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Typhus

Typhoid Fever

Typhus is a group of infectious diseases caused by rickettsial species. This disease result in acute febrile illness and is transmitted by arthropod vectors like lice, mites and fleas.


Presentation

Epidemic and murine typhus disease have common clinical manifestations. History of the patient may show many indicative features like occupational exposure, visit to endemic areas, overcrowding, or poor hygiene. War or civil unrest are found to be common risk factors in the development of rickettsiae infection. In epidemic typhus, the symptoms may be present in different systems. Fever and headache are the initial symptoms. In epidemic typhus a petechial rash may develop in the axilla 4-5 days after infection. The rashes may gradually spread to the trunk.
In scrub typhus disease, a small and painless papule develop at the site of mite bite. This may undergo necrosis and result in the formation of an eschar. Eschar is a confirmatory symptom in the case of scrub typhus. Eschar formation may be absent in around 40% of the patients and this makes diagnosis hard. Many other symptoms of this disease are non-specific. Localized lymphadenopathy is noted at the site of bite and this may develop into generalized lymphadenopathy. Pulmonary involvement is often noted in scrub typhus and hence patients may present with tachypnea and cough. Conjunctival suffusion also may be noted in some of them.
When left untreated, fever may be persistent and can be associated with relative bradycardia. Fever may persist for 2-3 days even after the start of antibiotic treatment. Maculopapular rashes spread from the axilla to the trunk and then to different parts of the body, except face, sole, and palms.

