RICKETTSIACEAE

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Dr.T.V.Rao MD

Zinsser, Lice And History

In 1935, Harvard Medical School physician and researcher Hans Zinsser wrote the brilliant and original Rats, Lice and History in which he traced the effects of vermin-borne disease on armies, cities and populations. From his extensive research on head and body lice, Zinsser stated unequivocally that "the body and head louse carry the infection [typhus] from one human to another.
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Zinsser, Lice And History

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General Characteristics
Small obligate intracellular coccobacilli Gram negative (poorly), better stained with Giemsa (Blue) Have cell wall, bigger than virus but smaller than bacteria Have DNA and RNA Have an ATP transport system that allows them to use host ATP Arthropod reservoirs and vectors ( e.g., ticks, mites, lice or fleas). Sensitive to antibiotics
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Category of rickettsia
Genus
Rickettsia, Coxiella ,Orientia,Ehrlichia Bartonella Species Rickettsia prowazekii (epidemic typhus), Rickettsia typhi (endemic typhus), Rickettsia rickettsii (spotted fever), Rochalimaea quintana (trench fever), Coxiella burnetii (Q fever)
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History
17th-19th century
Epidemics in Europe as a result of war, disaster, or in prisoners

1909: Transmission by lice 1917-1925: Russia

Estimated 25 million cases

End of WWII
DDT used for control Vaccine developed
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Historical Photograph on Typhus

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Similar with Gram negative bacteria Cell wall: outer membrane peptidoglycan lipopolysaccharide (LPS) Microcapsule and polysaccharide Two antigenically distinct groups: LPS: heat-stable, cross-reactive with somatic antigens of non-motile Proteus species (Weil-Felix test) Outer membrane protein: heatunstable, species-specific
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Structure: of Bacteria

Rickettsia
Small gram negative Bacilli Obligate intracellular pathogens. Parasites on - Lice, Fleas, Ticks Mites colonizes the Gut. In vertebrates colonizes Vascular endothelium and Reticuloendothelial system.
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Five genera in this class cause human diseases:

Rickettsia Bartonella Coxiella (does NOT cause skin rash) Ehrlichia Orientia

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Replication

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Five genera in this class cause human diseases:

Rickettsia Bartonella Coxiella (does NOT cause skin rash) Ehrlichia Orientia

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Genera
1.Rikettsia, 2.Orientia 3.Ehrcichia
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Typhus Group
Murine typhus (also known as endemic typhus and flea borne typhus) Rickettsia mooseri (typhi) Epidemic typhus (also known as BrillZinsser disease and louse borne typhus) Rickettsia prowazekii Scrub typhus (or Chigger fever) Rickettsia tsutsugamushi
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The Others
Q Fever
Coxiella burnetii Ehrlichiosis Ehrlichia canis Ehrlichia equi Ehrlichia chafeensis Several others now identified
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RICKETTSIAL INFECTIONS
Fever, headache, malaise, prostration, skin rash & Hepatosplenomegaly Classified into groups: 1. Typhus Group Epidemic typhus, Murine typhus, Scrub typhus 2. Spotted Fever Group RMSF, Rickettsia pox 3. Q Fever 4. Trench fever 5. Ehrlichiosis
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Diseases Caused by the Rickettsia

Disease Organism Vector
Tick Laval Mite (chiggers) Louse Flea None

Reservoir
Tick, wild rodents Mites, wild rodents Humans, squirrel fleas, flying squirrels Wild rodents Cattle, sheep, goats, cats

Rocky Mountain R. Rickettsii spotted fever Scrub typhus R. Tsutsugamushi

Epidemic typhus R. Prowazekii Murine typhus Q fever R. Thphi Coxiella Burnetii

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DISEASES

RICKETTSIAL AGENT

INSECT VECTOR

MAMMALIAN RESERVOIR

TYPHUS GROUP
a) Epidemic typhus b) Murine typhus
(Endemic typhus)

R. prowazekii Louse

Human

R. typhi

Flea

Rodents

c) Scrub typhus)

R. Mite tsutsugamush i Dr.T.V.Rao MD

Rodents
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Rickettsia Prowazekii
( Von Prowazekii )
Humans natural vertebrate hosts
Vector - Human body louse,( Pediculus humans corporis )
Lice get infected from patients. Life cycle get multiplied in gut 1 week Person person contact. Lice bite causes itching and scratching Enters through respiratory tract / Conjunctivae Incubation 5- 15 days
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Genus -Rickettsia
Two groups Typhus fevers, Spotted fever. Morphology Rickettsia pleomorphic Coco bacillary, Size 0.3 to 0.6 micron x 0.8 - 2 microns. Gram negative, non motile Non capsulate not stained easily Giemsa and Gimenez staining methods.
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Typhus Fever

