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Arch Clin Infect Dis. 2019 February; 14(1):e65779. doi: 10.5812/archcid.65779.

Published online 2019 March 5. Case Report

Difficulties in Diagnosis of Psittacosis or Ornithosis: A Case Report

Masoud Ebrahimi 1 , Abbas Fadii 2 , Masoud Mardani 1 , Kouros Aghazade 1 , Farshad Divsalar 1 and Javad
Minooeifar 4, *
1
Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2
Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3
Department of Infectious Disease and Tropical Medicine, Iran University of Medical Science, Tehran, Iran
4
Janbazan Medical and Engineering Research Center, Tehran, Iran
*
Corresponding author: Janbazan Medical and Engineering Research Center, Farrokh St., Moghaddas Ardabili St., Shahid Chamran Highway, Tehran, Iran. Tel: +98-9121193741,
Fax: +98-2122418180, Email: jminooeefar@yahoo.com

Received 2018 January 01; Revised 2018 August 30; Accepted 2018 September 29.

Abstract

Introduction: Chlamydia psittaci is an intracellular and zoonotic pathogen that is transmitted through contact with birds. This
pathogen causes various clinical manifestations, including subclinical cases and fatal cases. On the other hand, the variety and low
specificity of many of the symptoms make diagnosis difficult while early detection of the disease causes a significant reduction in
mortality.
Case Presentation: The patient was a 47-year-old man with a history of headache, fever, chills, dyspnea, and productive cough with
a primary diagnosis of sinusitis, which was treated with co-amoxiclav. Due to the lack of recovery, the patient was hospitalized with
the diagnosis of pneumonia and was treated with meropenem and levofloxacin. After showing no improvement and finding out
about the history of contact with a parrot, the treatment was changed to Doxycycline and Ceftriaxone, which led to the reduction
of symptoms. Eventually, due to the patient’s positive serological tests, the diagnosis of Chlamydia Pneumonia was established and
the patient was discharged with oral doxycycline.
Conclusions: As the fatality rate of psittacosis in absence of treatment is high, it is necessary to treat the patient immediately.

Keywords: Psittacosis, Birds, Doxycycline, CAP

1. Introduction 2. Case Presentation

Chlamydia psittaci is an intracellular pathogen (1). It is The patient was a 47-year-old man complaining of fever
a zoonotic pathogen that infects a wide range of birds as and chills, dyspnea, and cough that began two weeks be-
hosts and may cause severe disease when is transmitted fore admission. The patient visited a doctor in the out-
to humans (2). Infected birds are often asymptomatic, but patient service at the early stage of disease, who diag-
sometimes they may have symptoms like chills, anorexia, nosed acute sinusitis and prescribed co-amoxiclav and
and diarrhea (3). Contaminated birds pass pathogens clarithromycin subsequently. After seeing no improve-
through their stool and nasal secretions, and humans get ment, he once again returned to the clinic and was admit-
sick from contact with them (4). The disease caused by ted this time.
Chlamydia psittaci is called psittacosis or parrot fever (4). The patient or his family did not have a history of lung
Since this disease is not restricted to parrot and other birds disease or other illnesses. He traveled to India in the last
can also transmit microorganism, it is also called Ornitho- year. History revealed the presence of a parrot at home
sis (3). Infection in humans mostly presents as community- with no history of smoking. In his career, he had not been
acquired pneumonia (CAP), which is responsible for 1% - in contact with chemicals. The patient mentioned a weight
1.2% of all causes of CAP (5, 6). Human-to-human transmis- loss of 6 kg in the last 2 weeks. The vital signs were: Temp.
sion is rare and isolation and chemoprophylaxis are not 38°C, B / P 100/70 mm/Hg, RR 24 / Min and PR 90/Min. Clin-
necessary. This patient was chosen for the case presenta- ical examination was normal except for bilateral coarse
tion because of receiving various treatments. Diagnosis crackle in the lung. The examination of the heart did not
in the early stages of the disease and initiation of prompt have an abnormal point. The patient was admitted with
treatment can reduce mortality from 20% to 1% (3). a diagnosis of pneumonia and the treatment was started

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Archive of SID Ebrahimi M et al.

