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Epidemic Typhus

Louse Borne Typhus Epidemic

Epidemic typhus is the most severe form of rickettsial infections. This louse-borne typhus is an acute febrile illness that features a headache, rash, myalgia, vasculitis, and is complicated by severe central nervous system (CNS) manifestations, gangrene, and high rates of death in untreated individuals. It is diagnosed by a thorough history and evaluation of risk factors, clinical exam, and laboratory studies.


Presentation

Epidemic typhus (ET) is caused by Rickettsia prowazekii, which is transmitted by human body louse [1] [2]. As a part of the typhus group, it is described as an acute febrile illness. Significant outbreaks have occurred during the Napoleonic Wars and World War I and II, resulting in the death of millions [3] [4]. More recent epidemics emerged in Algeria, Burundi, and Russia [5] [6] [7]. Regions that have been affected include the parts of Africa, China, the Himalayas, and Central and South America. Risk factors encompass war, natural disaster, overcrowding, poor hygiene, and cold weather. Additionally, military personnel and medical relief workers are considered vulnerable populations.

The clinical presentation is characterized by nonspecific symptoms such as a high fever, intense headache, myalgia, and a rash [8]. The latter erupts approximately 5 to 7 days after the onset of the disease [8]. Additionally, ET may cause pneumonia, multisystemic vasculitis, and CNS manifestations such as mental status changes, encephalitis or coma. Other features are malaise, rigors, and sudden prostration.

Complications

ET can give rise to gangrene infection and the resultant loss of digits, extremities and other body parts. Also, patients may develop hypotension with vascular collapse, renal failure, and other severe sequelae. If left untreated, epidemic typhus leads to death in up to 30% of cases [4] [8] [9]. Note that nearly 15% of victims develop the Brill-Zinsser disease, which is a recrudescent form that may recur years later.

Physical exam

Findings are notable for a high fever that reaches 39-41ºC and remains elevated if untreated. Also remarkable is the rash, which appears as maculopapular or petechial. It manifests centrally and spreads to the extremities while sparing the face, palms, and soles. Other signs may comprise of splenomegaly and bruises.