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Typhus Fever group

1. Epidemic

Typhus 2. Recrudescent typhus ( Brill Zinsser disease ) 3. Endemic typhus

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EPIDEMIC TYPHUS (LOUSEBORNE TYPHUS)

Etiology: R. prowazekii severe systemic infection & prostration more fatal Brill-Zinsser Disease recrudescent disease
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Epidemic Typhus - 1
Also known as louse borne typhus because it is spread human-to-human via the body louse (which dies of its infection with Rickettsia prowazekii after about three weeks) This is a serious disease consisting of fever, severe headache, myalgia, and central rash Untreated, the mortality ranges from 2040% Major killer in concentration camps of WW II
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Cultivation
Needs cell culture lines Grows in the Cytoplasm Grows at 32 to 350 c Grows in yolk sac of developing chick embryo Grows in mouse fibroblasts, Hela,Hep2
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Cultivation
Rickettsia can not be grown in bacteriological media, Obligate intracellular pathogens. In continuous cell lines, Guinea pig, Mice Infect the endothelial cells of vascular system. Can synthesize ATP
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Life Cycle of Rickettsia

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Replication

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Transmission
Human body louse
Pediculus humanus corporis Infective for 2-3 days Infection acquired by feeding on infected person Excrete R. prowazekii in feces at time of feeding Lice die within 2 weeks
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Transmission
Louse feces rubbed into bite or superficial abrasions Inhalation of feces

Sylvatic typhus
Flying squirrel 30 human cases in eastern and central U.S.

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PATHOLOGY
Multiply in endothelial cells of small blood vessels Vasculitis (skin rashes;other organs DIC & vascular occlusion)

Swollen & necrotic

Thrombosis of the vessels

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Antigenic structure
Species differ with Group specific antigens. Sharing of antigens between Rickettsia and Proteus basis of Weil Felix Heterophile agglutination Test. Used Proteus strains 0X 19, OX2 OXK
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Epidemic Typhus
Also called as Louse borne Typhus Classical Typhus Russia Eastern Europe Devastating Epidemics in wars Napoleons retreat Russia 3 million deaths 1917 1921 India - Kashmir
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R. Prowazekii
Louse Human
Louse Epidemic typhus
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Human

R. Typhi
Rodent Flea Rat Tick Flea Human

Rodent Murine typhus (much milder than epidemic typhus)

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Lesions in Epidemic Typhus

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Rickettsia Prowazekii ( Von Prowazekii )

Humans - natural vertebrate hosts

Vector - Human body louse,( Pediculus humans corporis )

Lice get infected from patients. Life cycle get multiplied in gut 1 week Person person contact. Lice bite causes itching and scratching Enters through respiratory tract / Conjunctivae Incubation 5- 15 days
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Pediculus humanus corporis is the Vector

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Clinical Symptoms
Incubation: 7-14 days High fever, chills, headache, cough, severe myalgia
May lead to coma

Macular eruption
5-6 days after onset Initially on upper trunk, spreads to entire body
Except face, palms and soles of feet
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Clinical Features
Fever, chills Rash on 4 th day Spread from Trunk to Limbs Not face palms, sole. In 2 nd week may into stuporous,delirious state May reach 40 % fatality Bacteria remain latent in Lymphoid tissue, cloudy state. Because of called as Typhus May cause Recrudescent Typhus ( Called as Brill Zinser Disease.)
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Brill-Zinsser Disease
Occurs years after primary attack
Person previously affected or lived in endemic area Viable retained organisms reactivated Milder symptoms
Febrile phase 7-10 days

Rash often absent Low mortality rate

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Brill- Zinser Disease

Recrudescent typhus fever

Earlier recovery from typhus fever Latency of the organism in lymphoid tissue Reactivation leads to recrudescence. Even louse get infected from patients. Clinically similar but mild.
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Pattern of Temperature chart in Typhus Fever

