EPIDEMIC TYPHUS

By Dr. Addisu T. (MD, Internist)

July,08,2015
Etiology
• Rickettsia prowazekii
• Obligate intracellular bacteria
• Pleiomorphic rods
• Susceptible to moist heat and dry heat
Transmission
• Human body louse (Pediculus humanus corporis)
• Lives in clothing under poor hygienic conditions
• Infective for 2-3 days
• Infection acquired by feeding on infected person
• Excrete R. prowazeki in feces at time of feeding
• The patient autoinoculates the organisms by scratching
• The louse is killed by the rickettsiae within 2 weeks
• Humans or flying squirrel required for life cycle
• Host responsible for maintaining infection
• No person-to-person transmission
• Infection with R. prowazekii
• Carries high case-fatality rate
• Difficult-to-diagnose disease
• Highly infectious when inhaled as aerosols
• Resistance to tetracycline or chloramphenicol in the laboratory
Clinical Manifestations
• Incubation period - ~1–2 weeks
• Abrupt onset, with prostration, severe headache, and fever rising
rapidly to 38.8°–40.0°C.
• Cough is prominent (70% of patients)
• Myalgias - usually severe
• Rash
• Begins on the upper trunk, usually on the 5th day, and then becomes
generalized, involving the entire body except the face, palms, and soles.
• Initially macular; without treatment, it becomes maculopapular, petechial,
and confluent.
• Not detected in black skin.
• Photophobia, conjunctival injection and eye pain.
• The tongue may be dry, brown, and furred.
• Confusion and coma are common (12% of patients).
• Severe cases - skin necrosis, gangrene of the digits and interstitial
pneumonia.
• Untreated disease
• Fatal in 7–40% of cases, with outcome depending primarily on the condition
of the host.
• Develop renal insufficiency and multiorgan involvement with prominent
neurologic manifestations.
• Brill-Zinsser disease
• A recrudescent illness occurring 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
Diagnosis
• No laboratory test is diagnostic in the early phases of infection with
typhus.
• Initial diagnosis requires high index of clinical suspicion is based on
• Epidemiologic data
• History of exposure to vectors
• Travel to endemic locations
• Clinical manifestations
• Characteristic laboratory findings (thrombocytopenia, normal or low WBC
counts, elevated hepatic enzyme levels, and hyponatremia)
• Confirmatory diagnosis
• Culture
• Serology
• Biopsy
• PCR
• Epidemics may be recognized by the serologic or
immunohistochemical diagnosis of a single case or by detection of R.
prowazekii in a louse found on a patient.
Treatment
• Doxycycline (200 mg/d, given in two divided doses) is administered
orally or—if the patient is comatose or vomiting—intravenously.
• Under epidemic conditions a single 200-mg dose has proved effective
• Treatment is generally continued until 2–3 days after defervescence
• Pregnant patients
• Chloramphenicol early in pregnancy
• Doxycycline late in pregnancy
Prevention
• Control of body lice
• Clothes should be changed regularly
• Insecticides should be used every 6 weeks to control the louse population