05/14/2022 Glennah Kerubo 1

RICKETTSIACEAE FAMILY
General characteristics
• Obligate intracellular parasites
• Small Gram negative, coccobacilli (0.3-0.5 um)
• Often pleomorphic microorganisms which have typical bacterial cell walls
• No flagella and multiply via binary fission only inside host cells
• Cell membrane similar to Gram (-) bacteria with LPS & peptidoglycan
• They occur singly, in pairs, or in strands

05/14/2022 Glennah Kerubo 2

General characteristics

• The organisms will not show up on Gram stain, but can be seen with Giemsa stains

• Require growth co-factors

• Will not grow on artificial media

• Grown in embryonated eggs or tissue culture

• Cultivation is costly and hazardous because aerosol transmission can easily occur

• All, except Coxiella, are transmitted by arthropod vectors as fleas, ticks, mites and lice

05/14/2022 Glennah Kerubo 3

 The family Rickettsiaceae is taxonomically divided into three genera

Rickettsia ((11 species)--obligate intracellular parasites which do not multiply within

vacuoles and do not  parasitize white blood cells

Ehrlichia (2 species) – obligate intracellular parasites which do not multiply within

vacuoles but do parasitize white blood cells.

Coxiella (1 species) – obligate intracellular parasite which grows preferentially in

vacuoles of host cells.

05/14/2022 Glennah Kerubo 4

 Louse

Scanning electron microscope (SEM)

depiction of a flea
05/14/2022 Glennah Kerubo 5
 Engorged tick attached to back of Castor bean tick, Ixodes ricinus
toddler's head. Adult thumb
shown for scale.

05/14/2022 Glennah Kerubo 6

05/14/2022
Gimenez stain ofGlennah
tissueKerubo
culture cells infected 7
with Rickettsia rickettsii
Pathogenesis
• In their arthropod vectors, the rickettsia multiply in the
epithelium of the intestinal tract;

• they are excreted in the feces, but occasionally gain access to the
arthropods salivary glands.

• They are transmitted to man, via the arthropod saliva, through a

bite.

• In their mammalian host, they are found principally in the

endothelium of the small blood vessels, particularly in those of
the brain, skin and heart.
05/14/2022 Glennah Kerubo 8
Pathogenesis
• Hyperplasia of endothelial cells and localized thrombus formation
lead to obstruction of blood flow, with escape of RBC's into the
surrounding tissue.
• Inflammatory cells also accumulate about affected segments of blood
vessels.
• This angiitis appears to account for some of the more prominent
clinical manifestations, such as petechial rash, stupor and terminal
shock.
• Death is ascribed to damage of endothelial cells, resulting in leakage
of plasma, decrease in blood volume, and shock.
05/14/2022 Glennah Kerubo 9
Pathogenesis
• It is assumed that the observed clinical manifestations of a rickettsial
infection are due to production of an endotoxin

• However this endotoxin is quite different in physiological effects from

that produced by members of the Enterobacteriaceae.

05/14/2022 Glennah Kerubo 10

Pathogenesis: Rickettsia cell-to-cell
spread

05/14/2022 Glennah Kerubo 11

Antigenic structure
• Rickettsiae possess 3 types of antigens
• 1. Group specific soluble antigen:- It is present on surface of organism
and is protein in nature.
• 2. Species specific antigen:- It is adherent to the cell and act as
adhesin for host cell
• 3. An alkali stable polysaccharide:- Found in some rickettsiae and in
some non motile strains of Proteus (OX 19, OX 2, OXK). This sharing of
antigens forms the basis for Weil- Felix reaction used in diagnosis of
rickettsial infections. In this test agglutinins are detected against these
Proteus strains.
05/14/2022 Glennah Kerubo 12
Diseases
1.Louse-borne:
European epidemic typhus (Rickettsia prowazekii),   
Brill's disease (Rickettsia prowazekii),  
Trench fever (Bartonella quintana)
2. Flea-borne  
Endemic murine typhus (Rickettsia typhi),  
Cat scratch  fever /Bacilliary angiomatosis/  (Bartonella henselae)
3. Mite-borne   
Scrub typhus (Orientia /Rickettsia tsutsugamushi),   
Rickettsialpox (Rickettsia akari)

05/14/2022 Glennah Kerubo 13

Epidemic Typhus

• It is reported from all parts of the world but common in Russia and
eastern Europe.

