Summary Of Exposure |
A) TOXICOLOGY: Typhus is the result of a rickettsial infection. Rickettsiae are gram-negative, nonmotile, small obligate intracellular coccobacilli that multiply in the cytoplasm of infected host cells. Three types of typhus may occur and include: EPIDEMIC TYPHUS (Rickettsia prowazekii), ENDEMIC TYPHUS (Rickettsia typhi) and SCRUB TYPHUS (Rickettsia tusutugamushi). Rickettsia organisms from the bloodstream enter small vessel endothelium (especially in the skin, brain, heart and kidneys) and cause cell destruction, endovasculitis, thrombosis, and hemorrhage (DIC).
B) EPIDEMIOLOGY: EPIDEMIC TYPHUS: The only rickettsial disease that results in epidemics in humans, usually during periods of wars or famines. All ages and races and both sexes are affected. Geographic distribution is worldwide.
1) ENDEMIC TYPHUS: All races are affected. More common in adults and males. Seasonal incidences are more common in summer and autumn, with 50 to 70 cases per year reported in the United States. Geographic distribution is worldwide. Highest prevalence is primarily in urban areas.
2) SCRUB TYPHUS: All races and ages are affected. In Korea, it is more common in females. Geographic distribution is primarily in the Asian-Pacific region, ranging from northern Australia in the south to the far east of Russia in the north and Afghanistan in the west.
3) SYLVATIC (SQUIRREL-BORNE) TYPHUS: Although strains of Rickettsia prowazekii associated with louse-borne typhus appear identical to strains associated with squirrel-borne typhus, there are minor differences. Incidences occur year round.
C) WITH POISONING/EXPOSURE
1) MILD TO MODERATE TOXICITY: Fever and chills are common presenting symptoms. Rashes are typical: Epidemic typhus with maculopapular and petechial (trunk to extremities) rashes; murine typhus with macular and maculopapular rashes; and scrub typhus with macular and maculopapular (trunk and extremities) rashes with eschar. Nausea can occur in all types of typhus. 2) SEVERE TOXICITY: Vasculitis is a hallmark of rickettsial infections. Rickettsia increase capillary permeability leading to intravascular coagulation, organ failure, and peripheral vascular collapse, the primary cause of shock and death. Thrombocytopenia has been observed as a severe complication in all types of typhus. Central nervous system complications (all types) may include neuropsychiatric abnormalities and seizures in addition to confusion, delirium, slurred speech, and nuchal rigidity. Respiratory failure and adult respiratory distress syndrome (ARDS) have been reported in complicated cases of typhus (all types). a) EPIDEMIC TYPHUS: Incubation period is 6 to 15 days. One to three days of malaise precedes an abrupt onset of severe headache, chills and fever, and myalgia. Rash and petechiae are characteristic. More serious complications may include gangrene and cerebral thrombosis. Laboratory findings may include thrombocytopenia and elevations of aspartate aminotransferase and lactate dehydrogenase. Death has been reported.
b) ENDEMIC (MURINE) TYPHUS: After a 6 to 14 day incubation period, an abrupt onset of symptoms, including fever, followed by headache, chills, and nausea generally occurs. Rash may occur at various intervals after the onset of fever. Laboratory abnormalities may include leukopenia and thrombocytopenia, elevated liver function tests, hyponatremia, and hypocalcemia. Clinical course is usually uncomplicated and fatalities are rare.
c) SCRUB TYPHUS: A skin papule develops within 2 days of the chigger feeding and progresses to an eschar during the 6 to 18 day incubation period. Onset of symptoms is abrupt, and includes unremitting fever, chills, and headache. Symptoms have included myalgia, cough, and nausea. Generalized lymphadenopathy is common. With no antibiotic therapy, many complications, including death, may occur.
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Vital Signs |
3.3.1) SUMMARY
A) WITH POISONING/EXPOSURE 1) Chills and fever are commonly seen in all forms of typhus as presenting symptoms. Fever may be severe and persistent.
3.3.3) TEMPERATURE
A) WITH POISONING/EXPOSURE 1) SUMMARY a) Chills and fever, seen in the abrupt onset of symptoms, is common to all forms of typhus (Jung et al, 2014; Woodward, 1994; Baxter, 1996; Perine et al, 1992; Yi et al, 1993; Bise & Coninx, 1997; Berman & Kundin, 1973; Lee et al, 1995; Loh et al, 1996; Marschang et al, 1995; Singh, 1994; Raoult et al, 1998).