Splenomegaly
  • RESULTS: The most common CT finding was hepatomegaly (74.4%), followed by splenomegaly (66.7%). The majority of patients had at least three areas of abdominopelvic lymphadenopathy (71.8%).[ncbi.nlm.nih.gov]
  • METHODS: Children aged RESULTS: Mean age, duration of fever at presentation, presence of headache and, altered sensorium and presence of hepatomegaly/splenomegaly were statistically significantly different between the groups.[ncbi.nlm.nih.gov]
  • Physical and laboratory data showed cytopenia (thrombocytopenia and anemia), splenomegaly, hyperferritinemia, hypofibrinogenemia, and an elevated level of interleukin-2 receptor (soluble CD25).[ncbi.nlm.nih.gov]
  • High grade fever (90%), chills and rigors (68%), conjunctival suffusion (50%), body aches (43%), headache (41%), myalgias (37%), abdominal pain (21%), lymphadenopathy (17%), splenomegaly (17%), cough (16%), altered sensorium (16%), vomiting (15%), hepatomegaly[ncbi.nlm.nih.gov]
  • Splenomegaly is observed in 1/3 of cases. Most cases are mild, but pneumonitis, meningoencephalitis, multiorgan failure, bleeding and even death may occur, especially in untreated patients.[orpha.net]
Generalized Lymphadenopathy
  • Abstract Scrub typhus is an acute infectious disease caused by Orienta tsutsugamushi, which is clinically manifested by fever, generalized lymphadenopathy, diffuse myalgia, headache, maculopapular rash, and eschars at the site of chigger feedings.[ncbi.nlm.nih.gov]
  • Localized lymphadenopathy is noted at the site of bite and this may develop into generalized lymphadenopathy. Pulmonary involvement is often noted in scrub typhus and hence patients may present with tachypnea and cough.[symptoma.com]
Fever
  • Typhus fevers are a group of diseases caused by bacteria that are spread to humans by fleas, lice, and chiggers. Typhus fevers include scrub typhus, murine typhus, and epidemic typhus.[web.archive.org]
  • Abstract To determine prevalence of severe fever with thrombocytopenia syndrome in South Korea, we examined serum samples from patients with fever and insect bite history in scrub typhus-endemic areas.[ncbi.nlm.nih.gov]
  • These forms of spotted fever occur only rarely and affect patients who had spotted fever during the war years.[doi.org]
  • The second patient also presented to the hospital with a 1 week history of fever and upper quadrant abdominal pain. She was diagnosed with having cholecystitis.[ncbi.nlm.nih.gov]
  • The rickettsial pathogens most likely to be encountered during travel outside the United States include R. africae (African tick-bite fever), R. conorii (Mediterranean spotted fever), R. rickettsii (known as both Rocky Mountain spotted fever and Brazilian[wwwnc.cdc.gov]
Chills
  • Other frequent symptoms were chills, malaise, myalgia, and anorexia. A tetrad of reported laboratory abnormalities consisting of elevated liver enzymes, lactate dehydrogenase, erythrocyte sedimentation rate and hypoalbuminemia was detected.[ncbi.nlm.nih.gov]
  • High grade fever (90%), chills and rigors (68%), conjunctival suffusion (50%), body aches (43%), headache (41%), myalgias (37%), abdominal pain (21%), lymphadenopathy (17%), splenomegaly (17%), cough (16%), altered sensorium (16%), vomiting (15%), hepatomegaly[ncbi.nlm.nih.gov]
  • Synonyms: typhus fever Types: endemic typhus , murine typhus , rat typhus , urban typhus acute infection caused by rickettsia and transmitted by the bite of an infected flea; characterized by fever and chills and muscle aches and a rash Type of: rickettsial[vocabulary.com]
  • * It is a rickettsial disease with variable onset, but is often characterised by the sudden appearance of headaches, chills, prostration, high fever, coughing and severe muscular pain.[web.archive.org]
  • Symptoms include chills, headache and fever, lasting about 12 days. Rash and other manifestations are similar to epidemic typhus.[thirdworldtraveler.com]
High Fever
  • A case was defined as an inpatient in one hospital in Western Province, Solomon Islands with high fever ( 38.5 C) and a negative malaria microscopy test admitted between 1 and 31 May 2014.[ncbi.nlm.nih.gov]
  • […] ty·phus \ ˈtī-fəs \ : any of various bacterial diseases caused by rickettsias: such as a : a severe human febrile disease that is caused by one ( Rickettsia prowazekii ) transmitted especially by body lice and is marked by high fever, stupor alternating[merriam-webster.com]
  • * It is a rickettsial disease with variable onset, but is often characterised by the sudden appearance of headaches, chills, prostration, high fever, coughing and severe muscular pain.[web.archive.org]
  • CASE PRESENTATION: A 62-year-old previously healthy Sri Lankan native male from the Western province of Sri Lanka presented with high fever with malaise, myalgia and arthralgia for 17 days.[ncbi.nlm.nih.gov]
  • Symptoms are prolonged high fever, intractable headache, and a maculopapular rash. Epidemic typhus is a rickettsial disease.[merckmanuals.com]
Malaise
  • We report a previously healthy 74-year-old Thai female farmer who presented in Nakhon Ratchasima, Thailand, with a history of fever and malaise for 5 days, followed by abdominal pain for 1 day.[ncbi.nlm.nih.gov]
  • Initial signs and symptoms included fever (99%), malaise (82%), headache (77%), fatigue (70%), myalgias (68%), and rash (39%).[ncbi.nlm.nih.gov]