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Endemic Typhus R.mooseri

Also called as Murine or Flea borne typhus From Rats -Transmitted by Rat flea Rickettsia multiplies in Gut and shed in feces Humans bitten by infected Rat flees. Saliva or feces rubbed on bitten area, may lead to infection. R.typhi R. Prowazekii similar, Biological and Immunological tests.
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Clinical features
Mild disease Rat act as reservoir. Vector Rat flea -Xenopsylla cheopsis Rat flea bites rat Multiplies in the gut of the rat Fleas un affted. Man gets infected accidentally Mexico Kashmir - china
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T.V.Rao MD

Experiments on Animals Neill-Mooser Reaction

Male guinea pig inoculated intra peritioneally with blood of patients, or isolates of S.typhi produce Fever, and scrotal swelling, enlarged tests, and cannot be pushed back.-due inflammation and adhesions between layers of Tunica vagina Test positive in R.typhi

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Treatment
Chloramphenicol Tetracycline
Doxycycline 200mg

Response within 48 hrs. usually Vaccine

Developed after World War II
Not commercially available
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Spotted Fever Group

Rickets 1906 Rickettsia of this group, multiplies in Nucleus and Cytoplasm Ticks transmit
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DISEASES

RICKETTSIA L AGENT

INSECT VECTOR

MAMMALIA N RESERVOIR

SPOTTED FEVER GROUP

a) Indian tick typhus b) Rocky mountain spotted fever c) Rickettsial pox R. conorii Tick Rodent, Dog

R. rickettsii

Tick

Rodents, Dogs Mice

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R. akari

Mite
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Tick Typhus
R.rickettsii Rock mountain spotted fever R.siberica R.conori R.australis. Ticks transmits bite- Trans ovarian spread
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Rocky Mountain spotted fever

Ticks in North / South America Tick type R.conori. Rickettsial Pox Resembles like chicken pox R. akari by mite Mouse reservoir host.
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Ticks acts as vectors and reservoirs of Infection

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Rocky Mountain spotted fever

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Rocky mountain spotted fever

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Rocky Mountain spotted fever

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Rocky Mountain spotted fever

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Genus - Ehrlichia
Small Gram negative , obligate intracellular pathogens, Can infected Phagocytic cells. Called as Glandular fever Ehrlichia sennetsu causative agent. Cause atypical lymphocytosis No arthropod vector, Eating fish infected with flukes infected by these bacteria.
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Monocytic Ehrlichiosis
Caused by Ixodid ticks, E.chaffensis. Deer, cattle, Sheep reservoirs Leucopenia Thrombocytopenia Liver is involved. Doxycycline effective in Ehrlichosis Human granulocytic Ehrlichosis E.equi.
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Laboratory Diagnosis of Rickettsial diseases

Isolation Serology Isolations can be dangerous if not well protected. R.typhi R.conori, R.akari causes tunica reaction R.prowazeki only fever
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Diagnosis and Prevention

Microscopy Serological Test (Weil-Felix reaction, ELISA, IF, PCR) Breaking the infection chain ( controlling and killing the intermediate hosts and reservoir hosts) Inactivated vaccine has protective effect Chloromycetin, tetracycline are helpful for therapy, Sulphonamides are not administered (increasing the penetrating of the vessel).

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Laboratory Diagnosis
Tissue cultures In Vero cells, MRC 5 cells.
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Serology
Weil Felix Test
Test based on principle of Hetrophile agglutination tests Non motile strains of Proteus are selected.

OX19,OX2,OXK
Sharing alkali stable carbohydrate antigen by some Rickettsia X certain strains of Proteus vulgaris OX19,OX2, and Proteus mirabilis OXK.
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Laboratory Diagnosis
Weil Felix is simple to perform but of Historical importance Other tests Complement fixation tests, Agglutination, Passive hem agglutination.

PCR
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DISEASE

WEIL-FELIX
OX19 OX2 +/+ ? OXK ++ ? 66

Epidemic typhus Endemic typhus Scrub typhus RMSF Rickettsial pox Q fever Trench fever
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++ ++ + ?

Different Methods of Diagnosis

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Older Techniques
:to detect O. tsutsugamushi

1. Giemsa Staining Technique

:- utilizes peritoneal scrapings of infected mice.

2. Weil-Felix Proteus Agglutination Test

:-is a test which relies on the fact that Rickettsia and Proteus OX strains have common antigens. :-is a test for the presence & type of rickettsial disease based on the agglutination of Xstrain Proteus vulgaris with suspected Rickettsia in a patients blood serum sample. :-is commonly used in hospitals & clinics

:-This test is now being replaced by a complement-fixation test.