Fever
  • From Wikidata Jump to navigation Jump to search Human disease epidemic louse-borne typhus louse-borne typhus jail fever hospital fever ship fever famine fever putrid fever camp fever petechial fever exanthematic Typhus fever NOS sylvatic typhus Exanthematous[wikidata.org]
  • Hearing loss as a frequent complication of louse-borne epidemic typhus fever has been well documented in the reports of ENT specialists serving in both the Allied and the German armies in the last war.[ncbi.nlm.nih.gov]
  • A suspected case was fever or history of fever, from April 2012, in a resident of the rehabilitation center.[ncbi.nlm.nih.gov]
  • Typhus fever was also a significant killer during the American Civil War, although typhoid fever was the more prevalent cause of US Civil War "camp fever." Typhoid is a completely different disease from typhus.[en.wikipedia.org]
Chills
  • All had been counselors at the camp and had experienced febrile illness with myalgia, chills, and sweats; 2 had been hospitalized.[ncbi.nlm.nih.gov]
  • Nature of the disease The onset is variable but often sudden, with headache, chills, high fever, prostration, coughing and severe muscular pain.[who.int]
  • Malaise or general weakness occurs 1 to 3 days before the onset of sudden high fever, headache, chills, cough, muscle pain, sensitivity to light, and lack of energy.[iamat.org]
  • Read: Everything you need to know about head lice - Symptoms of this disease include chills, confusion, a cough, high fever, joint pain, sensitive eyes, a rash and a severe headache. - Blood tests for typhus may show a high level of typhus antibodies,[health24.com]
  • Chills, myalgias, and prostration are common, and a nonproductive cough may also be present. Fever rises to 39ºC-40 C (102.2 F-104 F) in an unremitting pattern. After 4-5 days of illness, a macular, papular, and/or petechial rash usually appears.[visualdx.com]
High Fever
  • Physical exam Findings are notable for a high fever that reaches 39-41ºC and remains elevated if untreated. Also remarkable is the rash, which appears as maculopapular or petechial.[symptoma.com]
  • Symptoms are prolonged high fever, intractable headache, and a maculopapular rash. Epidemic typhus is a rickettsial disease.[merckmanuals.com]
  • Nature of the disease The onset is variable but often sudden, with headache, chills, high fever, prostration, coughing and severe muscular pain.[who.int]
  • Epidemic typhus is characterized clinically by sudden onset, sustained high fever of about 2 weeks duration, a maculopapular rash, and altered mental state. There is effective antimicrobial therapy for the typhus fevers.[asmscience.org]
  • Malaise or general weakness occurs 1 to 3 days before the onset of sudden high fever, headache, chills, cough, muscle pain, sensitivity to light, and lack of energy.[iamat.org]
Malaise
  • Other features are malaise, rigors, and sudden prostration. Complications ET can give rise to gangrene infection and the resultant loss of digits, extremities and other body parts.[symptoma.com]
  • Malaise or general weakness occurs 1 to 3 days before the onset of sudden high fever, headache, chills, cough, muscle pain, sensitivity to light, and lack of energy.[iamat.org]
  • Fever, malaise, head and muscle ache, cough, and general weakness. Blotchy rash that spreads from the abdomen to chest to rest of body, but rarely to hands and feet. Severe disease includes prostration, delirium, very low blood pressure, and coma.[extension.entm.purdue.edu]
  • Common symptoms include fever, chills, headache, muscle aches, and malaise. There may be a prominent scab ('eschar') at the site of the ectoparasite bite.[health.nsw.gov.au]
  • Signs and symptoms include sudden headache, generalized muscle pain, malaise, and macular skin lesions. The infection may affect the central nervous system causing encephalitis.[fpnotebook.com]
Prisoner of War
  • Thousands of Austrian prisoners of war were taken by the Serbs, and, with doctors, nurses, and drugs in short supply, a few endemic cases blossomed into a massive epidemic. The first cases were reported in the Austrian prisoners at Valjevo.[kumc.edu]
  • A few days later cases were reported from the army and among the prisoners of war. Typhus fever had been endemic in Serbia for centuries and these first cases caused little alarm. There was, after all, a war on.[montana.edu]
  • Epidemics in the inner zone In November 1941, a Typhus epidemic broke out in a Romanian concentration camp for Russian prisoners: “ A large number of Russian prisoners of war fell in captivity [in summer 1941], staying in a camp inside the country [..[ncbi.nlm.nih.gov]
Dry Cough
  • […] extremities cough arthalgia myalgia photophobia delirium murine or endemic typhus abdominal pain diarrhea backache headache extremely high fever (105-106 F) may last for up to two weeks dull, red rash begins on the trunk and spreads peripherally hacking, dry[step2.medbullets.com]
  • Symptoms are chills, fever, dry cough, and pain in the affected side (a stitch).[sedgleymanor.com]
Diarrhea
  • Other symptoms may include nausea, diarrhea, and constipation. If untreated, the infection can lead to gangrene and necrosis (death of body tissue).[iamat.org]