  • Other frequent symptoms were chills, malaise, myalgia, and anorexia. A tetrad of reported laboratory abnormalities consisting of elevated liver enzymes, lactate dehydrogenase, erythrocyte sedimentation rate and hypoalbuminemia was detected.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: A 62-year-old previously healthy Sri Lankan native male from the Western province of Sri Lanka presented with high fever with malaise, myalgia and arthralgia for 17 days.[ncbi.nlm.nih.gov]
  • 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]
Anemia
  • Physical and laboratory data showed cytopenia (thrombocytopenia and anemia), splenomegaly, hyperferritinemia, hypofibrinogenemia, and an elevated level of interleukin-2 receptor (soluble CD25).[ncbi.nlm.nih.gov]
  • Murine typhus in children exhibits several different characteristics, with abdominal pain, diarrhea, and sore throat reported more commonly, higher frequency of anemia, lower frequency of hypoalbuminemia, hematuria and proteinuria and a much lower rate[ncbi.nlm.nih.gov]
  • […] 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 may be observed in patients with severe disease Evaluation Labs CBC may show anemia[medbullets.com]
  • Patients typically present with fever and headache or fever and rash and may also experience: Myalgia Anorexia Nausea Vomiting Abdominal pain Cough Altered mental status Common laboratory findings may include anemia, thrombocytopenia, leukopenia, hyponatremia[cdc.gov]
Cough
  • Despite such an extensive consolidation, respiratory symptoms such as cough and breathlessness were inconspicuous thereby posing a diagnostic dilemma.[ncbi.nlm.nih.gov]
  • High grade fever (90%), chills and rigors (68%), conjunctival suffusion (50%), body aches (43%), headache (41%), myalgias (37%), abdominal pain (21%), lymphadenopathy (17%), splenomegaly (17%), cough (16%), altered sensorium (16%), vomiting (15%), hepatomegaly[ncbi.nlm.nih.gov]
  • Major clinical manifestations were fever (100%), myalgia (65%), cough (51%) and vomiting (46%); major complications were meningitis/meningoencephatilitis (12.5%) and multi-organ failure (MOF) and pneumonia (5.3% each).[ncbi.nlm.nih.gov]
  • Common presenting complaints included fever (100%), generalized myalgia (83%), headache (65%), dyspnea (54%), cough (24.3%), and altered sensorium (14%). Almost half of the patients (49.4%) had normal chest radiographs.[ncbi.nlm.nih.gov]
  • Joint and muscle pain Nausea and vomiting Symptoms of epidemic typhus may include: High fever, chills Confusion, decreased alertness, delirium Cough Severe muscle and joint pain Lights that appear very bright; light may hurt the eyes Low blood pressure[nlm.nih.gov]
Dry Cough
  • Murine typhus is known to cause abdominal pain, backaches, rashes on the mid body, fevers up to 106 degrees, dry coughs, nausea, headaches, and joint pain.[study.com]
  • Symptoms of murine or endemic typhus may include: Abdominal pain Backache Dull red rash that begins on the middle of the body and spreads Fever, can be extremely high, 105 F to 106 F (40.6 C to 41.1 C), that may last up to 2 weeks Hacking, dry cough Headache[nlm.nih.gov]
  • […] 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[medbullets.com]
Nausea
  • Typical gastrointestinal manifestations in patients with scrub typhus include abdominal pain, nausea, vomiting, hematemesis, melena, and diarrhea.[ncbi.nlm.nih.gov]
  • Patients presented most commonly with fever (100%), nausea and vomiting (55%), and rash (55%). Respiratory (55%) and neurologic (45%) manifestations were also identified frequently.[ncbi.nlm.nih.gov]
  • Disease onset is often sudden, and symptoms may include fever, headache, chills, weakness, nausea/vomiting, body aches, and rash.[dshs.state.tx.us]
  • Symptoms Symptoms of typhus appear after an incubation period of two weeks and are as follows: a high fever; rash convering most of the body; headache ; chills; widespread pain; stupor, i.e. immobility and muteness; delirium ; coughing; nausea and vomiting[health.ccm.net]
  • Signs and symptoms may include: Fever and chills Headache Rapid breathing Body and muscle aches Rash Cough Nausea Vomiting Confusion Brill-Zinsser disease Some people can remain infected, without symptoms, for years after they first get sick.[web.archive.org]
Vomiting
  • Typical gastrointestinal manifestations in patients with scrub typhus include abdominal pain, nausea, vomiting, hematemesis, melena, and diarrhea.[ncbi.nlm.nih.gov]
  • Associated clinical features like pain abdomen, vomiting, and features of third space losses made us suspect a co-infection. IgM and IgG antibodies by ELISA in acute and convalescent serum were suggestive of scrub typhus.[ncbi.nlm.nih.gov]
  • Patients presented most commonly with fever (100%), nausea and vomiting (55%), and rash (55%). Respiratory (55%) and neurologic (45%) manifestations were also identified frequently.[ncbi.nlm.nih.gov]
  • High grade fever (90%), chills and rigors (68%), conjunctival suffusion (50%), body aches (43%), headache (41%), myalgias (37%), abdominal pain (21%), lymphadenopathy (17%), splenomegaly (17%), cough (16%), altered sensorium (16%), vomiting (15%), hepatomegaly[ncbi.nlm.nih.gov]
  • Major clinical manifestations were fever (100%), myalgia (65%), cough (51%) and vomiting (46%); major complications were meningitis/meningoencephatilitis (12.5%) and multi-organ failure (MOF) and pneumonia (5.3% each).[ncbi.nlm.nih.gov]
