ZODIAC ACADEMY, Trivandrum.

Health Inspector PSC EXAM Qn No:13.

Topic: Zoonoses - Bacterial - RICKETTSIAL DISEASES- Scrub Typhus

Time : 2.30 Hrs Date: 06.10.2020

Prepared by Manmadhan. D, 9744474936

RICKETTSIAL DISEASES are the diseases caused by rickettsia which are

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small, gram negative bacillus adapted for intracellular parasitism. These

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rickettsia are pleomorphic (ability to alter their morphology, physiology
in response to the environment) organisms or bacteria are parasites

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found in the alimentary canal of transmitter arthropod vectors such as
lice, fleas, ticks and mites. In vertebrates, including humans, they infect

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the vascular endothelium and reticuloendothelial cells.
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[ Note: Gram positive bacteria have a thick peptidoglycan layer and no outer lipid membrane
whilst Gram negative bacteria have a thin peptidoglycan layer and have an outer lipid
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membrane. Peptidoglycan or murein is a polymer consisting of sugars and amino acids that
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forms a mesh-like layer outside the plasma membrane of most bacteria, forming the cell wall.
The sugar component
 Commonly known rickettsial disease is Scrub Typhus. The family

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Rickettsiaeceae currently comprises of three genera – Rickettsia,

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Orientia and Ehrlichia which appear to have descended from a
common ancestor.

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EXTRA Reading: Former members of the family, Coxiella burnetii, which causes Q fever and
Rochalimaea quintana causing trench fever have been excluded because the former is not primarily
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arthropod borne and the latter is not an obligate intracellular parasite, being capable of growing in
cell-free media, besides being different in genetic properties.]
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SCRUB TYPHUS (Chigger borne typhus, Tsutsugamushi fever). The term scrub is used because of the
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type of vegetation (terrain between woods and clearings) that harbours the vector. The word typhus
(Greek) means fever with smoke.
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 Scrub typhus CAUSATIVE AGENT is Orientia tsutsugamushi in India (08 serotypes). Orientia is a
small (0.3 to 0.5 x 0.8 – 15 micron mm ), gram negative bacterium of the family Rickettsiaceae. It
differs from the other members in its genetic make up and in the composition of its cell wall
structure since it lacks lipopolysaccharide and peptidoglycan and does not have an outer slime

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layer. It is endowed with a major surface protein (56kDa) and some minor surface protein

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[Note: , Louse = small wingless parasitic insects that live on the skin of mammals and birds.

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• mite= a minute arachnid which has four pairs of legs when adult, related to the
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ticks. Many kinds live in the soil and a number are parasitic on plants or animals
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• Fleas = a small wingless jumping insect which feeds on the blood of mammals
and birds. It sometimes transmits diseases through its bite, including plague and
myxomatosis
• Chigger=a tropical flea, the female of which burrows and lays eggs beneath
the host's skin, causing painful sores

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• There are considerable differences in virulence and antigen composition

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among individual strains of O.tsutsugamushi. It has many serotypes (Karp,
Gillian, Kato and Kawazaki).

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Epidemiology and Geographic distribution: Globally over
01 billion people are at risk and an estimated 01 million

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cases occur annually, distributed in the tsutsugamushi
triangle , over a wide area of 13 million square Km bound
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by Japan, China, Philippines, tropical Australia in the
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south and west through India, Afghanistan and Pakistan to
the west; Russia to the north; Recently, rickettsioses has
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been an emerging disease along the Thai Myanmar

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border. There are reports of emergence of scrub typhus in

Maldives Islands
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Indian Scenario: In India, It is present in whole of the shivalik ranges from Kashmir to

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Assam, Eastern and Western Ghats, and the Vindhya chal and satpura ranges in the
central part of India. There were reports of ST outbreaks in Himachal Pradesh, Sikkim,

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and Darjeeling(WB) during 2003-04 and 2007. In Kerala, Rajasthan, Jammu & Kashmir
and Vellore in TN. Also prone to ST. In a study conducted from July through October
2004 in Himalayas, among several cases of acute febrile illness of unknown origin

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Certain areas such as forest clearings, river banks and grassy regions provide optimal
conditions for the infected mites to thrive. These small geographic regions are high-risk
areas for humans C
and have been called ST islands.
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It was first observed in Japan where it was found to be transmitted by mites. The disease
was, therefore, called tsutsugamushi (tsutsuga meaning dangerous and mushi meaning
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insect or mite). This is found only in areas with a suitable climate, plenty of moisture and
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scrub vegetation.
 O.tsutsugamushi was identified as causative agent by PCR and micro immune
fluorescence.