  • […] including sudden-onset fever (104 F) chills severe headache maculopapular rash appears 5-9 days after onset of symptoms spreads peripherally from trunk to extremities cough arthalgia myalgia photophobia delirium murine or endemic typhus abdominal pain diarrhea[step2.medbullets.com]
Tachycardia
  • […] local arteries with a consecutive softening of the brain), extrapyramidal syndrome (disappears with fever decrease and is due to vascular disorders of the basal nucleus), cerebellar syndrome, bulbo-protuberantial syndrome with bulbar phenomena (dyspnea, tachycardia[ncbi.nlm.nih.gov]
Myalgia
  • The clinical presentation is characterized by nonspecific symptoms such as a high fever, intense headache, myalgia, and a rash. The latter erupts approximately 5 to 7 days after the onset of the disease.[symptoma.com]
  • All had been counselors at the camp and had experienced febrile illness with myalgia, chills, and sweats; 2 had been hospitalized.[ncbi.nlm.nih.gov]
  • Headaches, fever, myalgias, and exanthems were among the presenting complaints. The disease seemed milder than classic louse-born epidemic typhus, but in some instances, it was life-threatening.[jamanetwork.com]
  • Clinically, patients have presented with fever (100%), headache (81%), skin rash (66%), confusion (44%), and myalgia (42%). The skin rash has been characterized as maculopapular, usually involving the trunk and spreading to the extremities.[cdc.gov]
Exanthema
  • We report a case of epidemic typhus in a patient from the Batna region of Algeria, who presented with generalized febrile exanthema. The clinical diagnosis was confirmed by serological cross-adsorption followed by Western blotting.[ncbi.nlm.nih.gov]
  • DOI: 10.1128/JCM.42.8.3898-3900.2004 ABSTRACT We report a case of epidemic typhus in a patient from the Batna region of Algeria, who presented with generalized febrile exanthema.[jcm.asm.org]
  • Pathological Anatomy At body inspection it is noticed that the exanthema do not persist long after death and can be confused with cadaveric lividness [ 40 ].[ncbi.nlm.nih.gov]
Petechiae
  • […] rash begins on the trunk and spreads peripherally hacking, dry cough arthralgia myalgia nausea vomiting Physical exam hypotension fever photophobia early rash light rose color and blanches under pressure late rash dull red that does not fade scattered petechiae[step2.medbullets.com]
Purpura
  • Puking Fever Milk sickness Pulmonary Consumption Probably Tuberculosis Purples/Purpura This is a rash due to spontaneous bleeding in to the skin. There are many causes.[sedgleymanor.com]
Headache
  • The clinical presentation is characterized by nonspecific symptoms such as a high fever, intense headache, myalgia, and a rash. The latter erupts approximately 5 to 7 days after the onset of the disease.[symptoma.com]
  • Headaches, fever, myalgias, and exanthems were among the presenting complaints. The disease seemed milder than classic louse-born epidemic typhus, but in some instances, it was life-threatening.[jamanetwork.com]
  • Clinically, patients have presented with fever (100%), headache (81%), skin rash (66%), confusion (44%), and myalgia (42%). The skin rash has been characterized as maculopapular, usually involving the trunk and spreading to the extremities.[cdc.gov]
  • Symptoms are prolonged high fever, intractable headache, and a maculopapular rash. Epidemic typhus is a rickettsial disease.[msdmanuals.com]
Stupor
  • Symptoms of epidemic typhus may include chills, cough, high fever (104 degrees Fahrenheit), delirium or stupor, joint pain, sensitivity to light, severe headache, severe muscle pain, low blood pressure, and a rash that begins on the chest and spreads[epi.publichealth.nc.gov]
  • The word typhus (from the Greek typhos, meaning smoky or hazy, and used by Hippocratesto describe a “confused state of intellect with a tendency to stupor”) was not applied to typhus fever itself until 1760; moreover, typhus was not clearly distinguished[nature.com]
  • Symptoms include severe headache, a sustained high fever, cough, rash, severe muscle pain, chills, falling blood pressure, stupor, sensitivity to light, delirium and death.[en.wikipedia.org]
Meningism
  • Epidemic typhus meningitis in the southwestern United States. Clin. Infect. Dis. 32 : 979 -982. McDade, J. E., C. C. Shepard, M. A. Redus, V. F. Newhouse, and J. D. Smith. 1980 . Evidence of Rickettsia prowazekii infections in the United States. Am.[jcm.asm.org]
  • Differential diagnosis includes malaria, typhoid fever, viral haemorrhagic fever, leptospirosis, endemic typhus, tick-borne and louse-borne relapsing fevers, non-typhoidal salmonellosis, meningococcal septicaemia and meningitis.[ecdc.europa.eu]
  • Tâche Cérébrale Red line on the forehead seen in tuberculous meningitis Teething The entire process which results in the eruption of the teeth.[sedgleymanor.com]
  • Unlike the nervous phenomena encountered in the disease, the nervous complications were durable and rarely observed: meningeal syndrome, epileptic seizures, syndromes of motor deficit (hemiplegia and monoplegia, due to a local arteries with a consecutive[ncbi.nlm.nih.gov]

