convalescent serologic testing limited definitive confirmation. Murine typhus is increasingly recognized as a cause of severe neurologic disease due to endothelial injury and systemic vasculitis. This case is notable for PRES-like neuroimaging abnormalities, normal CSF studies, and severe neurologic manifestations occurring in an otherwise healthy host without traditional risk factors for severe disease. The patient’s rapid clinical improvement following doxycycline therapy was consistent with a rickettsial infection but was not diagnostic of murine typhus. This case highlights the importance of early empiric treatment when rickettsial disease is suspected while awaiting confirmatory testing. This case expands the recognized neurologic spectrum of murine typhus and emphasizes the importance of considering rickettsial infections in patients presenting with unexplained febrile neurologic syndromes and nonspecific MRI abnormalities, particularly in endemic regions.