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Viral & Rickettsial Infections
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orally or intravenously; it is the drug of choice in pregnant women) or ciprofloxacin (500 750 mg orally twice a day) Treatment should be continued through 3 full days of defervescence
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Gikas A et al Comparison of the effectiveness of five different antibiotic regimens on infection with Rickettsia typhi: therapeutic data from 87 cases Am J Trop Med Hyg 2004 May; 70(5):576 9 [PMID: 15155995] Letaief AO et al Clinical and laboratory features of murine typhus in central Tunisia: a report of seven cases Int J Infect Dis 2005 Nov;9(6):331 4 [PMID: 16054415] Shalev H et al Murine typhus is a common cause of febrile illness in Bedouin children in Israel Scand J Infect Dis 2006; 38(6 7):451 5 [PMID: 16798692]
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of patients and correspond to the presence of superficial mucosal hemorrhage, multiple erosions, or ulcers in the gastrointestinal tract An attack confers prolonged immunity against homologous strains and transient immunity against heterologous strains Heterologous strains produce mild disease if infection occurs within a year after the first episode
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B Laboratory Findings
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Blood obtained during the first few days of illness may permit isolation of the rickettsial organism by mouse inoculation Serologic testing with immunofluorescence and immunoperoxidase assays or commercial dot-blot ELISA dipstick assays are convenient means of establishing the diagnosis, though PCR may be the most sensitive test A reticulonodular infiltrate is the most common finding on chest radiograph
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3 Scrub Typhus (Tsutsugamushi Fever)
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Exposure to mites in endemic area of Southeast Asia, the western Pacific (including Korea), and Australia Black eschar at site of the bite, with regional and generalized lymphadenopathy Conjunctivitis and a short-lived macular rash Frequent pneumonitis, encephalitis, and cardiac failure
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Differential Diagnosis
Leptospirosis, typhoid, dengue, malaria, and other rickettsial infections should be considered Scrub typhus is a recognized cause of obscure tropical fevers, especially in children When the rash is fleeting and the eschar is not evident, laboratory results are required for diagnosis, including a conventional indirect fluorescent assay or a more sensitive rapid immunochromatographic flow assay that is under development Upper tract endoscopy may help with gastrointestinal lesions
Prevention
Repeated application of long-acting miticides can make endemic areas safe Insect repellents on clothing and skin provide some protection For short exposure, chemoprophylaxis with doxycycline (200 mg weekly) can prevent the disease but permits infection No effective vaccines are available
General Considerations
Scrub typhus is caused by Orientia tsutsugamushi, which is principally a parasite of rodents transmitted by mites in the endemic areas listed above (Table 32 3) The mites live on vegetation but complete their maturation cycle by biting humans who come in contact with infested vegetation Vertical transmission occurs, and blood transfusions may transmit the pathogen Serosurveys from Bangkok show prevalences over 20% for blood donors and nearly 60% for febrile malaria clinic patients Rare occupational transmission via inhalation is documented among laboratory workers
Treatment & Prognosis
Without treatment, fever subsides spontaneously after 2 weeks, but the mortality rate may be 10 30% Empiric treatment for 3 days with doxycycline, 100 mg orally twice daily, or for 7 days with chloramphenicol, 25 mg/kg/d orally or intravenously in four divided doses, eliminates most deaths and relapses Chloramphenicol- and tetracycline-resistant strains have been reported from Southeast Asia, where azithromycin or roxythromycin may become the drug of choice for children, pregnant women, and patients with refractory disease Rifampin also appears to be effective HIV infection does not appear to influence the severity of scrub typhus
Aung-Thu et al Gastrointestinal manifestations of septic patients with scrub typhus in Maharat Nakhon Ratchasima Hospital Southeast Asian J Trop Med Public Health 2004 Dec;35(4):845 51 [PMID: 15916079] Blacksell SD Scrub typhus serologic testing with the indirect immunofluorescence method as a diagnostic gold standard: a lack of consensus leads to a lot of confusion Clin Infect Dis 2007 Feb 1;44(3):391 401 [PMID: 17205447] Parola P et al Tropical rickettsioses Clin Dermatol 2006 May Jun;24(3):191 200 [PMID: 16714200]
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