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 Host : Scrub typhus normally occurs in a range of mammals, particularly field
mice and rodents

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The typical vector L. deliense or L. akamushi is generally found associated with

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either established forest vegetation , abundant on grasses and herbs and even in
sandy beaches. Sentinel [ indicator of the presence of disease.] animals can also be
used for collection of trombiculid mites from the field.
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[Note: Laboratory mice or rats kept in small Human beings are infected when they
trespass into these mite islands and are bitten by the mite larvae (chiggers). On the
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body of mammalian hosts, the chiggers attach in clusters on the tragus (inner side
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of the external ear), the belly and on the thighs, may appear orange or pink.]
 Preservation: The mites can be preserved in 70% alcohol till they reach laboratory for identification.
Chigger index (average number of chiggers infesting a single host) of > 0.69 (critical value) is an

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indicator for implementation of vector control measures.

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Incubation Period: 1 – 3 weeks

TRANSMISSION: The infection of Scrub typhus to humans and rodents is

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transmitted by the mite Leptotrombidium deliense or L. akamushi.. we say
‘infective trombiculid mites or Chiggers. The mite (larva-) feeds on the

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serum(lymph and tissue fluid) of warm blooded animals only once during its life
cycle of development (egg, larva, nymph and adult) and adult mites do not feed on
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man. The larva is the only stage (Chigger) that can transmit the disease to humans
and other vertebrates.
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Once they are infected in nature by feeding on the body fluid of small mammals ,
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including the rodents, they maintain the infection throughout their life stages and
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as adults (Parent), pass the infection on to their eggs in a process called Transovarial
transmission. (infection passes from Egg to the larva or adult is transstadial
transmission) .
Mode Of Human infection : Infection takes place when humans accidentally pick up an infective larval
mite while walking, sitting, or lying on the infested ground. Approximately one week later, a spotted

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and then Maculopapular rash appears first on the trunk.

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CLINICAL PICTURE A Papule develops at the site of inoculation, eventually heals with development of
a black eschar (a dry, dark scab or falling away of dead skin, typically caused by a burn, an insect bite,

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or infection with anthrax.)

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• General symptoms: are sudden fever (>40ºC [104ºF]) with relative
bradycardia,(slower heart rate below 60) severe headache, apathy (lack of
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interest), myalgia (pain in muscles), generalized lymphadenopathy ( disease
affecting the lymph nodes), photophobia and a dry cough. Symptoms generally
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disappear after two weeks even without treatment.
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• [ Virulent = extremely severe or harmful in its effects]

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• Complications are interstitial pneumonia (30 to 65% of cases),

meningoencephalitis and myocarditis ( case of infection weakening the heart).
DIAGNOSIS : 3 Common clinical manifestations of the Rickettsial Diseases or ST are 1.axillary eschar. 2.
Maculopapular rash on back of a case. 3. Laboratory diagnosis S T: may be diagnosed in the laboratory
by: (i) isolation of the organism (ii) serology (iii) molecular diagnosis (PCR). However, investigation may

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reveal early lymphopenia [lower number of lymphocytes(a type of WBC)] with late lymphocytosis(an

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increase in lymphocytes or WBC ). Albuminuria ( the presence of albumin in the urine) is a common
laboratory finding. Thrombocytopenia is observed in more than half of the patients with epidemic
typhus.

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• Collection, storage & transportation of specimen: Specimen Serum Blood
collected in tubes containing EDTA (Ethylene Di amine Tetra Acetate.) or Sodium
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citrate Blood clot Blood collection in tubes and vials. Aseptically collect 4-5 ml of
venous blood. Allow blood to clot at room temperature, centrifuge at 2000 rpm
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to separate serum. Collect the serum in sterile dry vial. Fix the cap with adhesive
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tape, wax or other sealing material to prevent leakage during transport.

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• The name of the patient, identification number and date of collection must be
indicated on the label.
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Do’s/Don’ts while collecting specimen: Collect sufficient quantity of

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specimen Avoid contamination by using sterile equipment and aseptic
precautions. Despatch the specimen immediately to laboratory at 2-8ºC

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(ice box) as soon as possible. Don’t freeze whole blood as haemolysis (the
desrtruction of RBC). In case the delay is inevitable, keep the specimen at
+ 4ºC in a refrigerator.

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It comes under Risk Group 3 organisms. Isolation of Organism should be
done in laboratories equipped with appropriate safety provisions
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preferably Biosafety level-3 laboratory following strict biosafety
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precautions. Rickettsia may be isolated in male guinea pigs or mice; yolk
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sac of chick embryos;

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• Rickettsiae grow well in 3-5 days on Vero cell Cell culture cells from the epithelial cells

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of monkeys. Diagnosis of the etiology of rickettsial diseases can be accomplished most

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by demonstrating a significant increase in antibodies in the serum of the patient.

• Several serological tests are currently available for the diagnosis of rickettsial diseases.

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Weil-Felix Test (commonly used test) The Weil-Felix test is helpful in establishing
presumptive diagnosis in diseases caused by members of typhus and spotted fever
groups of Rickettsiae.

