Rickettsia, Ehrlichia

and Related Bacteria

Prof. Carl Jay B. Bregente. RMT, MPH, MSc

College of Medical Technology, Assistant Professor 1
SWU PHINMA
Case

A 35-year-old man living in Missouri came to the local emergency

department because of fever, arthralgias, myalgias, and malaise. He was
well until 4 days before admission, when he developed a fever reaching
40°C, chills, severe headache, and muscle aches. Physical examination
revealed a critically ill man with a temperature of 39.7°C, pulse of 110
beats/min, respiratory rate of 28 breaths/min, blood pressure of 100/60
mm Hg, and a rash over his extremities, including his palms and soles.
The patient recalled having had numerous tick bites 10 days before the
onset of symptoms. A serologic test confirmed the diagnosis.
Rocky Mountain spotted fever was considered in the diagnosis.

Questions:
• What antibiotics can be used to treat this infection? Which
antibiotics should not be used?
• Which rickettsiae are associated with the following vectors:
ticks, lice, mites, and fleas?
• Why is use of the Gram stain inappropriate for the diagnosis of
rickettsial infections?
• Ehrlichia and Anaplasma have been historically associated
with Rickettsia. Compare clinical disease caused by Ehrlichia
chaffeensis and A. phagocytophilum.
• What clinical diseases are caused by Coxiella burnetii?
 Bacteria of concern:

• Rickettsiaceae
• Rickettsia
• Orientia
• Anaplasmataceae
• Ehrlichia
• Anaplasma
• Coxiellaceae
• Coxiella

Source: Murray et al., Medical Microbiology (9th ed); Table 34-1 p. 345
 A1. Rickettsia
Generalities:

• Mx: 0.5-2 um; pleomorphic

• G/S: gram-negative cells (motile)
• Fastidious bacteria; obligate intracellular
parasites.
• Culture: will NOT grow in cell-free media –
grow only in the cytoplasm of eukaryotic
cells.
• Multiply via binary fission (GT: 9-12 hrs)
• MOA: Humans become infected ff the bite of
infected arthropod vectors. Image source:

• MOP: avoid contact w/ their respective https://upload.wikimedia.org/wikipedia/commons/8/86/Rickett

sia_rickettsii.jpg

vectors
Rickettsia is divided into 3 groups:
Organism Infection/Disease Vector Incubation Rash Mortality rate
(Days) and Eschar (%)
Onset
A. Spotted Fever Group

R. conorii Boutonneuse fever or Brown dog ticks (Rhipicephalus 6 Maculopapular low

Mediterranean sanguineus) (Abrupt onset) rash (face of the
spotted fever (MSF) afflicted)
YES - “tache
noire”

R. rickettsii Rocky Mountain Hard ticks: 7 Macular with 10-25

spotted fever (RMSF) Wood ticks (Dermacentor (Abrupt onset) centripetal
andersoni); spread (palms and
Dog ticks (Dermacentor variabilis) soles)
Brown dog ticks NO eschar

B. Typhus group

R. prowazekii Epidemic typhus/ Human body louse (Pediculus 8 Macular with 20

Brill-Zinsser disease humanus corporis) (Abrupt onset) centrifugal spread
Squirrel flea (Orchopeas howardi) NO eschar
Squirrel louse (Neohematopinus
sciuriopteri)
R. typhi Endemic (Murine) Rat flea (Xenopsylla cheopsis) 7-14 Maculopapular low
typhus Cat flea (Ctenocephalides felis) (Gradual rash on trunk
onset) NO eschar

C. Transitional group

R. akari Rickettsialpox Mouse mite (Liponyssoides 9-14 Generalized low

sanguineus) (Abrupt onset) papulovesicular
YES - eschar

R. felis Flea-borne spotted Flea bite or feces 7-14 days Maculopapular low
fever (Abrupt) rash (centripetal),.
YES -eschar
Centripetal rash Centrifugal rash
Source: Murray et al., Medical Microbiology (9th ed);
 Transmission and Spread of Rickettsia

• MOE: Skin abrasion or arthropod bites

• Disseminated homogenously
(vasculitis in the blood vessels)

• Outer membrane protein A (OmpA)

–adherence to endothelial cells
• Immune response: cytokine-
mediated intracellular killing & CD8
and antibody response (anti-OmpA)

• Typhus group: reproduce in the

cytoplasm= cellular injury and death

• Differences: INTRACELLULAR
MOTILITY
• SFG: able to polymerize host
cells
• TG: lacks the required gene
(unstable and die quickly) Pathogenesis: (Cell-to-cell spread) Rickettsia
A2: Orientia
Orientia tsutsugamushi

• Strict intracellular parasite;

• Lacks both peptidoglycan layer and LPS
(54-to58-kDa major surface proteins)
• It replicates in the cytoplasm – released
through a process that involves “pinching off”
the host cell.