Diarrhea
  • Typical gastrointestinal manifestations in patients with scrub typhus include abdominal pain, nausea, vomiting, hematemesis, melena, and diarrhea.[ncbi.nlm.nih.gov]
  • Murine typhus in children exhibits several different characteristics, with abdominal pain, diarrhea, and sore throat reported more commonly, higher frequency of anemia, lower frequency of hypoalbuminemia, hematuria and proteinuria and a much lower rate[ncbi.nlm.nih.gov]
  • […] 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[medbullets.com]
Acute Abdomen
  • It may rarely present as an acute abdomen which may lead to a diagnostic dilemma.[ncbi.nlm.nih.gov]
Loss of Appetite
  • Signs and symptoms may include: Fever and chills Body aches and muscle pain Loss of appetite Nausea Vomiting Stomach pain Cough Rash (typically occurs around day 5 of illness) Most people will recover without treatment, but some cases may be severe.[web.archive.org]
Hypotension
  • […] 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 cough arthralgia myalgia nausea vomiting Physical exam hypotension[medbullets.com]
  • Hypotension occurs in most seriously ill patients. Vascular collapse, renal insufficiency, encephalitic signs, ecchymosis with gangrene, and pneumonia are poor prognostic signs.[merckmanuals.com]
  • […] fever chills rash Symptoms of epidemic typhus usually appear suddenly and include: severe headache high fever (above 102.2 F) rash that begins on the back or chest and spreads confusion stupor and seeming out of touch with reality low blood pressure (hypotension[healthline.com]
Hepatomegaly
  • RESULTS: The most common CT finding was hepatomegaly (74.4%), followed by splenomegaly (66.7%). The majority of patients had at least three areas of abdominopelvic lymphadenopathy (71.8%).[ncbi.nlm.nih.gov]
  • METHODS: Children aged RESULTS: Mean age, duration of fever at presentation, presence of headache and, altered sensorium and presence of hepatomegaly/splenomegaly were statistically significantly different between the groups.[ncbi.nlm.nih.gov]
  • One enlarged lymph node in the right axilla and hepatomegaly were elicited. Weil-Felix reaction Ox-K was positive with 1:360 dilution. Doxycycline was advised for 7 days. Two months after follow-up, he had no symptoms.[ncbi.nlm.nih.gov]
  • High grade fever (90%), chills and rigors (68%), conjunctival suffusion (50%), body aches (43%), headache (41%), myalgias (37%), abdominal pain (21%), lymphadenopathy (17%), splenomegaly (17%), cough (16%), altered sensorium (16%), vomiting (15%), hepatomegaly[ncbi.nlm.nih.gov]
  • Most common findings on physical examination were eschar (58%), crepitations in the chest (36%), hepatomegaly (34%) and lymphadenopathy (30%).[ncbi.nlm.nih.gov]
Myalgia
  • KEYWORDS: Bhutan; Orientia tsutsugamushi eschar; chigger; conjunctival congestion; encephalitis/meningitis; eschar; larval mite; lymphadenitis; meningoencephalitis; myalgia; parasites; pediatric; rash; scrub typhus; thrombocytopenia; tsutsugamushi triangle[ncbi.nlm.nih.gov]
  • Abstract Scrub typhus is an acute infectious disease caused by Orienta tsutsugamushi, which is clinically manifested by fever, generalized lymphadenopathy, diffuse myalgia, headache, maculopapular rash, and eschars at the site of chigger feedings.[ncbi.nlm.nih.gov]
  • Initial signs and symptoms included fever (99%), malaise (82%), headache (77%), fatigue (70%), myalgias (68%), and rash (39%).[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: We report a 65-year old lady who was admitted in a Tertiary Care Center in the state of Kerala in India, with 7 day history of fever, myalgia and reduced urine output.[ncbi.nlm.nih.gov]
  • Other frequent symptoms were chills, malaise, myalgia, and anorexia. A tetrad of reported laboratory abnormalities consisting of elevated liver enzymes, lactate dehydrogenase, erythrocyte sedimentation rate and hypoalbuminemia was detected.[ncbi.nlm.nih.gov]
Arthralgia
  • Here one such case of a 55-year-old man is reported who presented with fever and arthralgia. There was an erythematous maculopapular rash on his body. One enlarged lymph node in the right axilla and hepatomegaly were elicited.[ncbi.nlm.nih.gov]
  • A 40 year old female presented with high grade fever, seizures, bodyache, arthralgia and severe breathlessness.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: A 62-year-old previously healthy Sri Lankan native male from the Western province of Sri Lanka presented with high fever with malaise, myalgia and arthralgia for 17 days.[ncbi.nlm.nih.gov]
  • Symptoms had started 8 days prior to hospitalization with fever, asthenia, arthralgia, and headache. Four days after the onset of symptoms she had developed a generalized maculopapular skin rash.[doi.org]
  • […] 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 cough arthralgia[medbullets.com]
Eruptions
  • A macular eruption (dark spot on the skin) appears on the fifth to sixth day, initially on the upper trunk, which then spreads to the entire body excepting, usually, the face, palms and soles of the feet.[web.archive.org]
  • After approximately six days, red eruptions appear on the torso, hands, feet, and face. Mortality is incredibly high under epidemic conditions, nearing 100%. Epidemic typhus victim with characteristic eruptions on torso, neck, and arms.[montana.edu]