Weil-Felix Proteus Agglutination Test

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Newer Techniques
:to detect O. tsutsugamushi

Immunological Assays
2. Indirect Immuno-Peroxidase (IIP)
IIP= is a modification of IFA technique that replaces the fluorochrome with peroxidase.
Slide is observed using a bright-field microscope. Staining reaction is positive when O. tsutsugamushi particles stain light brown.
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Control

Infected

Newer Techniques
:to detect O. tsutsugamushi

Immunological Assays
4. Enzyme-linked Immuno-Sorbant Assay (ELISA)
ELISA test is a technique for detecting & measuring antigen or antibody. :-It is one of the most reliable techniques to detect antibody against scrub typhus infection. :-Its procedure is the principal for development of recent rapid diagnostic kits. :-This technique is widely used in laboratories & hospitals.
Ag-Ab complex
Ag-coated well

Optical Density (OD) Reading

1. Add antigens

2. Add mouse serum

3. Add anti-Ab

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4. Add enzymesubstrate mix

5.Let colorize

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Prophylaxis

Control of vectors. Destruction animal reservoirs,

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Scrub Typhus
Scrub typhus caused by Mild to fatal 6-18 days after bite of Mite An Escher is formed at the site of bite With enlargement of Lymph nodes, Interstitial pneumonitis ,lymphadenopathy,spleenomegaly Encephalitis, Respiratory failure, circulatory failure
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SCRUB TYPHUS
Etiology: Orientia tsutsugamushi resembles Epidemic typhus except for the ESCHAR generalized lymphadenopathy & lymphocytosis cardiac & cerebral involvement may be severe
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Epidemiology
Source of infection--------Rat

Route of transmission-----Trombiculid mites

Susceptible population----All susceptible

Epidemic features----------Tsutsugamushi

triangle

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Epidemiology
Adul
Nymp h

Eg
t g

Infected animal Larva Eg Adul g t

Human
Larva
Nymp h

Natural cycle-natural focalization Natural focus disease-zoonosis-borne diseases

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Scrub Typhus
An important vector-borne disease, first described in 1899 in Japan. During World War II, this disease killed thousands of soldiers who were stationed in rural or jungle areas of the Pacific theatre. The disease occurred and threatened people throughout Asia & Australia. The range stretches from the Far-east to the Middle-east (from Japan and Korea, Southeast Asia, Pakistan, India, to Arab countries and Turkey). There are approx. 1 million cases each year world-wide, & over 1 billion people at risk.
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R. Tsutsugamushi
Eggs Adult stage Nymphal stage

Rats

Nymphal stage

Chigger

Nymphal stage

Human

Nymphal stage

Adult stage

Eggs

Scrub typhus
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Scrub typhus

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Scrub Typhus: A Rickettsial Disease

Pathogen: Orientia tsutsugamushi Rickettsial bacteria

Vector: Leptotrombidium

An acute febrile, rickettsial disease caused by a gram-negative, rodshaped (cocco-bacillus) bacterium, known as Orientia (Rickettsia) tsutsugamushi.
O. tsutsugamushi is transmitted to vertebrate hosts (rodents-primary host & humanssecondary or accidental host) by the bite of larval mites (chiggers) of the genus Leptotrombidium, e. g. L. deliense, L. dimphalum, etc.
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Chigger-Mite

Pathogenesis and pathology

Inoculation Invade Local lymph node Spread by Blood stream Invade Vascular endothelium

Papule maculoppular eschar ulcer

Enlargement of local lymph node

General symptoms of intoxication

General organ hyperaemia. Systemic lyphadenopath

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R. Tsutsugamushi
Eggs Adult stage Nymphal stage

Rats

Nymphal stage

Chigger

Nymphal stage

Human

Nymphal stage

Adult stage

Eggs

Scrub typhus
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Scrub typhus

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Clinical Manifestation
Incubation period is 4~21
Sudden onset with a fever 1st week, systemic toxic symptoms

2nd week, get worse, complication

3th week, convalesce
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Specific features
Eschar
Probability: Higher than 60%. Location: Axillary fossa, inguinal region, perianal region, scrotum, buttocks and the thigh. Appearance: an ulcer surrounded by a red areola, is often covered by a dark scab.

The most specific manifestation of scrub typhus.

