{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T15:52:29Z","timestamp":1790351549545,"version":"4.1.0"},"reference-count":113,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,5,30]],"date-time":"2026-05-30T00:00:00Z","timestamp":1780099200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Center for Chronic Infectious Diseases, Long School of Medicine, Division of Infectious Diseases, University of Texas San Antonio"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pathogens"],"abstract":"<jats:p>Typhus (FBT), caused by Rickettsia typhi, rarely causes neurological disease. Herein, we describe neurological involvement in two cases of FBT. In the first case, an adult presented with persistent fever which deteriorated into status epilepticus. He was successfully treated with doxycycline and made a complete recovery. In the second case, a patient suffered an ischemic stroke and had a protracted clinical course but ultimately made a near complete recovery. In addition to these cases, we conducted a comprehensive narrative review of 43 cases of neurologic involvement in FBT reported from 1989 to 2025. Cases were excluded if there were pathologic discrepancies with typical cases of FBT. Presentations ranged from cranial nerve palsies to meningitis and fulminant encephalitis. This review highlights the spectrum of CNS complications associated with FBT and underscores the importance of early recognition and treatment with doxycycline to improve outcomes. Given the potential severity of neurologic involvement, clinicians in endemic areas should maintain a high index of suspicion for FBT in patients presenting with a febrile illness and neurologic symptoms.<\/jats:p>","DOI":"10.3390\/pathogens15060590","type":"journal-article","created":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T02:37:26Z","timestamp":1780454246000},"page":"590","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Meningoencephalitis in Flea-Borne Typhus: A Report of Two Cases and a Review of CNS Complications"],"prefix":"10.3390","volume":"15","author":[{"given":"Camille E.","family":"Spears","sequence":"first","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7853-4681","authenticated-orcid":false,"given":"Divya","family":"Chandramohan","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3287-3327","authenticated-orcid":false,"given":"Melinda B.","family":"Tanabe","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas C.","family":"Anstead","sequence":"additional","affiliation":[{"name":"Department of Psychological Sciences, Texas Tech University, Box 42051, Lubbock, TX 79409, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily L. M.","family":"Turkily","sequence":"additional","affiliation":[{"name":"Department of Psychological Sciences, Texas Tech University, Box 42051, Lubbock, TX 79409, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4653-2323","authenticated-orcid":false,"given":"Lucas S.","family":"Blanton","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thelma","family":"Akien","sequence":"additional","affiliation":[{"name":"Cleveland Clinic Foundation, 10300 Carnegie Ave, Cleveland, OH 44106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3407-0213","authenticated-orcid":false,"given":"Christopher L.","family":"Dayton","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Texas San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229, USA"},{"name":"Division of Critical Care and Pulmonology, Department of Medicine, University of Texas San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James C.","family":"Saca","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, University of Texas San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5473-9375","authenticated-orcid":false,"given":"Gregory M.","family":"Anstead","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA"},{"name":"Division of Infectious Diseases, Medical Service, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.actatropica.2016.10.018","article-title":"Clinical and laboratory characteristics, epidemiology, and outcomes of murine typhus: A systematic review","volume":"166","author":"Tsioutis","year":"2017","journal-title":"Acta Trop."