• Humans are the only natural vertebrate hosts.

• Its causative agent is R. prowazekii.

• Human body louse (Pediculus humanus corporis) and head louse

(Pediculus humanus capitis) act as vector.
05/14/2022 Glennah Kerubo 14
Epidemic Typhus
• Incubation period is 10-14 days.

• Clinical features include: high fever, chills, severe headache and

vomiting. On 4-7 days a characteristic maculopapular rash appear
which start from trunk and spread over limbs but sparing face, palm
and soles. Patient become stuporous and delirious in 2nd and 3rd
week.

• The case fatality is about 40%.

05/14/2022 Glennah Kerubo 15

Brill-Zinsser disease (recrudescent infection)

• Rickettsiae may remain latent in the lymphoid tissue for years.

• Such latent infection may be reactivated leading to recrudescent
typhus.
• It is milder illness with shorter duration (ˆ2weeks) and lower case
fatality.
• Skin rashes are also mild.
• Disease itself is not importance but patient is infectious for louse and
an outbreak can occur.

05/14/2022 Glennah Kerubo 16

 Endemic typhus
• Clinical disease is similar but milder than epidemic typhus and case fatality is 1%.

• It is caused by R. typhi.

• Its reservoir is rat and are transmitted by flea (Xenopsylla cheopsis).

• Rat flea acquire infection by feeding on infected rat.

• Natural cycle is rat-flea-rat and man are the dead end host.

• They acquire infection by the bite of infected fleas when their saliva of feces is rubbed in
05/14/2022 Glennah Kerubo 17
Rocky Mountain Spotted Fever

• Etiologic agent: Rickettsia rickettsiae

• Most common rickettsial disease

• Individuals younger than 19 years old are usually at risk

• Males affected twice as often as females

• It is common during summer months

05/14/2022 Glennah Kerubo 18
 Rocky Mountain Spotted Fever
• Serious disease with 35% mortality rate

• Transmitted by ticks that must remain attached for hours in order to

transmit the disease

• Incubation of 2-6 days

• Followed by a severe headache, chills, fever, aching, and nausea

05/14/2022 Glennah Kerubo 19

Rocky Mountain Spotted Fever

• After 2-6 days, a maculopapular rash develops, first on the extremities,

including palms, foot soles, and spreading to the chest and abdomen

• If left untreated, the rash will become petechial with hemorrhages in the
skin and mucous membranes due to vascular damage as the organism
invades the blood vessels

• Death may occur during the end of the second week due to kidney or
heart failure

05/14/2022 Glennah Kerubo 20

Rocky Mountain Spotted Fever

05/14/2022 Glennah Kerubo 21

Scrub typhus
• It is caused by Orientia tsutsugamushi.
• Migratory birds may act as reservoir and transporter of disease agent.
• Vector is trombiculid mites.
• Man are the accidental host and may acquire infection when they
trespass into mite islands and are bitten by their larvae.
• After 1- 3 weeks of bite, patient develops severe headache, fever,
conjunctivitis, deafness and eschar at site of bite.
• After 1 week of fever, maculopapular rash appears which starts from
trunk.
• Mortality varies from 10- 60%

05/14/2022 Glennah Kerubo 22

LABORATORY DIAGNOSIS OF
RICKETTSIAL INFECTIONS
• Samples which can be processed for diagnosis are
i) Blood clots
ii) Serum
iii) Biopsy specimen of rashes
iv) Impression smear from organs of infected animals
v) Endolymph of ticks
• Diagnosis is carried out by
(a) Isolation of rickettsiae in lab animals, fertile hen’s egg and cell cultures
(b) Direct detection of organism and their antigen in clinical samples
(c) Serology
05/14/2022 Glennah Kerubo 23
i) Isolation of Rickettsiae
• Blood clots ground in skimmed milk or BHI broth is inoculated
intraperitoneally in male guinea pig or mice.
• Animal will be observed for 3-4 weeks.
• Smears from peritoneum, tunica and spleen of infected animals are
stained by Giemsa or Gimenez method to demonstrate rickettsiae.
• They can also be grown in yolk sac of embryonated hen’s eggs and
cell culture.