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Ricketisial pox
Transmitted by mites, Similar other spotted fever Head ache ,fever Escher at the site of bite by mite. Maculopapular rash, can be vesicular, Fever lasts for 1 week
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Skin Lesion

Mite

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Q Fever
Occurs in veterinarians, ranchers, and animal researchers who are in contact with infected placenta from sheep, cattle, or goats (no arthropod vector for C. burnetii) Incubation period is 10-28 days Fever and headache are common; 50% will develop pneumonia after inhaling the organism; hepatitis & endocarditis are rare Specific serology establishes the diagnosis Bioterrorist threat?
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Coxiella Burnetii
Q feverquery fever Self-limiting flu-like syndrome with high fever (40) Primary reservoirs are wild (cattle, sheep, goat etc.) Non-cross reactive antigen with nonmotile Proteus (Weil-Felix reaction negative) Live in macrophages of vertebrate host
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Genus Coxiella Q Fever

Etiological agent ? Small in size called Coxiella burnetti Ixodid tick spread the disease Domestic live stock get infected. Coxiella abundant in Tick feces, Survive in dried feces, Milk too infective Cause Human infection.
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Coxiella burnetti
Q fever Cow and sheep tick High resistance
abrupt onset ,fever,headache,chills, myalgia,granulomatous hepatitis

chronic diaease with subacute onset ,endocarditis,hepatic dysfunction

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Q - Fever

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Q Fever
Wool hides, Meat, Milk Enters through abrasions System infection through Intestine, pulmonary, All organs are involved Can cause serious infection, Hepatitis and meningitis, May last for 2 3 years as chronic condition Infects Monocytes and Macrophages,
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Q Fever

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Pasteurization of Milk Which method is better ? Pasteurization by holders method not effective Flash method effective. Phase variation applicable Phase I and Phase II
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Clinical features Present with head ache, chills, Pneumonia Endocarditis, Meningitis, Encephalitis Can cause latent infections.
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Q Fever

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Laboratory Diagnosis
Indirect Immunofluorescence methods Polymerase chain reaction, Genus specific applications in progress. Isolation of the organism is dangerous.
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Treatment
Doxycycline is effective. Tetracycline are highly effective Nursing care May need blood transfusion.
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Ehrlichiosis
Ehrlichia chaffeensis most common
Human monocytotropic ehrlichiosis (HME)

E. ewingii has also been identified Transmitted by lone star tick (Amblyomma americanum) White-tailed deer major host for tick species and natural reservoir for bacteria Infections in coyotes, dogs, and goats have been documented

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Proposed life cycle for the agent of Human Granulocytic Ehrlichiosis

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Ehrlichiosis Clinical Information

Onset occurs 510 days after tick bite Infects leukocytes
E. chaffeensis prefers monoctyes E. ewingii prefers granuloctyes Morulae can be identified

Rash observed ~33% of patients with HME

Vary from petechial or maculopapular to diffuse erythema Occurs later in disease

Rash rarely seen with E. ewingii infections

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E. Chaffeensis Laboratory

Criteria
Confirmed
Fourfold change in IgG by IFA in paired serum samples Detection of DNA by PCR Demonstration of antigen by IHC in biopsy or autopys sample Isolation of bacteria by cell culture

Supportive
Elevated IgG or IgM by IFA, ELISA, dot-ELISA or other formats Morulae identification by blood smear microscopic examination
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Bartonella
Gram ve bacilli/Anthropoids B.bacilliform, B.quintana,B henselae Bartonella bacilliform Also called as Oroya fever, A Medical student Peruvian Daniel Carrion Credited for isolation. Called as Carrions Disease
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Bacterial Morphology
B.bacilliform Pleomorphic gram negative bacteria Carries a tuft of polar flagella.
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Clinical features
Progressive Anemia, Bacterial invasion of Erythrocytes Carries high mortality
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Bartonella ( Rochalimia )
Bartonella Quintana Called as trench fever Called as five day fever. Grows in cell free culture media. Chronic/Latent infections Infection may lost > 20 years
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Bartonella Henselae
Cat scratch disease (CSD) Weil-Felix reaction negative Infection by cats or dogs Parinaud Eye-Lymph node syndrome The eye looks red, irritated, and painful, similar to conjunctivitis.
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Bartonella henselae
Also called s cat scratch disease Caused by B.henselae Needs lymph node biopsy Staining sections with Warthim Starry sating Associated in AIDS patients.
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Prevention
Use of repellents in endemic areas Protective clothing in endemic areas Careful inspection & quick removal of ticks Useful vaccine for RMSF is available for high risk groups such as forest rangers that work in endemic areas Weekly doxycycline may prevent scrub typhus infection in field workers
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 Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World Email doctortvrao@gmail.com

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