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"863","DOI":"10.4269\/ajtmh.19-0118","article-title":"Case report: Early doxycycline therapy for potential rickettsiosis in critically ill patients in flea-borne typhus endemic areas","volume":"101","author":"Chueng","year":"2019","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1146\/annurev.en.35.010190.003005","article-title":"Epidemiology of murine typhus","volume":"35","author":"Azad","year":"1990","journal-title":"Annu. Rev. Entomol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1186\/s13071-016-1511-8","article-title":"Transmission mechanisms of an emerging insect-borne rickettsial pathogen","volume":"9","author":"Brown","year":"2016","journal-title":"Parasit. Vectors"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Anstead, G.M. (2020). History, rats, fleas, and opossums. II. The decline and resurgence of flea-borne typhus in the United States, 1945\u20132019. Trop. Med. Infect. Dis., 6.","DOI":"10.3390\/tropicalmed6010002"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"142","DOI":"10.4269\/ajtmh.23-0272","article-title":"Surveillance of flea-borne typhus in California, 2011\u20132019","volume":"110","author":"Yomogida","year":"2023","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Anstead, G.M. (2025). A One Health perspective on the resurgence of flea-borne typhus in Texas in the 21st Century. Part 1. The bacteria, the cat flea, urbanization, and climate change. Pathogens, 14.","DOI":"10.3390\/pathogens14020154"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Roberts, T., Parker, D.M., Bulterys, P.L., Rattanavong, S., Elliott, I., Phommasone, K., Mayxay, M., Chansamouth, V., Robinson, M.T., and Blacksell, S.D. (2021). A spatio-temporal analysis of scrub typhus and murine typhus in Laos; implications from changing landscapes and climate. PLoS Negl. Trop. Dis., 15.","DOI":"10.1371\/journal.pntd.0009685"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"319","DOI":"10.3201\/eid0303.970308","article-title":"Flea-borne rickettsioses: Ecologic considerations","volume":"3","author":"Azad","year":"1997","journal-title":"Emerg. Infect. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"606","DOI":"10.7326\/0003-4819-104-5-606","article-title":"Acute febrile cerebrovasculitis: A syndrome of unknown, perhaps rickettsial, cause","volume":"104","author":"Wenzel","year":"1986","journal-title":"Ann. Int. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1753","DOI":"10.1001\/archinte.1991.00400090051010","article-title":"Rickettsial meningitis and encephalitis","volume":"151","author":"Silpapojakul","year":"1991","journal-title":"Arch. Intern. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.ijid.2015.08.001","article-title":"Hypoglycorrhachia in adults with community-acquired meningitis: Etiologies and prognostic significance","volume":"39","author":"Shrikanth","year":"2015","journal-title":"Int. J. Infect. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Anstead, G.M. (2020). History, rats, fleas, and opossums: The ascendency of flea-borne typhus in the United States, 1910\u20131944. Trop. Med. Infect. Dis., 5.","DOI":"10.3390\/tropicalmed5010037"},{"key":"ref_14","unstructured":"(2009). Typhus [ti\u2032 f\u0259s]. Emerg. Infect. Dis., 15, 977."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1016\/S0025-7125(16)35021-0","article-title":"Rickettsial involvement of the nervous system","volume":"37","author":"Harrell","year":"1953","journal-title":"Med. Clin. N. Am."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"797","DOI":"10.1093\/ajcp\/17.10.797","article-title":"Endemic (murine) typhus; report of autopsy findings in three cases","volume":"17","author":"Binford","year":"1947","journal-title":"Am. J. Clin. Pathol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1093\/ajcp\/91.6.720","article-title":"Histopathology and immunohistologic demonstration of the distribution of Rickettsia typhi in fatal murine typhus","volume":"91","author":"Walker","year":"1989","journal-title":"Am. J. Clin. Pathol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"306","DOI":"10.4269\/ajtmh.18-0084","article-title":"Case report: Fulminant murine typhus presenting with status epilepticus and multi-organ failure: An autopsy case and a review of the neurologic presentations of murine typhus","volume":"99","author":"Stephens","year":"2018","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"132","DOI":"10.3390\/idr15010014","article-title":"Flea-borne typhus causing hemophagocytic lymphohistiocytosis: An autopsy case","volume":"15","author":"Chandramohan","year":"2023","journal-title":"Infect. Dis. Rep."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"838","DOI":"10.15585\/mmwr.mm7231a1","article-title":"Fleaborne typhus-associated deaths\u2014Los Angeles County, California, 2022","volume":"72","author":"Alarcon","year":"2023","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Klinnert, J., Ovechko, V., Felicella, M.M., McDougal, A., Muir, S.E., Crocquet-Valdes, P.A., Walker, D.H., and Blanton, L.S. (2026). The paucity of typical pathology: An autopsy series of Typhus Group Rickettsiosis-associated hemophagocytic lymphohistiocytosis. Pathogens, 15.","DOI":"10.3390\/pathogens15020230"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"700","DOI":"10.3390\/idr15060063","article-title":"Murine typhus: A review of a reemerging flea-borne rickettsiosis with potential for neurologic manifestations and sequalae","volume":"15","author":"Blanton","year":"2023","journal-title":"Infect. Dis. Rep."