96 mg/dL. A urine test showed proteinuria and hematuria. Having considered a salmonella infection (including Salmonella Typhi), we started empirical use of ceftriaxone from the day of admission. On the eighth day of illness, finding suffusion and maculopapular rash on the face and trunk, which then spread peripherally, we considered a rickettsial infection and therefore started minocycline 100 mg q12h. mTOR inhibitor The patient’s general condition started to improve from the next day. Minocycline was administrated for 14 days. We diagnosed it as murine typhus, because polymerase chain

reaction (PCR) analysis and direct sequencing showed R typhi positive from all specimens taken on the eighth day of illness at the National Institute of Infectious Diseases, including those from the skin, serum, urine, and buffy coat (Figure 1).2,3 A 23-year-old man traveled to Bali, Indonesia, for 2 weeks in late March 2008. Two days after his return, he visited a local hospital due to a fever of 39°C. He was prescribed with cefcapene but started to experience a headache

on the fourth day after returning. On the fifth day of the illness, he was admitted to Kameda General Hospital. On admission, his constitutional condition was good but his temperature had risen to 37.7°C with a small erythematous rash on his chest and arm, and subcutaneous bleeding was found on his precordium. A blood test showed no serious disorders buy Compound Library but an increased bilirubin level of 1.5 mg/dL and CRP of 9.3 mg/dL. Dengue fever was first suspected and a blood test was performed in the National Institute of Infectious Diseases. The dengue virus PCR

and antibodies were both negative see more and since his medical history and travel area were similar to case 1, we tested for R typhi infection by PCR and antibodies by an indirect immunofluorescent assay. Subsequently we diagnosed it as murine typhus, because PCR detection and direct sequencing was R typhi positive from serum taken on the 5th day of illness, and the antibody titers were elevated in the paired sera from <40/<40 (IgG/IgM) on the 5th day of illness to 320/640 on the 13th day of illness.2–4 In Japan, there have been no subsequent reports of R typhi following a domestic case in 20035 and a case originating in Vietnam in 2003.6 However, these two different Japanese travelers who visited Bali, Indonesia, in the same season were confirmed to have murine typhus. In Japan, many cases were reported in the 1940s and 1950s, yet there were only three suspected cases after the 1950s and one diagnosed case in 2003.5,6 Besides Indonesia, murine typhus is reported as being endemic worldwide.7,8 Endemic areas include Asia, Africa, Europe, and the United States, but reports of infected travelers amount to no more than about 50.