2) ENDEMIC TYPHUS a) INCIDENCE: In cases of endemic (murine) typhus, fever is the most common presenting symptom, occurring in up to 96% of cases. In a study of 87 American soldiers with scrub typhus, all were reported to have fever (Baxter, 1996). In another study of 60 patients with epidemic typhus, all were reported to have abrupt onset of chills and fever (Perine et al, 1992). In a retrospective study of 30 children diagnosed with murine typhus, 100% developed fever (Fergie et al, 2000).
3) EPIDEMIC TYPHUS a) EPIDEMIC TYPHUS: Recent outbreaks were reported in Burundi and areas of Russia. Fever with severe headache and myalgias were the usual presenting symptoms (Raoult et al, 1998; Tarasevich et al, 1998). In another study of children with murine typhus, fever and headache or rash were also early findings of illness and reported in 90% (n=83) of cases
4) SCRUB TYPHUS a) Acute undifferentiated fever is a common early finding of scrub typhus. However, it can be confused with many other diseases or illnesses in tropical areas including malaria, dengue fever, rickettsioses, leptospirosis, and enteric fever (Jung et al, 2014).
3.3.4) BLOOD PRESSURE
A) WITH POISONING/EXPOSURE 1) Severe, untreated cases of typhus may present with decreased blood pressure (Woodward, 1994).
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Heent |
3.4.1) SUMMARY
A) WITH POISONING/EXPOSURE 1) Tinnitus, conjunctivitis, papilledema and ophthalmoplegia have been reported in some typhus cases.
3.4.3) EYES
A) WITH POISONING/EXPOSURE 1) Conjunctival suffusion and photophobia have been reported in typhus cases and is a diagnostic clue (Watt & Strickman, 1994; Perine et al, 1992). Conjunctivitis, with episcleral vessel dilation and subconjunctival hemorrhage, and retinal and papillary edema may occur in scrub typhus and is referred to as "scrub typhus retinopathy" (Boyd & Neldner, 1992; Kato et al, 1997).
2) Papilledema and ophthalmoplegia have been reported in severe cases (Wenzel et al, 1986).
3) Photophobia has been described in a case of murine typhus (Beaman & Marinovitch, 1999).
3.4.4) EARS
A) WITH POISONING/EXPOSURE 1) Transient deafness and tinnitus, which may occur in up to one-third of scrub typhus patients, is a diagnostic clue (Watt & Strickman, 1994; Singh, 1994). Tinnitus was reported in 23% of epidemic typhus patients in one study (Perine et al, 1992).
3.4.6) THROAT
A) WITH POISONING/EXPOSURE 1) A nonproductive cough and pharyngitis, or sore throat, are common early symptoms in all forms of typhus (Woodward, 1994; Perine et al, 1992; Berman & Kundin, 1973; Beaman & Marinovitch, 1999).
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Cardiovascular |
3.5.2) CLINICAL EFFECTS
A) VASCULITIS 1) WITH POISONING/EXPOSURE a) In untreated and complicated cases of typhus, vasculitis, due to increased capillary permeability caused by the rickettsiae organism, may occur and progress to peripheral vascular collapse and shock (Baxter, 1996; Hornick, 1996; Wenzel et al, 1986; Pai et al, 1997; Watt & Strickman, 1994).
B) SHOCK 1) WITH POISONING/EXPOSURE a) Severe and/or untreated cases may result in vasculitis leading to shock and peripheral vascular collapse (Baxter, 1996; Hornick, 1996; Lee et al, 1995).
b) SCRUB TYPHUS: In a study conducted in India, scrub typhus was diagnosed in 49 patients with nonspecific acute febrile illness. Of those 49 patients, severe complications included ARDS (n=28), acute kidney illness (n=26), shock (n=8) and death in 8 patients (Kumar et al, 2014).
C) GANGRENOUS DISORDER 1) WITH POISONING/EXPOSURE a) Gangrene, secondary to vasculitis and peripheral vascular collapse, is a serious complication of epidemic typhus. The gangrene is generally symmetric, affecting the distal fingers, toes, nose, and genitalia due to occlusion of arteries and veins over bony prominences and distally (Baxter, 1996; Boyd & Neldner, 1992).