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1982","DOI":"10.3201\/eid2411.171373","article-title":"Rickettsia typhi as cause of fatal encephalitic typhus in hospitalized patients, Hamburg, Germany, 1940\u20131944","volume":"24","author":"Rauch","year":"2018","journal-title":"Emerg. Infect. Dis."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"665","DOI":"10.1007\/s004150050264","article-title":"Murine typhus presenting as subacute meningoencephalitis","volume":"245","author":"Masalha","year":"1998","journal-title":"J. Neurol."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Xu, Z., Zhu, X., Lu, Q., Li, X., and Hu, Y. (2015). Misdiagnosed murine typhus in a patient with multiple cerebral infarctions and hemorrhage: A case report. BMC Neurol., 15.","DOI":"10.1186\/s12883-015-0383-4"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1682","DOI":"10.1001\/archinte.1989.00390070182031","article-title":"Acute febrile cerebrovasculitis: A non\u2014Spotted fever group rickettsial disease","volume":"149","author":"Linnemann","year":"1989","journal-title":"Arch. Intern. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.pediatrneurol.2013.09.017","article-title":"Murine typhus as a cause of cognitive impairment: Case report and a review of the literature","volume":"50","author":"Carr","year":"2014","journal-title":"Pediatr. Neurol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"232","DOI":"10.4269\/ajtmh.15-0119","article-title":"Blood-brain barrier function and biomarkers of central nervous system injury in rickettsial versus other neurological infections in Laos","volume":"93","author":"Dittrich","year":"2015","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/1348-0421.12865","article-title":"The landscape of extrapulmonary manifestations of human parainfluenza viruses: A systematic narrative review","volume":"65","author":"Farahmand","year":"2021","journal-title":"Microbiol. Immunol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e00040-18","DOI":"10.1128\/CMR.00040-18","article-title":"Nonsuppurative (aseptic) meningoencephalomyelitis associated with neurovirulent astrovirus infections in humans and animals","volume":"31","author":"Reuter","year":"2018","journal-title":"Clin. Microbiol. Rev."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"584","DOI":"10.2174\/1871527319666200708133103","article-title":"Autoimmune encephalitis: Current knowledge on subtypes, disease mechanisms and treatment","volume":"19","author":"Nissen","year":"2020","journal-title":"CNS Neurol. Disord. Drug Targets"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1136\/pgmj.64.754.614","article-title":"Rickettsial infection presenting as culture-negative meningitis","volume":"64","author":"Woo","year":"1988","journal-title":"Postgrad. Med. J."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"122","DOI":"10.24171\/j.phrp.2018.9.3.07","article-title":"Case of Rickettsia typhi-induced brain abscess mimicking brain tumor","volume":"9","author":"Jang","year":"2018","journal-title":"Osong Public Health Res. Perspect."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"949","DOI":"10.1001\/archinte.1989.00390040143033","article-title":"Delayed neurologic display in murine typhus: Report of two cases","volume":"149","author":"Samra","year":"1989","journal-title":"Arch. Intern. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"872","DOI":"10.1001\/archinte.159.8.872","article-title":"Murine typhus as a common cause of fever of intermediate duration: A 17-year study in the south of Spain","volume":"159","author":"Viciana","year":"1999","journal-title":"Arch. Intern. Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1177\/088307380201700217","article-title":"Rickettsia typhi infection presenting as subacute meningitis","volume":"17","author":"Galanakis","year":"2002","journal-title":"J. Child. Neurol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"826","DOI":"10.1046\/j.1469-0691.2002.00502.x","article-title":"Aseptic meningitis as a delayed neurologic complication of murine typhus","volume":"8","author":"Wittel","year":"2002","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"886","DOI":"10.1080\/00365540310016853","article-title":"Facial paralysis and meningitis caused by Rickettsia typhi infection","volume":"35","author":"Vander","year":"2003","journal-title":"Scand. J. Infect. Dis."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"740","DOI":"10.3201\/eid1004.030532","article-title":"Murine typhus with renal involvement in Canary Islands, Spain","volume":"10","author":"Santana","year":"2004","journal-title":"Emerg. Infect. Dis."