• MOA: bite of an infected vector à Mites:

Chigger (Leptotrombidium deliense) and red
mites
• Dse: Scrub typhus
• IP: 10-12 days
• Abrupt onset (fever, headache and muscle
pain)
• Maculopapular rash (centrifugal)-trunk
• NO eschar
• 1-15% mortality
 B Anaplasmataceae
Ehrlichia chaffeensis
Ehrlichia ewingii
Anaplasma phagocytophilum

• Remain in the phagocytic vacuole after entry in the

host cells
• Multiply via binary fission
• Developmental stages:
• Elementary bodies (smaller: 0.2-0.4um)-
infectious
• Reticulate bodies (larger: 0.8-1.5um)
• Morulae* -intravacuolar microcolony (“mulberries”)
• Mx: gram-negative bacteria (lack genes for
peptidoglycan and LPS synthesis)
• Pathology and Immunity:
• Initiates inflammatory response- pathogy
• Intracellular growth – protected from Ab
response Source: Murray et al., Medical Microbiology (9th ed)

• Prevent fusion of phagosome w/ lysosomes

of monocytes or granulocyte
 Organism Infection/Disease Vector Incubation (Days) Rash Mortality rate
Clinical Eschar (%)
Presentation
A. Ehrlichia

E. chaffeensis Human monocytic Soft ticks: Lone star tick 7-14 Rash- common in 2-3
ehrlichiosis (Amblyomma americanum) Fever, headache, children
malaise, myalgias,
leukopenia, No eschar
thrombocytopenia and
inc. serum
transaminases

E. ewingii Human granulocytic Soft ticks: Lone star tick 7-14 Rash - present Insufficient data
ehrlichiosis Similar to HME
No eschar

B. Anaplasma

A. Human granulocytic Deer tick (Ixodes scapularis 5-10 Rash - <10% of <!%
phagocytophilum anaplasmosis and Ixodes pacificus) Fever, headache, patients
Soft ticks: Blacklegged tick malaise, myalgias,
leukopenia, No eschar
thrombocytopenia and
inc. serum
transaminases
 A. phagocytophilum

E. ewingii
E. chaffeensis
Source: http://www.infectionlandscapes.org/2011/06/ehrlichiosis.html
 C. Coxiellaceae

Coxiella burnetii

• GN bacteria; grow intracellularly in eukaryotic cells

• 2 structural forms:
• Small cell variants – resistant to environment
• Large cell variants – metabolically active form
• Associated with arthropods (ticks) – incidental
• MOA: inhalation of contaminated aerosols from Source: https://c8.alamy.com/comp/E5R195/colored-transmission-
electron-micrograph-tem-of-coxiella-burnetii-E5R195.jpg
dried animal feces and ingestion of contaminated
unpasteurized milk. [ID: <10 bacteria]
• Dse: Q fever (Query fever)
• IP: 10-14 days
• Abrupt onset; high fever, headache, malaise myalgias;
progress to hepatitis, pneumonia or SBE (chronic Q
fever).
• No rash and eschar formation
• <5% mortality rate
• 2 Phases: Phase 1 (virulent); Phase II (Avirulent)
LABORATORY DIAGNOSIS

• Specimen: biopsy of skin tissues, peripheral blood and CSF

• Processing of specimen: Biosafety level 3

1. Direct Microscopy
• Immunohistology (immunofluorescence or immunoenzyme stains)
of skin biopsy material
• Giemsa stain – detection of morulae (febrile stage of ehrlichiosis)

2. Culture
• Culture media: yolk sacs of embryonated eggs and tissue culture
• Lung tissue cells- preferred for C. burnetii
https://www.researchgate.net/profile/John-Antony-Jude- https://www.researchgate.net/profile/Rachael-Thomas-
8/publication/26742950/figure/fig2/AS:394332612907008@1471027629135/Examples-of-
Prakash/publication/7076422/figure/fig1/AS:601587240140802@15204409
Anaplasma-phagocytophilum-and-Ehrlichia-chaffeensis-morulae-in-peripheral.png
83044/Immunohistochemical-results-showing-rickettsiae-in-inflammatory-
infiltrates-of-the-dermis.png

http://paramedicsworld.com/wp-content/uploads/2018/03/EMBRYONATED-CHICK-EGG.jpg
 LABORATORY DIAGNOSIS
3. Polymerase Chain Reaction / Nucleic acid amplification
– diagnostic for ehrlichiosis