D) MYOCARDITIS 1) WITH POISONING/EXPOSURE a) Myocarditis may occur, leading to conduction disturbances and heart failure in epidemic typhus. Interstitial myocarditis is more common in scrub typhus, while occurring less commonly in endemic typhus (Woodward, 1994). One case of heart failure was reported in a scrub typhus-infected soldier in Vietnam (Berman & Kundin, 1973).
E) ELECTROCARDIOGRAM ABNORMAL 1) WITH POISONING/EXPOSURE a) An inappropriate bradycardia may typically be seen in early epidemic typhus, followed by tachycardia later in the disease (Boyd & Neldner, 1992).
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Respiratory |
3.6.2) CLINICAL EFFECTS
A) RESPIRATORY FAILURE 1) WITH POISONING/EXPOSURE a) Respiratory failure, a severe complication of the typhus group, has been reported (Baxter, 1996).
B) ACUTE LUNG INJURY 1) WITH POISONING/EXPOSURE a) SCRUB TYPHUS: In a study conducted in India, scrub typhus was diagnosed in 49 patients with nonspecific acute febrile illness. Of those 49 patients, severe complications included ARDS (n=28), acute kidney illness (n=26), shock (n=8) and death in 8 patients (Kumar et al, 2014).
b) Adult respiratory distress syndrome (ARDS) has been reported as a severe complication of scrub typhus in a traveler returning from Thailand (Watt & Strickman, 1994) and in two other patients with scrub typhus, one of whom died due to multiple organ failure (Lee et al, 1995).
C) PNEUMONIA 1) WITH POISONING/EXPOSURE a) Pneumonia, with pleural effusions, may occur and be seen on chest radiograph (Oh et al, 2001; Dupon et al, 1992; Niang et al, 1999). b) CASE REPORTS 1) Scrub typhus pneumonitis was confirmed in a laboratory worker following exposure to the organism Orientia tsutsugamushi. On the day of admission the patient had a fever (40 degrees Celsius), chest tightness, cough, and decreased breath sounds in the left lung. Chest x-ray showed interstitial infiltrates of the lower lobes and a CT of the chest revealed enlarged lymph nodes in the mediastinum, ground-glass opacity in both lower lung fields, and pleural effusion. Symptoms improved within three days with doxycycline therapy (Oh et al, 2001).
2) Chan et al (1995) reported a case of interstitial pneumonitis, confirmed on open lung biopsy, and with delayed resolution, in an adult diagnosed with scrub typhus (Chan et al, 1995).
3) A case of pneumonia, requiring mechanical ventilation, was reported in a nurse following a needle stick exposure to scrub typhus (Jee et al, 1996).
4) Yang et al (1995) reported a case of bilateral diffuse alveolar infiltration on chest x-ray and right pleural effusion in an adult with scrub typhus (Yang et al, 1995).
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Neurologic |
3.7.2) CLINICAL EFFECTS
A) CEREBRAL THROMBOSIS 1) WITH POISONING/EXPOSURE a) Secondary to vasculitis, cerebral thrombosis is a serious complication of epidemic typhus. Neurological deficits, due to cerebral thrombosis, may take 2 to 4 weeks to resolve, with residual deficits uncommon (Baxter, 1996). Acute febrile cerebral vasculitis and perivasculitis were found on brain biopsy samples and autopsy in 3 patients with confirmed typhus. In the most severe case, vascular lesions involved the brainstem and thalami (Wenzel et al, 1986).
B) HEADACHE 1) WITH POISONING/EXPOSURE a) An abrupt onset of headache is common in all forms of typhus. Following 1 to 3 days of malaise, abrupt onset of headache occurs with epidemic typhus (Perine et al, 1992). With endemic and scrub typhus, abrupt onset of headache occurs after an incubation period of 6 to 14 days (Baxter, 1996; Chien et al, 1995; Berman & Kundin, 1973; Wenzel et al, 1986; Marschang et al, 1995; Raoult et al, 1998). In a retrospective case series of 30 children diagnosed with murine typhus, 77% complained of headache (Fergie et al, 2000).
b) INCIDENCE: Fever and headache were common presenting symptoms in pediatric patients diagnosed with murine typhus. In one study, 84% (65/77) of children 4 years of age and older reported headache (Whiteford et al, 2001).