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1097\/01.PHM.0000157106.73355.90","article-title":"Neuroimaging and clinical manifestations of bilateral temporal encephalopathy secondary to murine typhus infection","volume":"84","author":"Lew","year":"2005","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/j.ijid.2004.09.011","article-title":"Clinical and laboratory features of murine typhus in central Tunisia: A report of seven cases","volume":"9","author":"Kaabia","year":"2005","journal-title":"Int. J. Infect. Dis."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1016\/j.revmed.2006.10.325","article-title":"Meningitis revealing Rickettsia typhi infection","volume":"28","author":"Toumi","year":"2007","journal-title":"Rev. Med. Interne"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1111\/j.1708-8305.2010.00435.x","article-title":"Murine typhus as a cause of fever in travelers from Tunisia and Mediterranean areas","volume":"17","author":"Angelakis","year":"2010","journal-title":"J. Travel Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"652","DOI":"10.5694\/j.1326-5377.2011.tb03152.x","article-title":"Murine typhus returns to New South Wales: A case of isolated meningoencephalitis with raised intracranial pressure","volume":"194","author":"Simon","year":"2011","journal-title":"Med. J. Aust."},{"key":"ref_45","first-page":"36","article-title":"Murine typhus with presentation of unilateral abducens nerve palsy: A case report","volume":"25","author":"Hsu","year":"2014","journal-title":"J. Intern. Med. Taiwan"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"620","DOI":"10.4269\/ajtmh.14-0559","article-title":"Case report: Abducens nerve palsy and meningitis by Rickettsia typhi","volume":"92","author":"Moy","year":"2015","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/j.kjms.2018.02.006","article-title":"Murine typhus associated abducens nerve palsy","volume":"34","year":"2018","journal-title":"Kaohsiung J. Med. Sci."},{"key":"ref_48","first-page":"e4450","article-title":"Murine typhus presenting with acute psychosis and disseminated intravascular coagulation: A case report","volume":"11","author":"Pervaiz","year":"2019","journal-title":"Cureus"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.ijid.2019.04.012","article-title":"Murine typhus presenting with status epilepticus","volume":"83","author":"Shafi","year":"2019","journal-title":"Int. J. Infect. Dis."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e00852","DOI":"10.1016\/j.idcr.2020.e00852","article-title":"Rickettsia typhi central nervous system infection","volume":"21","author":"Talhelm","year":"2020","journal-title":"IDCases"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s12348-021-00239-1","article-title":"Abducens nerve palsy with associated retinal involvement secondary to rickettsia typhi infection","volume":"11","author":"Abderrahim","year":"2021","journal-title":"J. Ophthalmic Inflamm. Infect."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"100073","DOI":"10.1016\/j.dscb.2023.100073","article-title":"Flea-borne typhus with rare neurological manifestations\u2014Case report","volume":"10","author":"Hasnuddin","year":"2023","journal-title":"Brain Disord."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"e242","DOI":"10.1097\/INF.0000000000004306","article-title":"Localized myositis and transient encephalopathy as presenting symptoms in murine typhus","volume":"43","author":"Mehta","year":"2024","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"123281","DOI":"10.1016\/j.jns.2024.123281","article-title":"Typhus group Rickettsia community-acquired bacterial central nervous system infections: We must think outside the box!","volume":"466","author":"Roxas","year":"2024","journal-title":"J. Neurol. Sci."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"123412","DOI":"10.1016\/j.jns.2025.123412","article-title":"Rickettsia typhi group central nervous system infection: End of the beginning","volume":"470","author":"Madril","year":"2025","journal-title":"J. Neurol. Sci."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"23247096251345086","DOI":"10.1177\/23247096251345086","article-title":"A flea-borne mystery: Unraveling murine typhus in a patient with unexplained encephalopathy","volume":"13","author":"Aboytes","year":"2025","journal-title":"J. Investig. Med. High Impact Case Rep."},{"key":"ref_57","unstructured":"Murray, P.R., Baron, E.J., Pfaller, M.A., Tenover, F.C., and Yolken, R.H. (1995). Rickettsia and Coxiella. Manual of Clinical Microbiology, ASM Press. [6th ed.]."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1007\/s11910-016-0671-4","article-title":"Isolated abducens nerve palsy: Update on evaluation and diagnosis","volume":"16","author":"Elder","year":"2016","journal-title":"Curr. Neurol. Neurosci. Rep."