  • After 5–6 days, a macular skin eruption (dark spots) develops first on the upper trunk and spreads to the rest of the body but usually not to the face, palms of the hands or soles of the feet.[who.int]
  • It typically begins as a maculopapular eruption on the trunk of the body and spreads to the extremities, usually sparing the palms of hands and soles of feet. When the disease is severe, petechiae may develop.[cdc.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[medbullets.com]
  • Petechiae are uncommon. Physician Diagnosis It is important to treat scrub typhus early in the course of the disease in order to avert life-threatening complications.[cdc.gov]
Exanthema
  • 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.[doi.org]
  • Biopsies (exanthema specimens) and peripheral leukocytes can be used. To confirm rickettsial species in blood by using PCR, EDTA or citrate blood is required.[doi.org]
Alopecia
  • Because these ticks often suck blood on the hairy scalp, localized alopecia in patients has been reported in some cases.[doi.org]
Headache
  • The most common symptoms are fever, headaches, and sometimes rash. Clinical Guidelines Diagnosis and management of Typhus fevers Murine Typhus Bacterial disease spread by fleas Scrub Typhus Spread by chiggers in Southeast Asia[web.archive.org]
  • METHODS: Children aged RESULTS: Mean age, duration of fever at presentation, presence of headache and, altered sensorium and presence of hepatomegaly/splenomegaly were statistically significantly different between the groups.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: A 74-year-old male farmer was admitted to the hospital with fevers and a headache that had lasted for 10 days, followed by 4 days of unconsciousness, and his condition continued to deteriorate.[ncbi.nlm.nih.gov]
  • Abstract Scrub typhus is an acute infectious disease caused by Orienta tsutsugamushi, which is clinically manifested by fever, generalized lymphadenopathy, diffuse myalgia, headache, maculopapular rash, and eschars at the site of chigger feedings.[ncbi.nlm.nih.gov]
  • Abstract A 19-year-old man had an unexplained fever, dizziness, headache, fatigue, and pain in the scrotum. An FDG PET/CT imaging was acquired to assess fever of unknown origin.[ncbi.nlm.nih.gov]
Confusion
  • […] tenderness, agitation, bloody stool, chills, confusion, delirium, hallucinations, nose bleeds and fatigue.[passporthealthusa.com]
  • […] symptoms may include: Figure 2: Adult and larval chiggers (mites) on the head of a pin Fever and chills Headache Body aches and muscle pain A dark, scab-like region at the site of the chigger bite (also known as eschar) Mental changes, ranging from confusion[web.archive.org]
  • Signs and symptoms may include: Fever and chills Headache Rapid breathing Body and muscle aches Rash Cough Nausea Vomiting Confusion Brill-Zinsser disease Some people can remain infected, without symptoms, for years after they first get sick.[web.archive.org]
  • Simultaneous symptoms may include severe headaches, bronchial disturbances, and mental confusion. Indeed, typhus is from the Greek word typhos meaning stupor. After approximately six days, red eruptions appear on the torso, hands, feet, and face.[montana.edu]
Agitation
  • . * Warning signals: Louse-borne typhus should be suspected when people in crowded, louse-infected conditions experience sudden onset of high fever, chills, headaches, general pain and severe exhaustion alternating with agitation, followed on the fifth[web.archive.org]
  • […] similarity, and why many have thought them to be the same disease for so long, is the symptoms: Typhus: Abdominal pain, rash, high fever, cough, headache, joint and muscle pain, nausea, chills, confusion and low blood pressure Typhoid: Abdominal tenderness, agitation[passporthealthusa.com]
  • —I have an idea that agitation does it as much harm as fatigue” (8 September 1816); “I am almost entirely cured of my rheumatism; just a little pain in my knee now & then” (20 February 1817); “I have still a tendency to Rheumatism” (26 March 1817).[jasna.org]
Altered Mental Status
  • Typical signs and symptoms include: Fever and chills Headache Myalgia Eschar Altered mental status, ranging from confusion to coma or delirium Lymphadenopathy Rash Most patients have thrombocytopenia and may also show elevated levels of liver enzymes,[cdc.gov]
  • Other signs of meningoencephalitis include sensitivity to light (photophobia), altered mental status (delirium), or coma. Untreated cases are often fatal. Multiple diseases include the word "typhus" in their descriptions.[en.wikipedia.org]
Tremor
  • Clinical examination revealed a high amplitude low frequency resting tremor in his right hand, a mask-like face and increased muscle tone limited to the right side with normal reflexes.[ncbi.nlm.nih.gov]
  • We present a 55-year-old man experiencing acute onset bilateral limb tremor, rigidity, and myoclonus with small-stepped gait, and skin rash involving the trunk and limbs, after a fever.[ncbi.nlm.nih.gov]
  • Around the 5th day of the clinical illness he had developed intermittent resting tremor in his right arm and leg. By the time he presented to us he had stiffness and very frequent intermittent resting tremor (Additional file 1 : Video).[bmcresnotes.biomedcentral.com]