C) CENTRAL NERVOUS SYSTEM FINDING 1) WITH POISONING/EXPOSURE a) Neuropsychiatric effects may occur in untreated scrub typhus patients and in complicated epidemic and endemic typhus. Effects may include encephalopathy with confusion, delirium, hallucinations, slurred speech, gait ataxia, nuchal rigidity, and cranial nerve dysfunction. Meningism and coma have been reported in complicated epidemic typhus (Baxter, 1996; Boyd & Neldner, 1992; Shaked, 1991; Berman & Kundin, 1973; Wenzel et al, 1986; Pai et al, 1997; Raoult et al, 1997; Singh, 1994). EEG readings may be abnormal, with diffuse slow waves (Wenzel et al, 1986). 1) CASE REPORT: In a complicated case of endemic typhus, a global encephalopathy, with sixth nerve palsies, ophthalmoplegia, increased intracranial pressure, and cerebral vasculitis were reported. This patient was comatose and died 8 weeks after onset of the typhus. Another case reported by the same author died of fulminant cerebral edema with histopathologic evidence of widespread extravasation of plasma and fibrin (Wenzel et al, 1986).
2) Mild CSF pleocytosis was reported in 12 (48%) of 25 scrub typhus patients; CSF protein level was increased (greater than 50 mg/dL) in 7 patients. The scrub typhus organism appears to invade the CSF (Pai et al, 1997).
D) SEIZURE 1) WITH POISONING/EXPOSURE a) Seizures have been reported in complicated cases of epidemic and endemic typhus and may occur in untreated cases of scrub typhus (Baxter, 1996; Wenzel et al, 1986; Raoult et al, 1997).
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Gastrointestinal |
3.8.2) CLINICAL EFFECTS
A) NAUSEA, VOMITING AND DIARRHEA 1) WITH POISONING/EXPOSURE a) One of the more common initial clinical symptoms in the initial phases of typhus is nausea, occurring in 33% of endemic typhus patients and 28% of scrub typhus patients (Baxter, 1996). Berman & Kundin (1973) reported emesis in 23% of scrub typhus patients and diarrhea in 21% of scrub typhus patients in a study of 87 cases of American servicemen in Vietnam. Marschang et al (1995) reported a 36% incidence of diarrhea. Nausea, vomiting and diarrhea were reported in a 65-year-old man diagnosed with epidemic typhus (Niang et al, 1999).
B) ABDOMINAL PAIN 1) WITH POISONING/EXPOSURE a) Acute abdominal pain, accompanied by nausea and vomiting, may be a severe presenting symptom in typhus cases, but is generally uncommon in scrub typhus cases (Yang et al, 1995).
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Hepatic |
3.9.2) CLINICAL EFFECTS
A) LIVER ENZYMES ABNORMAL 1) WITH POISONING/EXPOSURE a) Approximately 50% of scrub typhus, 90% of endemic typhus and most epidemic typhus patients have elevated serum aspartate aminotransferase levels. Most epidemic and endemic typhus patients also have increased lactate dehydrogenase serum levels. Elevated liver enzyme levels generally return to baseline within 14 days of initiating therapy (Baxter, 1996; Perine et al, 1992; Dumler & Walker, 1994; Loh et al, 1996; Silpapojakul et al, 1996). Hepatic dysfunction occurred in 36 out of 47 (77%) scrub typhus patients in one study (Yang et al, 1995a).
b) CASE SERIES: In a retrospective series of 30 children with endemic murine typhus, 67% were reported to have elevated transaminase levels (Fergie et al, 2000).
B) SPLENOMEGALY 1) WITH POISONING/EXPOSURE a) In one study, 43% of scrub typhus patients experienced splenomegaly (Berman & Kundin, 1973) and in another study, 13% of epidemic typhus patients experienced splenomegaly (Perine et al, 1992). Hepatosplenomegaly is described in endemic typhus infected patients (O'Connor et al, 1996).
C) TOXIC HEPATITIS 1) WITH POISONING/EXPOSURE a) A case of granulomatous hepatitis has been reported in a patient with confirmed scrub typhus. Hepatic biochemical tests and liver biopsy confirmed acute hepatitis, which resolved soon after antibiotic treatment (Chien et al, 1995). Liver biopsies in 4 patients infected with endemic typhus revealed portal tract and sinusoidal infiltrates, cloudy swelling and necrosis of the hepatocytes and some pseudogranuloma formation (Silpapojakul et al, 1996).
D) JAUNDICE 1) WITH POISONING/EXPOSURE a) Jaundice has been reported following complicated courses of typhus (Baxter, 1996; Silpapojakul et al, 1996; Yang et al, 1995).