Workup

During the assessment, the clinician should elicit the risk factors and patient history, and perform a careful physical exam and the appropriate tests. Note the administration of antibiotics should be started as soon as the provisional diagnosis for this diseases is established.

Laboratory tests

Generally, laboratory studies such as complete blood count (CBC) and comprehensive metabolic panel (CMP) consisting of liver and renal function tests, electrolyte levels, serum albumin concentration, and others should be obtained. Common findings may include but are not limited to leukopenia, leukocytosis, thrombocytopenia, mild increase in transaminases, hyponatremia, hypoalbuminemia, and azotemia.

The diagnostic panel consists of indirect immunofluorescence assay (IFA) and enzyme immunoassay (EIA), which are used to measure immunoglobulin (Ig) M antibodies. Serological testing is not useful in acute cases since the immune response is not demonstrable during this period. Moreover, polymerase chain reaction (PCR) performed on blood or skin biopsy samples suggests Rickettsia and the specific species of this pathogen [10]. Culture is not helpful.

Brill-Zinsser disease is identified in patients with recurrent manifestations and a measurable elevation of IgG titer.

Imaging

A chest X-ray should be obtained in those with pneumonia [11].

Hyponatremia
  • Common findings may include but are not limited to leukopenia, leukocytosis, thrombocytopenia, mild increase in transaminases, hyponatremia, hypoalbuminemia, and azotemia.[symptoma.com]
  • […] late rash dull red that does not fade scattered petechiae may be observed in patients with severe disease Evaluation Labs CBC may show anemia and thrombocytopenia typhus antibody present in individuals with active or previous infection hypoalbuminemia hyponatremia[step2.medbullets.com]
Rickettsia Prowazekii
  • Epidemic typhus is another life-threatening louse-borne disease caused by Rickettsia prowazekii and known to occur in conditions of war, famine, refugee camps, cold weather, poverty, or lapses in public health.[ncbi.nlm.nih.gov]
  • The historical significance and current epidemiology of typhus, including the reservoir of Rickettsia prowazekii in flying squirrels in the United States, are reviewed, and the clinical presentation, laboratory findings, and hospital course in the cases[ncbi.nlm.nih.gov]
  • Serum from each patient had evidence of infection with Rickettsia prowazekii. Analysis of blood and tissue from 14 southern flying squirrels trapped in the woodlands around the cabin indicated that 71% were infected with R. prowazekii.[ncbi.nlm.nih.gov]
  • We tested sera of nine patients by microimmunofluorescence for antibodies to Rickettsia prowazekii and Rickettsia typhi.[ncbi.nlm.nih.gov]
  • Abstract Epidemic typhus is an infectious disease caused by the bacterium Rickettsia prowazekii and transmitted by body lice (Pediculus humanus corporis). This disease occurs where conditions are crowded and unsanitary.[ncbi.nlm.nih.gov]

Treatment

  • Treatment of this disease with oral doxycycline, tetracycline, or chloramphenicol prevents complications and results in prompt resolution of symptoms.[ncbi.nlm.nih.gov]
  • After the patient is stabilized then the treatment with antibiotics is started.[epainassist.com]
  • Primary treatment of epidemic typhus is doxycycline 200 mg po once followed by 100 mg bid until the patient improves, has been afebrile for 24 to 48 hours, and has received treatment for at least 7 days.[msdmanuals.com]
  • The disease can be severe with a mortality of up to 60% without antibiotic treatment. But this can be reduced to below 5% with antibiotic and supportive treatment [1].[ecdc.europa.eu]

Prognosis

  • Scrub Typhus and Murine Typhus, Vietnam, 2015-2017. ( 30882318 ) Trung NV...Van Kinh N 2019 18 Evaluation of Th1 and Th2 immune response in clinical and sub-clinical scrub typhus infection. ( 30904436 ) Bora T...Khan SA 2019 19 Indicators of severe prognosis[malacards.org]
  • , Prevention, and Comlications Prognosis epidemic typhus can be fatal is left untreated in 10-60% of patients caused by peripheral vascular collapse elderly patients are at greater risk murine typhus is fatal in less than 2% of patients if left untreated[medbullets.com]
  • Suppurative parotiditis claims an unfavorable prognosis and require surgical treatment as early as possible [ 24, 31 ].[ncbi.nlm.nih.gov]

Etiology

  • Differences in IFA titers against R. typhi and R. prowazekii allowed the identification of the etiological agent in 8 of 12 patients. Western blot studies enabled the identification of the etiological agent in six patients.[ncbi.nlm.nih.gov]
  • The patient had contracted the disease in Mexico. 1 The Centers' Virology Division of the Bureau of Laboratories described case histories of eight persons who had serologic reactions that indicated recent infection with Rickettsia prowazekii, the etiologic[nejm.org]
  • The patient had contracted the disease in Mexico. 1 The Centers' Virology Division of the Bureau of Laboratories described case histories of eight persons who had serologic reactions that indicated recent infection with Rickettsia prowazekii , the etiologic[nejm.org]
  • On the basis ofinteractions of host endothelial cells with R. prowazekii and R. typhi (the etiologic agent of endemic typhus), wehave identified activation of nuclear factor kappa B (NF- B) and stress-activated p38 protein kinase as criticallyimportant[grantome.com]
  • […] emphasize that: (1) the present diagnosistic criteria must be revised; (2) the reported incidence of Brill's disease may be expected to increase; (3) Brill's disease may indeed be important in initiating new epidemics of louse-borne typhus, and (4) the etiologic[jamanetwork.com]