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• Indirect Immunofluorescent antibody (IFA) test IFA is used as a reference technique;
however, availability and cost are major constraints and is not available in most of the
laboratories. C
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• Enzyme linked Immunosorbent Assay (ELISA) ELISA techniques, particularly
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immunoglobulin M (IgM) capture assays, are probably the most sensitive tests available
for rickettsial diagnosis, and the presence of IgM antibodies, indicate recent infection
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with rickettsial diseaseswhereas IgG antibodies appear at the end of the second week.
 PCR TEST: The whole blood or serum can also be used for the detection of O.tsutsugamushi,
R.rickettsii, R. typhi and R.prowazekii organisms by PCR test. Facilities for laboratory diagnosis of
Rickettsial diseases are available at National Centre for Disease Control (NCDC), Delhi where samples

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can be sent for confirmation.

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• TREATMENT : Effective antibiotic therapy against rickettsiae is the single most effective measure

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for preventing morbidity and mortality due to rickettsial diseases.
• In a controlled trial, the weekly administration of 200 mg doxycycline decreased the incidence of
clinical illnesses.

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OTHER RICKETTSIAE INFECTIONS EPIDEMIC TYPHUS : Epidemic typhus (Louseborne
typhus, Classical typhus, Gaol fever) has been one of the great scourges of mankind,
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occurring in devastating epidemics during times of war and famine. During 1917-1922,
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there were some 25 million cases in Russia, with about three million deaths. In recent
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times, the main foci have been Eastern Europe, Africa, South America and Asia.
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In India, the endemic spot is Kashmir. The causative agent of epidemic typhus is
R.prowazekii, named after von Prowazek. Humans are the only natural vertebrate hosts.

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Natural infection in flying squirrels has been reported from South- eastern USA. The human
body louse, Pediculus humanus corporis, is the vector. The rickettsiae multiply in the gut
of the lice and appear in the faeces in 3-5 days. Lice succumb to the infection within 2-4

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weeks, remaining infective till they die. They can transmit the infection after about a week
of being infected. Transmission Lice may be transferred from person to person. patient or

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the cooling carcass and parasitise other persons. Lice defecate while feeding. Infection is
transmitted when the contaminated louse faces is rubbed through the minute abrasions
caused by scratching. Occasionally, infection may also be transmitted by aerosols of dried
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louse faces through inhalation or through the conjunctiva. Incubation period: 5 - 15 days.
Clinical Presentation The disease starts with fever and chills. A characteristic rash appears
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on the fourth or fifth day, starting on the trunk and spreading over the limbs but sparing
the face, palms and soles.
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• Towards the second week, the patient becomes stuporous and delirious.
The name typhus comes from the cloudy state of consciousness in the

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disease. The case fatality may reach 40% and increases with age lesion is

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covered with a brownish black scab (tachy noire) and may ulcerate.
• Recall of a tick bite cannot always be elicited from the patient. Regional

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lymphandenitis is common. The fever lasts for 1 to 2 weeks and is
accompanied by headache, arthralgias, myalgias and a generalized

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maculopapular rash which develops between the third and fifth days of
illness or which may not appear. It disappears at the time of defervescence.
Alterations in cytokine profiles, hypercoagulability and deep venous
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thrombosis may occur. In severe cases – particularly in elderly patients and
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those with diabetes mellitus, alcoholism or heart failure –
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meningoencephalitis with coma and seizures and/or disseminated vasculitis

of internal organs (e.g. in the heart, lungs, kidneys, liver and pancreas) are
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observed. The mortality rate is 1 to 5%.

PREVENTION AND Control: Except Doxycycline. there is no vaccine for ST. In
endemic areas, certain precautions should be taken.

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• Wear protective clothing. eg; Glowses, long pants, full sleeve shirts and

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Gumboots.
• Use any one of the following Insect repellents containing Dibutyl phthalate,

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benzyle benzoate, Diethyl toluamide, apply to the skin and clothing to prevent
chigger bites.

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• Do not sit or lie on bare ground or grass, use a ground sheet.
• Cleaning of Vegetation Cut grass no more than 02 inches tall and chemical
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treatment of the soil, rodent control may help to break up the cycle of
transmission.
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• Use rodent control methods such as exclusion of them by all ways from rice,
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cereals flour and cooked food – keep them in sealed containers.

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• Avoid the means of attracting Rodents such as food and shelter

• Apply Sanitation routine every day to expel them by keep pet food and water
left out overnight in a bag or secure container.

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• Do not keep open the Fruits or vegetables left outside the refrigrator.

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• Cover the leaky pipes, closets, trash and compost containers or piles and
firewood far away from the residence

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• Seal the entry points of the property and the building, cracked foundations,
ventilations, Holes.

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• Don’t plant Ivy plants which provides shelter and a food source for rodents,
snails and slugs.
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• Use city - issue plastic trash bins. Avoid bird feeder near the residence.
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• Promote predators like hawks and owls.
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• Use Rodent traps.

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• Be sure to wash your hands after cleaning the premises.

• Use Abamectin 2% EC as baiting chemical to kill rodents