32 The most common symptoms were fever (100%), rash (57%), lymphadenopathy (37%), and severe headache (29%). R typhi infections are reported in Greece and mostly in the island of Crete.12,33 The predominant clinical manifestations were fever (100%), headache (88%), chills (86.7%), and rash Natural Product Library order (79.5%).12 In Italy, murine typhus was the most widespread rickettsioses,

especially in Sicily during World War II.34Rickettsia typhi still exist, at least in Sicily; in particular, asymptomatic cases of murine typhus were reported in Sicily in the late 1980s.34 In the south of Spain a prospective study over 17 years (1979–1995) identified 104 cases of murine typhus.17Rickettsia typhi infection was the cause in 6.7% of 926 cases of fever lasting PTC124 mouse for 7 to 28 days. Sero-epidemiological

studies reveal that murine typhus probably exists in other Mediterranean countries. In Morocco indirect immunofluorescence test on human sera obtained from 300 donors and 126 patients from clinical laboratories identified R typhi antibodies in 1.7 and 4%, respectively.35 In France R typhi antibodies were identified in homeless patients from Marseille.36 An R typhi-positive serology was identified in 68.1% of the residents in the northern Dalmatian islands of Croatia in an epidemiological study.37Rickettsia typhi has also identified and cultivated from Monopsyllus sciurorum sciurorum fleas collected in southern Slovenia.38 There is evidence that murine typhus also exists in North Spain as the R typhi seroprevalence was in 7.6% of the people living in urban, 8.5% in semirural, and 21.4% in

rural areas.39 In Malta, contrary to current belief, R typhi did not account for any of the cases seen.40 Finally, there have not been any studies to determine if murine typhus is endemic in Libya, Lebanon, Syria, Turkey, Albania, Serbia, and Montenegro. In the countries of North Europe autochthones cases of murine typhus have not been described. However, sporadic cases are identified in travelers who visited endemic areas like the countries of check details the south Mediterranean area. As a result, R typhi infection was found in a Norwegian tourist with fever, chills, and severe headache who had visited the island of Crete.41 The patient did not present a rash and recovered without sequelae. The diagnosis of murine typhus was based on the detection of IgM antibodies against R typhi in serum samples during reconvalescence.41 Murine typhus was also identified in a traveler from the UK after her return from Spain.42 The patient presented fever (39.5°C), chills, severe headache, photophobia, a sore throat, neck stiffness, purpuric rash, and she was passing very little urine. Unfortunately, murine typhus was not considered from the beginning of the symptoms and she was treated with IV cefotaxime.