Workup

History of the patient with characteristic symptoms of the disease are very important in the diagnosis of typhus disease. Laboratory studies are more helpful in assessing the severity of the condition rather than confirmatory diagnosis of typhus disease. It also helps in differential diagnosis. Laboratory studies are useful in assessing the vasculitic changes caused by the infection. Some of the common abnormalities noted include proteinuria, leukopenia, thrombocytopenia, higher levels of transaminase, and hypoalbuminemia.
Acute primary disease is diagnosed using immunofluorescence assay (IFA) or enzyme immunoassay which may show an increase in IgM titer. Brill-Zinsser disease is confirmed with a history of primary epidemic typhus disease with an increase in antibody titer and also recurrent symptoms of typhus. The increase in the levels of IgM indicates secondary response. Biopsy and PCR helps in confirmatory diagnosis of the disease [9]. Complement fixation test is useful in identifying the causative species of rickiettsiae. Chest radiography is used to assess the course of scrub typhus and is usually done one week after the onset of symptoms [10].

Salmonella Typhi
  • Rickettsia typhi is the proper name of typhus and it’s Salmonella typhi for typhoid.[passporthealthusa.com]
  • The antibiotic-resistant strain of Salmonella Typhi, the primary cause of typhoid, emerged within the last 30 years and may represent an ongoing, previously unrecognized epidemic in Africa, reports a study published online this week in Nature Genetics[natureasia.com]

Treatment

Antibiotics are the standard of care in the treatment of the disorder [11]. Doxycycline and chloramphenicol are used as antirickettsial agents.