with meropenem and levofloxacin. for example in the atypical pneumonia form, viral pneu-
Laboratory investigation revealed leukocytosis with monia, Q fever, Legionellosis, Mycoplasmal pneumonia are
16300 WBC and 78% Polymorphonuclear (PMN) and considered to be differential diagnoses (3). Although pneu-
platelet count was 453,000 and eosinophil and band-bone monia is the most common manifestation of psittacosis,
were higher than normal but other CBC indices were nor- all organs can be involved in this disease (8). Several cases
mal (Table 1). Collagen-vascular tests, including P-ANCA, of severe pneumonia with ARDS and pericarditis have been
C-ANCA, ANA, and Anti-dsDNA were reported normal. In reported (9). Severe pneumonia may be the primary mani-
the liver tests, alkaline phosphatase showed higher than festation of the disease that led to ICU admission (10).
normal range but other indices were normal. The CRP and In a study of 85 patients with suspected Psittacosis, 48
ESR were 47 and 72, respectively. cases were confirmed as definitive or probable psittacosis
In bronchoscopy, there was copious purulent dis- (7). In another study that reviewed 11 articles over a 30-year-
charge but other findings were normal. Bronchoalveolar period, it was found that in patients with psittacosis and
lavage (BAL) was performed and the samples were sent severe respiratory insufficiency, 10 out of 12 patients had
to the laboratory for bacterial, mycobacterial and fungal exposure to birds as a major risk factor. Severe hypoxemia
smear and culture, which gram-positive cocci (Staphylo- and kidney failure were associated with poor prognosis.
coccus) and gram-negative bacilli were reported. Eight patients died of psittacosis or complications of the
Due to the lack of recovery, the history of contact with infection (11).
a parrot and the previous antibiotic regimen (meropenem The most common symptom is fever, occurring in 50
and levofloxacin), the treatment was changed to Doxycy- to 100% of cases but most often in the last stages of the
cline and Ceftriaxone. In the next visit, the fever discon- disease. Headache and myalgia have been reported in 30
tinued and RR reached 16/Min. In subsequent tests, the to 70 percent of the cases; however, these symptoms are
patient’s leukocyte was reduced to 10,200 with a predom- misleading until the cough occurs due to lack of speci-
inance of 71% PMN. Serological test results for Chlamydia ficity. Even at this time, there are many distinct diagnoses.
psittaci were IgM 1.5 RU/ML (normal range less than 0.8 The most common findings in the examination are fever,
RU/ML) and IgG 61.5 RU/ML (normal range less than 16 throat erythema, rale or other abnormal findings in lung
RU/ML), which were positive and diagnosis of pneumonia auscultation and hepatosplenomegaly. Horder’s Spot, one
due to Chlamydia psittaci was established for the patient. of the cutaneous manifestations of psittacosis, is a macu-
Eventually, the patient was discharged in a good general lopapular lesion on the chest or trunk that is pink. The
condition with oral doxycycline. involvement of other organs, such as cardiac and kidney
involvement, hepatitis, neurological manifestations, etc.,
are consequences of the systemic nature of the disease (3).
3. Discussion In one study, the prevalent symptoms were fever, cough,
headache, myalgia, nausea, diarrhea, chills, sputum, chest
After 5 to 15 days of incubation period, the disease may pain and shortness of breath (7). Our patient’s presenta-
start insidiously and suddenly lead to multiple syndromes. tions were pulmonary involvement, headache, fever, chill,
The disease may present as atypical pneumonia with non- and productive cough.
productive cough, fever, headache, and abnormal changes In the CBC test, WBC usually is normal or increased
in chest graph, which is usually more than expected on the slightly and two-thirds of cases have a leftward shift. In 50%
basis of clinical symptoms and examination (3). In a study, of cases, liver tests are abnormal. The CXR is abnormal in
11% of patients with probable or confirmed psittacosis had 75% of cases, which is more than expected on the basis of
productive cough (7). respiratory signs and symptoms. The most common ab-
According to the signs and symptoms of the patient, he normal appearance in X-ray is a consolidation in a single
was hospitalized with the diagnosis of pneumonia, which lower lobe. Other patterns include ground glass opacity
was treated with meropenem and levofloxacin. Finally, due (GGO), patchy view, segmental view, or lobar and miliary
to no relief in symptoms, history of contact with a par- view, and sometimes have Halo Sign view that may be mis-
rot, and the possibility of chlamydial induced pneumo- leading with other respiratory illnesses. In 50% of cases,
nia psittaci, antibiotics were changed to Doxycycline and we have pleural effusion, which is small and asymptomatic
Ceftriaxone. The patient responded quickly to the treat- (3). In this patient, leukocytosis was observed with the left-
ment. It is notable that in one study, 60% of patients with ward shift and patchy infiltration in right lower lobe in X-
probable or definite psittacosis had no history of contact ray (Figure 1).
with birds (7). There are many differential diagnoses that According to the CDC, the definitive case of psittacosis
are variable according to psittacosis-induced syndromes, is a person with consistent clinical symptoms and labora-