Epidemiology

  • Author information 1 Rwanda Field Epidemiology and Laboratory Training Program, School of Public Health, University of Rwanda, Kigali, Rwanda. umulisa5@gmail.com. 2 CTS Global assigned to U.S.[ncbi.nlm.nih.gov]
  • Abstract Differentiation of murine typhus due to Rickettsia typhi and epidemic typhus due to Rickettsia prowazekii is critical epidemiologically but difficult serologically.[ncbi.nlm.nih.gov]
  • The historical significance and current epidemiology of typhus, including the reservoir of Rickettsia prowazekii in flying squirrels in the United States, are reviewed, and the clinical presentation, laboratory findings, and hospital course in the cases[ncbi.nlm.nih.gov]
  • These 30 patients illustrate the clinical, epidemiologic and serologic characteristics of primary epidemic typhus. 2.[jimmunol.org]
  • Between January and September, 1997, nationwide epidemiological data on the prevalence and distribution of sutama was obtained through liaison with local health services.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Prevention

  • Centers for Disease Control and Prevention, Kigali, Rwanda. 10 National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. 11 University of British Columbia, Vancouver, Canada.[ncbi.nlm.nih.gov]
  • Treatment of this disease with oral doxycycline, tetracycline, or chloramphenicol prevents complications and results in prompt resolution of symptoms.[ncbi.nlm.nih.gov]
  • A novel molecular assay was performed at the Centers for Disease Control and Prevention, and Rickettsia prowazekii, the agent of epidemic typhus, was found, rather than R. typhi.[ncbi.nlm.nih.gov]
  • Infection can also be prevented by vaccination. Some of the simplest methods of prevention and treatment focus on preventing infestation of body lice.[en.wikipedia.org]
  • Visit the Centers for Disease Control and Prevention website at . January 2013[vdh.virginia.gov]

References

Article

  1. Svraka S, Rolain JM, Bechah Y, Gatabazi J, Raoult D. Rickettsia prowazekii and Real-time Polymerase Chain Reaction. Emerg Infect Dis. 2006;12(3):428-432.
  2. Azizi MH, Bahadori M, Azizi F. An Overview of Epidemic Typhus in the World and Iran during the 19th and 20th Centuries. Arch Iran Med. 2016;19(10):747-750.
  3. Raoult D, Dutour O, Houhamdi L, et al. Evidence for louse-transmitted diseases in soldiers of Napoleon's Grand Army in Vilnius. J Infect Dis. 2006;193(1):112-20.
  4. Raoult D, Roux V. The body louse as a vector of reemerging human diseases. Clin Infect Dis. 1999;29(4):888-911.
  5. Mokrani K, Fournier PE, Dalichaouche M, et al. Reemerging threat of epidemic typhus in Algeria. J Clin Microbiol. 2004;42(8):3898-900.
  6. Raoult D, Ndihokubwayo JB, Tissot-Dupont H, et al. Outbreak of epidemic typhus associated with trench fever in Burundi. Lancet. 1998;352(9125):353-8.
  7. Tarasevich I, Rydkina E, Raoult D. Epidemic typhus in Russia. Lancet. 1998;352(9134):1151.
  8. Raoult D, Roux V. Rickettsioses as paradigms of new or emerging infectious diseases. Clin Microbiol Rev. 1997;10(4):694-719.
  9. Bechah Y, Capo C, Mege JL, Raoult D. Epidemic typhus. Lancet Infect Dis. 2008; 8(7):417- 426.
  10. Giulieri S, Jaton K, Cometta A, Trellu LT, Greub G. Development of a duplex real-time PCR for the detection of Rickettsia spp. and typhus group rickettsia in clinical samples. FEMS Immunol Med Microbiol. 2012;64(1):92-7.
  11. Chen HC, Chang HC, Chang YC, et al. Chest radiographic presentation in patients with scrub typhus. Trans R Soc Trop Med Hyg. 2012;106(1):48-53.

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Last updated: 2019-07-11 21:55