Prognosis

Prognosis of the disease often depends on the severity of the disease and also the health of the patient at the time of infection. More severe form of clinical features are seen with epidemic typhus. Patients with severe form of epidemic typhus may develop gangrene that leads to loss of limb or other appendages. Vasculitis may also result in neurological symptoms, multiorgan failure, and even death. Early diagnosis and treatment are good prognostic factors for any type of typhus disease. Starting antibiotic therapy as early as possible helps to improve the symptoms and to reduce mortality.

Etiology

Typhus is caused by pleomorphic bacteria belonging to the group of rickettsiae. These are obligate intracellular parasites and may be cocci or bacilli in form. Epidemic typhus is caused by Rickettsia prowazekii [1]. Body louse is the vector for this form of typhus fever, commonly Pediculus corporis, P capitis, and Phthirus pubis. Occasionally, flying squirrels are also found to harbor these bacteria [2]. Bacteria gains access into a louse when the louse feeds on the blood of an infected person. The louse often dies of rickettsiae infection caused by obstruction of alimentary canal.
Brill-Zinsser disease is a recrudescent form of epidemic typhus. If the patient gets lice infestation at the same time, the louse may become infested by feeding and may result in an outbreak of the disease [3].
Murine typhus is transmitted by cat or rat flea and is caused by R typhi. Fleas Xenopsylla cheopis (rat flea), and Ctenocephalides felis (cat flea), well known to act as vectors for R typhi. Usual hosts for the bacteria are mice and cat. These fleas are not usually affected by the infection, unlike lice in epidemic typhus. Aerosol contaminated with fecal matter of fleas is a possible route of infection.
Scrub typhus is caused by the species Orientia tsutsugamushi spread through mites. The common vectors of these bacteria are Leptotrombidium akamushi and Leptotrombidium delicense. Mites are not affected by the presence of bacteria [4]. Mammals like rats and mice are the usual hosts of the bacteria. Human beings are accidental hosts. The intracellular parasites are transmitted to the hosts during feeding. Many behavioral factors were found to be associated with increased risk of developing scrub typhus [5]. Some of them include taking rest near scrubs, working with bare hands, wearing short-sleeved dresses, and squatting.

Epidemiology

Epidemic typhus is more prevalent in Central and South America, Africa, the northern parts of China, and the central regions of Himalayas. About 15% of the people who have a history of typhus may develop Brill-Zinsser disease at a later stage. It may occur up to 40 years after the initial typhus infections. When conditions for transmission and propagation of the vector are conducive, epidemic typhus outbreaks occur. It is often associated with wars and other conditions that lead to poor hygiene that favor infestation of lice. This disease is often found in cold regions, poverty, and during civil unrest. Men and women are equally affected by this disease [3]. Incomplete and inappropriate treatment of infection may increase the risk of recurrence, mostly in the form of Brill-Zinsser disease.
Murine typhus is more common in the coastal areas of subtropical and temperate countries. It is endemic in many areas and is mostly sporadic in nature. In temperate climates the population of fleas increase during summer months, thus increasing the incidence of the disease. Homeless people are at an increased risk of developing this form of typhus [6].
Northern Australia, Indian subcontinent and Pacific regions are more susceptible to scrub typhus. Many endemic areas of this disease lack appropriate diagnostic facilities, a condition which results in a serious underestimation of the incidence. In Malaysia, the incidence of scrub typhus was about 3% in a month. Multiple infections were found in the same individual indicating absence of cross immunity [7].
In general, typhus infections occur equally among males and females. Furthermore, there is no age predilection for the occurrence of this disease, even though in United States murine and epidemic typhus are found to be more common among adults [8].