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Genitourinary |
3.10.2) CLINICAL EFFECTS
A) RENAL FAILURE SYNDROME 1) WITH POISONING/EXPOSURE a) Mild renal insufficiency has been reported in approximately 22% of endemic typhus patients, and renal failure with hematuria and proteinuria may occur in complicated cases of scrub, epidemic, and endemic typhus (Baxter, 1996; Lee et al, 1995; Yang et al, 1995a). Five patients with murine typhus were reported to have renal impairment; the most severe cases had renal failure with multifocal perivascular interstitial nephritis (Shaked et al, 1994). 1) Renal failure with severe hemolysis and hemoglobinuria, as well as persistently elevated serum transcobalamin II, was reported in a patient diagnosed with malaria and scrub typhus (Areekul et al, 1995). Acute renal failure and disseminated intravascular coagulation were reported in a patient with epidemic typhus (Niang et al, 1999).
2) Renal failure was reported in a traveler returning from Thailand as a complication of untreated scrub typhus (Watt & Strickman, 1994).
b) CASE REPORT/SCRUB TYPHUS: A 74-year-old man presented with a fever of 5 days duration along with headache, myalgia, and productive cough. Upon examination the patient was disoriented and irritable with a fever (38.8 degrees C) and hypotension (90/60 mm Hg). Pedal edema was also noted. Antibiotic therapy was initiated for probable sepsis. Laboratory studies were significant for severe thrombocytopenia (INR 1.6, platelet count 18 x 10(9)/L, aPTT prolongation 10 seconds, and D-dimer 400 ng/mL) and renal insufficiency (serum creatinine 2.6 mg/dL). By day 2, he developed a symmetrical purpuric rash found on the palms, soles of the feet, arms and legs which became black and necrotic within 48 hours. Further serological testing was performed. By day 4, a serology test was positive for scrub typhus. Doxycycline was initiated and other antibiotic therapies were discontinued. Systemic symptoms gradually improved and his skin lesions resolved without sequelae and the patient was discharged to home on day 7 (Jain et al, 2014). c) SCRUB TYPHUS: In a study conducted in India, it was found that 24% of patients that presented with unexplained febrile illness were diagnosed with scrub typhus. Renal abnormalities were observed in 84% of these patients with evidence of acute kidney illness (AKI) in 53%. Jaundice, oliguria, and mortality were more likely to occur in patients with AKI. It was suggested that all patients with unexplained febrile illness be investigated for scrub typhus and of those that are diagnosed be monitored for the potential development of AKI (Kumar et al, 2014). B) GLOMERULONEPHRITIS 1) WITH POISONING/EXPOSURE a) Patients with epidemic typhus may experience acute glomerulonephritis with hematuria due to rickettsial damage to the kidney (Woodward, 1994).
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Acid-Base |
3.11.2) CLINICAL EFFECTS
A) ACIDOSIS 1) WITH POISONING/EXPOSURE a) Metabolic acidosis may occur in patients with severe typhus due to low oxygen utilization by peripheral tissue and poor oxygen exchange resulting from rickettsial damage to lung and vasculature (Baxter, 1996).
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Hematologic |
3.13.2) CLINICAL EFFECTS
A) LYMPHOCYTOSIS 1) WITH POISONING/EXPOSURE a) A normal white blood cell count is typical in scrub typhus, with a lymphocytosis in most patients. An atypical appearance of the lymphocyte is expected (Baxter, 1996; Chien et al, 1995; Berman & Kundin, 1973).
B) LEUKOPENIA 1) WITH POISONING/EXPOSURE a) Mild leukopenia may initially occur in a minority of endemic typhus patients (Baxter, 1996; O'Connor et al, 1996) and in a minority of scrub typhus patients ((Ghorbani et al, 1997; Yang et al, 1995a). In a retrospective case series involving 30 children diagnosed with murine typhus, 40% developed leukopenia (Fergie et al, 2000).