4. Serological test
– the only test performed for the diagnosis of rickettsial diseases
(confirmed rickettsioses during convalescent phase)
a) Indirect Immunofluorescent antibody (IFA) assay
• Reference method in diagnosing rickettsioses and Q fever (antibody to phase I
and II)
b) Weil-Felix reaction – presumptive test
• agglutination of certain strain of Proteus species (OX strain)
• See table for interpretation
c) Microimmunofluorescent dot test –
• Used for early diagnosis of RMSF after
onset of symptoms
d) Other tests
i. Latex agglutination
ii. Enzyme immunoassay
iii. Line blot

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g=AOvVaw2HvYkKCQKjk8sgZ0T9Mk6c&ust=1635364735874000&source=images&cd=vfe&ved=0CAsQj
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 Treatment and Control
Rickettsial infections
Treatment: Doxycycline – drug of
choice
(Tetracycline,
fluoroquinolones,
chloramphenicol)
Control: • No vaccines (except for
louse-borne typhus)
• Avoiding tick-infested
area
• Use of protective
clothing
• Insect repellants
• Prompt removal of
attached ticks
• Rodent control
• Louse control measures
Ehrlichiosis and Anaplasmosis
Doxycycline – drug of choice
• No vaccines
• Avoiding tick-infested area
• Use of protective clothing
• Insect repellants
• Prompt removal of attached
ticks
Q fever
Doxycycline – drug of
choice (acute infections)
Hydroxychloroquine +
doxycycline – chronic
infections
• Whole-cell vaccine
and partially purified
antigen for Q fever
• Vaccines prepared
from phase 1 antigen
– protective*
Rocky Mountain spotted fever was considered in the diagnosis.
Questions:
• What antibiotics can be used to treat this infection? Which antibiotics
should not be used?
– Rickettsial infections are treated with tetracyclines (e.g., doxycycline) or
fluoroquinolones (e.g., ciprofloxacin). Although chloramphenicol has in vitro activity, a
high incidence of relapse is associated with this antibiotic. β-Lactam antibiotics (e.g.,
penicillins, cephalosporins, carbapenems), aminoglycosides, and trimethoprim-
sulfamethoxazole are inactive.

• Which rickettsiae are associated with the following vectors: ticks, lice,
mites, and fleas? Ticks are vectors for the following rickettsiae and their diseases: R.
rickettsii- Rocky Mountain spotted fever; R. africae,- African tick bite fever; R. australis,-
Australian tick typhus; R. conorii,- Mediterranean spotted fever; R. japonica -Japanese
spotted fever; and R. sibirica- Siberian tick typhus. Only R. rickettsii is commonly recovered
in the United States. Lice are associated with R. prowazekii (endemic typhus), mites are
associated with R. akari (rickettsialpox) and Orientia tsutsugamushi (scrub typhus), and
fleas are associated with R. typhi (murine typhus).
• Why is use of the Gram stain inappropriate for the diagnosis of rickettsial
infections?
– Rickettsiae are small and stain poorly with the Gram stain because the peptidoglycan
layer is minimal.

• Ehrlichia and Anaplasma have been historically associated with Rickettsia.

Compare clinical disease caused by Ehrlichia chaffeensis and A.
phagocytophilum.
– E. chaffeensis, the etiologic agent of human monocytic ehrlichiosis, infects blood
monocytes and mononuclear phagocytes in tissues and organs. Approximately 1 to
3 weeks after exposure, patients develop a flulike illness with high fever, headache,
malaise, and myalgias. A rash develops in about one-third of patients.
– A. phagocytophilum, the agent of human anaplasmosis, infects granulocytes
(neutrophils, eosinophils, basophils). Approximately 5 to 11 days after exposure, a
similar flulike illness develops, but a rash is uncommon. In both diseases, more than
half of the infected persons require hospitalization, and recovery is prolonged.

• What clinical diseases are caused by Coxiella burnetii?

– The majority of infections with C. burnetii are asymptomatic or present
with mild flulike symptoms. Severe diseases include pneumonia,
hepatitis, or isolated fever; however, the most common presentation is
subacute endocarditis.
Points to remember:
References:

• Jawetz, M. A. (2013). Medical microbiology (26th ed). United States of America:

TheMcGraw-Hill Companies.

• Murray, P R, Rosenthal, K and Pfaller, M.A. (2021). Medical microbiology (9th ed).
USA: Elsevier

• Rodriguez, M.T (2018). Review handbook in diagnostic microbiology (2nd ed).

Philippines: C&E Publishing Inc.
ANY QUESTIONS?
Email at cbbregente.swu@phinmaed.com