2 Arch Clin Infect Dis. 2019; 14(1):e65779.

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Archive of SID Ebrahimi M et al.

Table 1. Laboratory Values Throughout Hospitalization

Test First Day Third Day Normal Range Flag

WBC 16300 10200 4500 - 11000 High

Neutrophil, % 77.9 71.5 55 - 75 High

Lymphocyte, % 12.4 18.1 20 - 45 Low

CRP, mg/L 47.7 —– <8 High

ESR 1st hour, mm/h 72 —– 0 - 22 High

Chlamydia psittaci (IgM), RU/mL 1.5 —– < 0.8 High

Chlamydia psittaci (IgG), RU/mL 61.5 —– < 16 High

ment of new molecular methods such as PCR and RT-PCR

for diagnosis has been discussed and was emphasized that
modern methods are more standardized (12).
Drug of choice is doxycycline, 100 mg twice daily or
tetracycline 500 mg four times a day for 10 to 21 days.
Macrolides are effective in vitro and are recommended as
alternative therapies in children and pregnant women;
however, they may be less effective in severe cases and do
not protect the fetus during pregnancy. Fluoroquinolones
need more clinical experiences. Most patients feel better
within 24 hours with therapy. Without treatment, the fa-
tality rate of psittacosis is approximately 20%; however, it
is reduced to 1% following the treatment (3).

3.1. Conclusions
Given the high mortality rate of disease in the absence
of treatment, it is necessary that the disease is quickly diag-
Figure 1. There is a patchy infiltration in RLL in the lung graphy affecting the right nosed and treated. Due to the non-specificity of the symp-
diaphragm border
toms and on the other hand, the absence of contact with
birds in a considerable number of patients, many differen-
tory confirmation having one of the following criteria: tial diagnoses may be possible and achieving an accurate
1- A titer of 1/16 IgM by MIF (microimmunofluorescence) diagnosis is more difficult. However, paying attention to
method. the symptoms and history of contact with birds can im-
2- Positive culture of respiratory secretions. prove the diagnosis. As soon as the disease is diagnosed,
3- Four-fold or greater rise in titer in CF (Complement the treatment should be started and continued for 10 to 21
fixation) or MIF antibody to a titer 1/32 in the specimens days. The shorter course of the treatment will be associated
with two weeks intervals. with possible recurrence.
The probable case is an individual with compatible
symptoms along with a confirmed history of contact with Footnotes
a patient with confirmed disease or a titer of 1/32 in a sam-
ple by CF or MIF assay (3). Based on a single serologic test, Authors’ Contribution: Javad Minooeifar and Masoud
which was positive, the patient is considered a probable Ebrahimi were responsible for the study design. Abbas
case of psittacosis. Fadii, Masoud Mardani, Kouros Aghazade, Farshad Di-
The blood and sputum cultures are possible in the first vsalar, Javad Minooeifar, and Masoud Ebrahimi analyzed
4 days and the first two weeks of the disease, respectively and interpreted the data. Masoud Ebrahimi and Javad Mi-
but usually cultures are not considered. Because the risk nooeifar wrote the manuscript. All authors read and ap-
for laboratory staff and serological method is preferred (3). proved the final manuscript.
In a study, because of the cross-reactions of old methods Conflict of Interests: The authors declared they had no
such as cultural, serological, and MIF assays, the replace- conflict of interests.

Arch Clin Infect Dis. 2019; 14(1):e65779. 3

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Archive of SID Ebrahimi M et al.

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