05/14/2022 Glennah Kerubo 24

ii) Direct detection of organism and their
antigen
• Aggregates of the organism or their antigen in biopsy specimen from rashes
and liver, impression smears from organs of infected animals may be
demonstrated by
i) Giemsa staining
ii) Macciavello staining
iii) Gimenez staining
iv) Direct immunoflourescence
v) Indirect immunoflourescence
vi) PCR
vii) Sequence Amplification
05/14/2022 Glennah Kerubo 25
iii) Serology
(a) Non-specific reaction:- Weil- Felix Reaction
Weil- Felix Reaction in diagnosis of rickettsial diseases
Agglutination with Proteus
Disease Strains
  OX19 OX2 OXK
Epidemic typhus ++++ ± -
Brill-Zinsser disease ± - -
Endemic typhus +++ ± -
Spotted fever group ++ ++ -
Scrub typhus - - +++
Rickettsial pox - - -

05/14/2022 Glennah Kerubo 26

iii) Serology
b) Specific:-
i) using rickettsial antigen
ii) CFT with purified antigen
iii) Immunofluorescence on microdots of purified rickettsial antigen
iv) ELISA with particulate or extracted antigen
v) Latex agglutination

05/14/2022 Glennah Kerubo 27

Treatment
Tetracyclines and chloramphenicol can be given to treat rickettsial
infections.

05/14/2022 Glennah Kerubo 28

 GENUS EHRLICHIA
• They are small, gram negative, obligate intracellular bacteria.
• They have affinity towards blood cells and their vacuoles inside phagocytic
cells are known as morula.
• They are tick borne.
• Leucopenia, thrombocytopenia and raised liver enzymes are seen in patients.
• Three species have been reported to infect humans.
(a) E. sennetsu
(b) (b) E. chaffeensis
(c) (c) E. phagocytophila

05/14/2022 Glennah Kerubo 29

 GENUS EHRLICHIA
Laboratory Diagnosis:
• Demonstration of bluish intracytoplasmic inclusion (morula) in Geimsa
stained blood smears.
• Demonstration of specific antibodies by immunofluorescence using cell
cultures.
• PCR
Treatment:
Doxycycline is recommended for treatment of ehrlichioses

05/14/2022 Glennah Kerubo 30

 Coxiella burnetii (Q FEVER)
• Q fever is a worldwide zoonosis and is caused by Coxiella burnetii.
• It is also an obligate intracellular pathogen.
• It is pleomorphic coccobacilli 0.2µm- 0.4µm × 0.4- 1.0µm.
• It is Gram negative but better stained with Gimenez and other
rickettsial stains.
• It can survive holder method (63°C for 30 min) of pasteurization of
milk but flash method is effective.
• It can be inactivated by 2% formaldehyde, 1% Lysol and 5% H2O2.

05/14/2022 Glennah Kerubo 31

 Pathogenesis
• It is transmitted among cattle, sheep and poultry by ticks.
• They can be shed in milk of infected animals and products of conception.
• They can contaminate the environment during parturition.
• Humans can get infection through consumption of infected milk, handling of infected
wool, meat and other animal products contaminated soil, straw and clothing
• Coxiella may enter through abraded skin, inhalation, ingestion.
• Incubation period is 2-4 weeks.
• Patient develop fever, chill, headache, pneumonia, endocarditis and
meningoencephalitis.
• Spontaneous recovery is usual.

05/14/2022 Glennah Kerubo 32

 Laboratory Diagnosis
• Coxiella can be isolated from blood, sputum and other clinical samples
but is not recommended due to serious risk of infection to laboratory
personnel.
• Culture can be done in guinea pig, mice and embryonated hen’s eggs.
Cell cultures can also be used.
• Diagnosis mainly relies upon the demonstration of antibodies by
complement fixation test and indirect immunofluorescence assay.
• PCR can be done.

05/14/2022 Glennah Kerubo 33

Treatment
• Doxycycine may be given for treatment.

• In serious cases prolonged treatment with tetracycline,

chloramphenicol may be required.

05/14/2022 Glennah Kerubo 34