Sex distribution
Age distribution

Pathophysiology

Louse bite causes a pruritic reaction on the skin. Scratching of the site crushes the lice, and fecal matter containing the bacteria enters the wound. Rickettsia then moves to the blood stream where it parasitizes the endothelial cells of blood vessels. Incubation period for the pathogen is about 12 days. These bacteria then proliferate in the cells resulting in cell enlargement and multiorgan vasculitis. Deposition of leukocytes, macrophages and platelets occurs in the affected area resulting in small nodules. Proliferation of the bacteria may also result in thrombosis leading to gangrene in the extremities. Vasculitis is the reason for intravascular colloid loss, hypovolemia and reduced tissue perfusion. It may also lead to organ failure.
Some of the people who have suffered from a Rickettsia infection may develop recrudescent typhus, the Brill-Zinsser disease. Even after successful treatment of the infection, the bacteria may remain in the tissues. After several months, or even years, this bacteria may become active resulting in recurrence of typhus. The method by which the pathogen remains inactive and silent is not clearly known. The manifestations of Brill-Zinsser disease are less severe than the actual infection. Pathophysiology of murine and scrub typhus disease are similar to that of epidemic typhus.

Prevention

Louse-borne infections can be prevented by de-lousing clothes and maintaining good personal hygiene. Avoiding contact with ticks and mites help in preventing diseases caused by them. Control of vectors and animal reservoirs are also helpful. Arthropod vectors can be controlled by the use of insecticides. Reducing rodent population, wearing protective clothing and avoiding overcrowding help in preventing the spread of the disease. Try to avoid exposure to areas endemic to the particular type of typhus disease.

Summary

Typhus is a group of infectious diseases caused by rickettsial species. This disease result in acute febrile illness and is transmitted by arthropod vectors like lice, mites and fleas. The most common among them are :

Epidemic typhus is a major threat to public health, particularly during war or a civil unrest. Brill-Zinsser disease is a mild form of recurrent epidemic typhus and is more prevalent among elderly people. Murine typhus is rat flea-borne and is more common in Southern United States, particularly in summer and fall. Clinical manifestations of murine typhus are similar to that of epidemic typhus, but are less severe. Both epidemic and murine typhus infections render the patient immune to subsequent infections. Scrub typhus is mite-borne and is more commonly found in Asia-Pacific region.

Patient Information

Typhus is a group of infectious diseases caused by by Rickettsia bacteria. This disease result in acute febrile illness and is transmitted by vectors like lice, mites and fleas. The most common among them are :

The signs and symptoms depend on the form of the disease. Antibiotics are the standard of care in the treatment of typhus.

References

Article

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  2. Reynolds MG, Krebs JS, Comer JA, et al. Flying squirrel-associated typhus, United States. Emerg Infect Dis. 2003;9(10):1341-3.
  3. Bechah Y, Capo C, Mege JL, Raoult D. Epidemic typhus. Lancet Infect Dis. 2008;8: 417-426.
  4. Watt G, Walker DH. Scrub typhus. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases Principles, Pathogens and Practice. Vol 1. 2nd ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2006:Chapter 52.
  5. Kweon SS, Choi JS, Lim HS, Kim JR, Kim KY, Ryu SY, et al. A community-based case-control study of behavioral factors associated with scrub typhus during the autumn epidemic season in South Korea. Am J Trop Med Hyg. 2009;80(3):442-446.
  6. Badiaga S, Benkouiten S, Hajji H, Raoult D, Brouqui P. Murine typhus in the homeless. Comp Immunol Microbiol Infect Dis. 2012; 35(1):39-43. 
  7. Saah AJ. Orientia tsutsugamushi (Scrub typhus). In: Principles and Practice of Infectious Diseases. Philadelphia: Churchill Livingstone;2000: 2056-2057.
  8. Civen R, Ngo V. Murine typhus: an unrecognized suburban vectorborne disease. Clin Infect Dis. 2008;46(6):913-8.
  9. 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. 2011; 64(1):92-97. 
  10. Chen HC, Chang HC, Chang YC, Liu SF, Su MC, Huang KT, et al. Chest radiographic presentation in patients with scrub typhus. Trans R Soc Trop Med Hyg. 2011; 106(1):48-53. 
  11. Krause DW, Perine PL, McDade JE, Awoke S. Treatment of louse-borne typhus fever with chloramphenicol, tetracycline and doxycycline. East Afr Med J. 1975;52:421-427. 

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Last updated: 2017-08-09 18:21