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"e104","DOI":"10.1016\/S2214-109X(14)70289-X","article-title":"Orientia, rickettsia, and leptospira pathogens as causes of CNS infections in Laos: A prospective study","volume":"3","author":"Dittrich","year":"2015","journal-title":"Lancet Glob. Health"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"489","DOI":"10.4103\/0972-9062.383643","article-title":"A case series of Mediterranean spotted fever and murine typhus with neurological manifestations","volume":"61","author":"Hammami","year":"2024","journal-title":"J. Vector Borne Dis."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"1088","DOI":"10.4269\/ajtmh.16-0465","article-title":"Fatal fleaborne typhus in Texas: A retrospective case series, 1985\u20132015","volume":"96","author":"Pieracci","year":"2017","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"779","DOI":"10.3109\/00365548.2014.943283","article-title":"Murine typhus in elderly patients: A prospective study of 49 patients","volume":"46","author":"Tsioutis","year":"2014","journal-title":"Scand. J. Infect. Dis."},{"key":"ref_63","unstructured":"Poels, L.G., and Jap, P.H.K. (2025, July 01). A Plasmacytoid Lymphocyte in Peripheral Blood Smear (Human). Available online: https:\/\/collections.lib.utah.edu\/ark:\/87278\/s6128vx0."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1159\/000439160","article-title":"Cerebrospinal fluid cytology of Lyme Neuroborreliosis: A report of 3 cases with literature review","volume":"59","author":"Xing","year":"2015","journal-title":"Acta Cytol."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"e12","DOI":"10.1086\/375692","article-title":"Plasma cell pleocytosis in cerebrospinal fluid in patients with West Nile Virus Encephalitis","volume":"37","author":"Carson","year":"2003","journal-title":"Clin. Infect. Dis."},{"key":"ref_66","first-page":"149","article-title":"Zoster meningitis and radiculomeningitis after tick bite: Cytological findings in cerebrospinal fluid","volume":"18","author":"Shoji","year":"1979","journal-title":"Eur. Neurol."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1097\/00006454-200006000-00009","article-title":"Murine typhus in south Texas children","volume":"19","author":"Fergie","year":"2000","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1001\/archpedi.155.3.396","article-title":"Clinical, laboratory, and epidemiologic features of murine typhus in 97 Texas children","volume":"155","author":"Whiteford","year":"2001","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1080\/00365540500540459","article-title":"Murine typhus is a common cause of febrile illness in Bedouin children in Israel","volume":"38","author":"Shalev","year":"2006","journal-title":"Scand. J. Infect. Dis."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1007\/s10096-007-0310-8","article-title":"Murine typhus in Cyprus: 21 paediatric cases","volume":"26","author":"Koliou","year":"2007","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1111\/j.1469-0691.2008.02133.x","article-title":"Murine typhus in children: Clinical and laboratory features from 41 cases in Crete, Greece","volume":"15","author":"Gikas","year":"2009","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1097\/INF.0000000000001954","article-title":"Murine typhus in South Texas children. An 18-year review","volume":"37","author":"Howard","year":"2018","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"168","DOI":"10.4269\/ajtmh.1988.38.168","article-title":"Murine typhus among Khmers living at an evacuation site on the Thai-Kampuchean border","volume":"38","author":"Brown","year":"1988","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_74","first-page":"549","article-title":"Endemic typhus in Singapore-A re-emerging infectious disease","volume":"42","author":"Ong","year":"2001","journal-title":"Singap. Med. J."},{"key":"ref_75","first-page":"613","article-title":"Tifus murino en Tenerife: Estudio clinicoepidemiol\u00f3gico y caracter\u00edsticas cl\u00ednicas diferenciales con la fiebre Q","volume":"121","author":"Laynez","year":"2003","journal-title":"Med. Cl\u00edn."},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1196\/annals.1374.126","article-title":"Serologic study of rickettsioses among acute febrile patients in central Tunisia","volume":"1078","author":"Kaabia","year":"2006","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_77","first-page":"U2661","article-title":"Murine typhus: A newly recognised problem in the Waikato region of New Zealand","volume":"120","author":"Gray","year":"2007","journal-title":"N. Z. Med. J."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"e591","DOI":"10.1016\/j.ijid.2012.03.010","article-title":"Murine typhus in central Greece: Epidemiological, clinical, laboratory, and therapeutic-response features of 90 cases","volume":"16","author":"Chaliotis","year":"2012","journal-title":"Int. J. Infect. Dis."