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RICKETTSIAL DISEASES TYPHUS GROUP 1 Epidemic Louse-Borne Typhus
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ESSENTIALS OF DIAGNOSIS
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Prodrome of headache, then chills and fever Severe, intractable headaches, prostration, persisting high fever Macular rash appearing on the fourth to seventh days on the trunk and in the axillae, spreading to the rest of the body but sparing the face, palms, and soles Diagnosis confirmed by specific antibodies using complement fixation, microagglutination, or immunofluorescence
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Epidemic louse-borne typhus is due to infection with Rickettsia prowazekii, a parasite of the body louse (Table 32 3) Transmission is favored by crowded, unsanitary living conditions, famine, war, or any circumstances that predispose to heavy infestation with lice When the louse sucks the blood
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Table 32 3 Rickettsial diseases
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Disease Typhus group Epidemic (louse-borne) typhus Endemic (murine) typhus Rickettsia prowazekii Rickettsia typhi South America, Central Africa Worldwide; small foci (United States: southeastern Gulf Coast) Southeast Asia, Japan, Australia, Western Siberia Western Hemisphere; United States (especially midAtlantic coast region) Worldwide Africa, India, Mediterranean regions Louse Flea Humans, flying squirrels Rodents Rare Often Rickettsial Pathogen Geographic Areas of Prevalence Insect Vector Mammalian Reservoir Travel Association
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Scrub typhus group Scrub typhus Spotted fever group Rocky Mountain spotted fever Rickettsia rickettsii Tick1 Rodents, dogs Rare Orientia tsutsugamushi Mite1 Rodents Often
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California flea rickettsiosis Mediterranean spotted fever, Boutonneuse fever, Kenya tick typhus, South African tick fever, Indian tick typhus Queensland tick typhus Siberian Asian tick typhus African tick bite fever Rickettsialpox Other Ehrlichiosis and anaplasmosis, human Monocytic Granulocytic Q fever
Rickettsia felis Rickettsia conorii
Flea Tick1
Cats, opossums Rodents, dogs Often
Rickettsia australis Rickettsia sibirica Rickettsia africae Rickettsia akari
Eastern Australia Siberia, Mongolia Rural sub-Saharan Africa Eastern Caribbean United States, Korea, former USSR Southeastern United States
Tick1 Tick1 Tick1 Mite1
Rodents, marsupials Rodents Cattle Mice
Rare Rare Often
Ehrlichia chaffeensis, Anaplasma equi, Ehrlichia canis Anaplasma phagocytophilum, Ehrlichia ewingii Coxiella burnetii
Tick1
Dogs
Northeastern United States Worldwide
Tick1 None2
Rodents, deer, sheep Cattle, sheep, goats
Also serve as arthropod reservoir by maintaining rickettsiae through transovarian transmission Human infection results from inhalation of dust
of a person infected with R prowazekii, the organism becomes established in the gut of the louse and grows there When the louse is transmitted to another person (through contact or clothing) and has a blood meal, it defecates simultaneously, and the infected feces are rubbed into the itching bite wound Dry, infectious louse feces may also enter the respiratory tract In a person who recovers from clinical or subclinical typhus infection, R prowazekii may survive in lymphoid tissues Years later, there may be a recrudescence of disease (Brill-Zinsser disease) without exposure to infected lice, which can serve as a point source for future outbreaks Mild and atypical cases of R prowazekii infection have rarely occurred in the United States after contact with flying squirrels or their ectoparasites or decades following exposure
(eg, among concentration camp victims of World War II) Cases can be acquired by travel to pockets of infection (eg, central and northeastern Africa, Central and South America) Recent outbreaks were reported from Peru, Burundi, and Russia
Clinical Findings
A Symptoms and Signs
(Table 32 2) Prodromal malaise, cough, headache, backache, arthralgia, and chest pain begin after an incubation period of 10 14 days, followed by an abrupt onset of chills, high fever, and prostration, with flu-like symptoms progressing to delirium and stupor The headache is severe and the fever is prolonged
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in the United States or Canada An improved cell culture vaccine is being developed
Other findings consist of conjunctivitis, hearing loss from neuropathy of the eighth cranial nerve, flushed facies, rales at the lung bases, and often splenomegaly A macular rash (that may become confluent) appears first in the axillae and then over the trunk, spreading to the extremities but rarely involving the face, palms, or soles In severely ill patients, the rash becomes hemorrhagic, and hypotension becomes marked There may be renal insufficiency, stupor, and delirium In spontaneous recovery, improvement begins 13 16 days after onset with a rapid drop of fever
Treatment
Treatment consists of either doxycycline (200 mg/d orally) or chloramphenicol (50 100 mg/kg/d in four divided doses, orally or intravenously, and is the drug of choice in pregnant women) for 4 10 days
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