Murine typhus is an infection by rickettsia typhi transmitted by rat fleas. Typical symptoms are non-specific, consisting of rash, fever, myalgia, and headache with hematologic derangements. Severe disease is rare, usually occurring in older males with underlying liver, lung disease, or in individuals with glucose-6-phosphate dehydrogenase deficiency. Neurological complications are rare, with few case reports of meningoencephalitis, cognitive impairment, and seizures. Here we describe a case of severe murine typhus in a young female who presented with thunderclap headache.

20-year-old otherwise healthy female presented with acute onset 10/10 headache and vomiting. She underwent computed tomography and lumbar puncture, which were unrevealing, and was discharged on supportive therapy. She returned 5 days later with shortness of breath and fever that progressed to respiratory failure requiring intubation and was placed on empirical antibiotics with vancomycin, piperacillin-tazobactam, and levofloxacin. Four days later, she developed severe kidney injury that prompted auto-immune workup, renal biopsy, and initiation of doxycycline for rickettsial coverage. She had persistent headache with bilateral papilledema 10 days into her hospitalization with normal brain and vascular imaging. Extensive infectious, autoimmune, and vasculitic evaluations were unrevealing until rickettsial titers returned elevated for typhus. Patient completed 10 days of doxycycline and had full kidney, pulmonary, and neurologic recovery over the ensuing month.

This case illustrates an atypical presentation of murine typhus with thunderclap headache and severe disease in an otherwise healthy young female without predisposing co-morbidities. Lack of initial fever, rash, and rapid progression to severe disease may have contributed to delay in doxycycline initiation. Clinical diagnosis remains challenging given lack of pathognomonic signs and symptoms. Although neurological complications are rare, papilledema has been reported. Broadening the differential to include murine typhus in setting of papilledema and infectious signs may help avoid treatment delays in future cases.