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"972","DOI":"10.4269\/ajtmh.14-0806","article-title":"Clinical and epidemiological characteristics of scrub typhus and murine typhus among hospitalized patients with acute undifferentiated fever in Northern Vietnam","volume":"92","author":"Hamaguchi","year":"2015","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"520","DOI":"10.7326\/0003-4819-23-4-520","article-title":"Endemic (murine) typhus fever: Clinical observations of 180 cases","volume":"23","author":"Stuart","year":"1945","journal-title":"Ann. Intern. Med."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/00005792-194602000-00001","article-title":"Murine typhus fever","volume":"25","author":"Miller","year":"1946","journal-title":"Medicine"},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"2173","DOI":"10.1001\/jama.1986.03370160071029","article-title":"Epidemiology of murine typhus in Texas: 1980 through 1984","volume":"255","author":"Taylor","year":"1986","journal-title":"JAMA"},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"1365","DOI":"10.1001\/jama.1991.03470100057033","article-title":"Clinical and laboratory features of murine typhus in south Texas, 1980 through 1987","volume":"266","author":"Dumler","year":"1991","journal-title":"JAMA"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1007\/BF00144812","article-title":"Clinicoepidemiological study of murine typhus on the Greek island of Evia","volume":"8","author":"Tselentis","year":"1992","journal-title":"Eur. J. Epidemiol."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/S0035-9203(02)90090-8","article-title":"Murine typhus in Greece: Epidemiological, clinical, and therapeutic data from 83 cases","volume":"96","author":"Gikas","year":"2002","journal-title":"Trans. R. Soc. Trop. Med. Hyg."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"321","DOI":"10.4269\/ajtmh.2008.78.321","article-title":"Murine typhus in Caldas, Colombia","volume":"78","author":"Hidalgo","year":"2008","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"1656","DOI":"10.3201\/eid1410.080236","article-title":"Murine typhus and febrile illness, Nepal","volume":"14","author":"Zimmerman","year":"2008","journal-title":"Emerg. Infect. Dis."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"412","DOI":"10.3201\/eid1603.091028","article-title":"Murine typhus in Austin, Texas, USA, 2008","volume":"16","author":"Adjemian","year":"2010","journal-title":"Emerg. Infect. Dis."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"141","DOI":"10.4269\/ajtmh.2012.11-0465","article-title":"Murine typhus in southern Taiwan during 1992\u20132009","volume":"87","author":"Chang","year":"2012","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.4269\/ajtmh.2012.11-0794","article-title":"Murine typhus in returned travelers: A report of thirty-two cases","volume":"86","author":"Walter","year":"2012","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1016\/j.trstmh.2012.02.010","article-title":"Murine typhus in Cyprus: A 9-year survey","volume":"106","author":"Psaroulaki","year":"2012","journal-title":"Trans. R. Soc. Trop. Med. Hyg."},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1016\/j.medmal.2013.02.007","article-title":"Murine typhus in Tunisia: A neglected cause of fever as a single symptom","volume":"43","author":"Znazen","year":"2013","journal-title":"M\u00e9d. Mal. Infect."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1016\/j.medmal.2015.01.009","article-title":"Epidemiological, clinical and laboratory features of murine typhus in central Tunisia","volume":"45","author":"Aouam","year":"2015","journal-title":"Med. Mal. Infect."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"1268","DOI":"10.3201\/eid2308.161861","article-title":"Acute febrile illness and complications due to murine typhus, Texas, USA","volume":"23","author":"Afzal","year":"2017","journal-title":"Emerg. Infect. Dis."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"88","DOI":"10.4103\/ni.ni_139_22","article-title":"Neurological manifestations of scrub typhus: The clinical spectrum, determinants, and outcome","volume":"73","author":"Majumdar","year":"2025","journal-title":"Neurol. India"},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.4269\/ajtmh.15-0380","article-title":"An unusual cutaneous manifestation in a patient with murine typhus","volume":"93","author":"Blanton","year":"2015","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"470","DOI":"10.2307\/4579959","article-title":"The Typhus-Rocky Mountain Spotted Fever group: An epidemiological and clinical study in the eastern and southeastern states","volume":"46","author":"Rumreich","year":"1931","journal-title":"Public. Health Rep."