Stroke and Guillain-Barre syndrome secondary to spotted fever –A case report

Rickettsial infection is an important differential diagnosis in prolonged febrile illness and in returned travellers.
We report a 44-year-old male from Deraniyagala, Sri Lanka, with spotted fever Rickettsiosis presenting with stroke and Guillain-Barre syndrome. He presented with dysarthria, reduced sensorium, and acute renal failure on the background of a prolonged febrile illness over two weeks. Following admission there was rapid deterioration of consciousness due to renal failure requiring intubation and repeated haemodialysis. On brain imaging, there were bilateral basal ganglia and internal and external capsule infarctions. His serology was positive for spotted fever Rickettsial infection and there was rapid improvement following treatment with doxycycline. However, difficulty in weaning off from the ventilator due to poor respiratory effort and symmetrical flaccid quadriparesis with areflexia raised concerns of concomitant Guillain-Barre syndrome. Serial cerebrospinal fluid (CSF) studies showed the development of elevated CSF protein with cytoalbuminologic dissociation during his stay in the intensive care unit (ICU). A diagnosis of co-existing Guillain-Barre syndrome was supported by the neuro-physiological findings and marked motor improvement following therapeutic plasmapheresis. This unmasked the right-sided mild residual hemiparesis he suffered due to stroke.