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.rr6502a1","article-title":"Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain Spotted Fever and other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis\u2014United States","volume":"65","author":"Biggs","year":"2016","journal-title":"MMWR Recomm. Rep."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1093\/trstmh\/trx017","article-title":"Clinical manifestations of scrub typhus","volume":"111","author":"Rajapakse","year":"2017","journal-title":"Trans. R. Soc. Trop. Med. Hyg."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"421","DOI":"10.7326\/0003-4819-51-3-421","article-title":"Status of the rickettsioses in the United States","volume":"51","author":"Smadel","year":"1959","journal-title":"Ann. Intern. Med."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"12","DOI":"10.2307\/4581424","article-title":"Endemic typhus in Alabama","volume":"50","author":"Baker","year":"1935","journal-title":"Public Health Rep."},{"key":"ref_102","doi-asserted-by":"crossref","unstructured":"Taylor, A.J., Paris, D.H., and Newton, P.N. (2015). A systematic review of mortality from untreated scrub typhus (Orientia tsutsugamushi). PLoS Negl. Trop. Dis., 9.","DOI":"10.1371\/journal.pntd.0003971"},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"174","DOI":"10.4269\/ajtmh.2010.09-0752","article-title":"Rocky Mountain Spotted Fever in the United States, 2000\u20132007: Interpreting contemporary increases in incidence","volume":"83","author":"Openshaw","year":"2010","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"107151","DOI":"10.1016\/j.ijid.2024.107151","article-title":"Global and regional seroprevalence, incidence, mortality of, and risk factors for scrub typhus: A systematic review and meta-analysis","volume":"146","author":"Wang","year":"2024","journal-title":"Int. J. Infect. Dis."},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1001\/archinte.1952.00240100021003","article-title":"Residual effects of rickettsial disease on the central nervous system: Results of neurologic examinations and electroencephalograms following Rocky Mountain spotted fever","volume":"90","author":"Rosenblum","year":"1952","journal-title":"AMA Arch. Intern. Med."},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1097\/QCO.0000000000001135","article-title":"Neurological complications of scrub typhus","volume":"38","author":"Reba","year":"2025","journal-title":"Curr. Opin. Infect. Dis."},{"key":"ref_107","doi-asserted-by":"crossref","unstructured":"Raoult, D., and Parola, P. (2007). Pathogenesis, immunity, pathology, and pathophysiology in rickettsial diseases. Rickettsial Diseases, CRC Press.","DOI":"10.3109\/9781420019971"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"e52","DOI":"10.1097\/INF.0000000000002595","article-title":"Sequelae following acute encephalitis syndrome caused by Orientia tsutsugamushi","volume":"39","author":"Thangaraj","year":"2020","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_109","first-page":"e79055","article-title":"Clinical profile and long-term outcomes of scrub typhus meningoencephalitis in children","volume":"17","author":"Mishra","year":"2025","journal-title":"Cureus"},{"key":"ref_110","doi-asserted-by":"crossref","first-page":"S138","DOI":"10.5005\/jp-journals-10071-23841","article-title":"Scrub typhus and other rickettsial infections","volume":"25","author":"Gunasekaran","year":"2021","journal-title":"Indian J. Crit. Care Med."},{"key":"ref_111","first-page":"17","article-title":"The penetration of doxycycline into CSF","volume":"9","author":"Andersson","year":"1976","journal-title":"Scand. J. Infect. Dis. Suppl."},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1086\/313604","article-title":"Minocycline versus doxycycline in the treatment of Lyme neuroborreliosis","volume":"30","author":"Cunha","year":"2000","journal-title":"Clin. Infect. Dis."},{"key":"ref_113","doi-asserted-by":"crossref","unstructured":"Gundamraj, S., and Hasbun, R. (2020). The use of adjunctive steroids in central nervous infections. Front. Cell Infect. Microbiol., 10.","DOI":"10.3389\/fcimb.2020.592017"}],"container-title":["Pathogens"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-0817\/15\/6\/590\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T03:23:49Z","timestamp":1780457029000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-0817\/15\/6\/590"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,30]]},"references-count":113,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["pathogens15060590"],"URL":"https:\/\/doi.org\/10.3390\/pathogens15060590","relation":{},"ISSN":["2076-0817"],"issn-type":[{"value":"2076-0817","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,30]]}}}