C) THROMBOCYTOPENIC DISORDER 1) WITH POISONING/EXPOSURE a) SUMMARY: Thrombocytopenia may occur in a minority of endemic typhus patients (Loh et al, 1996; O'Connor et al, 1996), in approximately 40% of epidemic typhus patients (Baxter, 1996), and in scrub typhus patients (Jain et al, 2014; Ghorbani et al, 1997; Yang et al, 1995a; Beaman & Marinovitch, 1999).
b) SCRUB TYPHUS: Hematologic abnormalities that have been observed with scrub typhus include thrombocytopenia, leucocytosis, and severe anemia (Kumar et al, 2014).
c) CASE REPORT/EPIDEMIC TYPHUS: Niang et al (1999) described a patient with epidemic typhus and severe thrombocytopenia (4,900 thrombocytes/mm(3)) and Zanetti et al (1998) described another patient with a platelet count of 16 x 10(9)/L (Niang et al, 1999; Zanetti et al, 1998).
d) CASE REPORT/SCRUB TYPHUS: A 74-year-old man presented with a fever of 5 days duration along with headache, myalgia, and productive cough. Upon examination the patient was disoriented and irritable with a fever (38.8 degrees C) and hypotension (90/60 mm Hg). Pedal edema was also noted. Antibiotic therapy was initiated for probable sepsis. Laboratory studies were significant for severe thrombocytopenia (INR 1.6, platelet count 18 x 10(9)/L, aPTT prolongation 10 seconds, and D-dimer 400 ng/mL) and renal insufficiency. By day 2, he developed a symmetrical purpuric rash found on the palms, soles of the feet, arms and legs which became black and necrotic within 48 hours. Further serological testing was performed. By day 4, a serology test was positive for scrub typhus. Doxycycline was initiated and other antibiotic therapies were discontinued. Systemic symptoms gradually improved and his skin lesions resolved without sequelae and the patient was discharged to home on day 7 (Jain et al, 2014).
D) DISSEMINATED INTRAVASCULAR COAGULATION 1) WITH POISONING/EXPOSURE a) Untreated and complicated typhus may progress to disseminated intravascular coagulation and death (Yi et al, 1993; Lee et al, 1995; Loh et al, 1996; Niang et al, 1999).
E) ANEMIA 1) WITH POISONING/EXPOSURE a) SCRUB TYPHUS: Hematologic abnormalities that have been observed with scrub typhus include thrombocytopenia, leucocytosis, and severe anemia (Kumar et al, 2014).
F) ESR RAISED 1) WITH POISONING/EXPOSURE a) The erythrocyte sedimentation rate (ESR) may be increased in typhus infections (Marschang et al, 1995).
b) CASE REPORTS: Loh et al (1996) reported an ESR of 53 mm/hr and 46 mm/hr in two endemic typhus infected patients, respectively (Loh et al, 1996).
c) CASE SERIES: An elevated ESR was reported in 75% of children (n=30) in a retrospective case series of patients diagnosed with murine typhus (Fergie et al, 2000).
G) HEMOPHAGOCYTIC SYNDROME 1) WITH POISONING/EXPOSURE a) HEMOPHAGOCYTIC SYNDROME has been described in a scrub typhus patient based on cytologic findings of many histiocytes containing phagocytosed blood cells in marrow aspirate. The patient recovered following antibiotic therapy (Chen et al, 2000).
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Dermatologic |
3.14.2) CLINICAL EFFECTS
A) ERUPTION 1) WITH POISONING/EXPOSURE a) EPIDEMIC TYPHUS 1) A maculopapular and petechial rash is most typical in epidemic typhus, with the rash being most evident on the trunk but also seen on the extremities. Rash may not always be evident (Zanetti et al, 1998). Petechiae may be seen on the conjunctival and soft palate. The rash typically begins in the axillary folds and upper trunk on the fifth day of illness and spreads to the extremities. Initially, the rash appears as non-confluent erythematous macules that blanch on pressure. The rash becomes maculopapular and petechial, affecting trunk and extremities, but sparing the face, palms, and soles (Baxter, 1996). Groen et al (1999) reported a patient with a macular-papular rash that evolved into an ulcer with a black necrotic eschar on the foot.
b) ENDEMIC TYPHUS 1) Macular and maculopapular rashes may be seen in cases of endemic (murine) typhus. Only 18% of patients will demonstrate a rash at presentation, however, 54% to 63% will develop rashes over the course of the illness. Median onset of the rash is 6 days, with a range of up to 18 days. Absence of a rash should not dissuade the clinician from a diagnosis of murine typhus. Appearance of the rash has been described as macular (in 49%), maculopapular (29%), papular (14%), petechial (6%), and morbilliform (3%). The rash spreads from trunk to extremities and vice versa equally, with rare involvement of the palms (Baxter, 1996; O'Connor et al, 1996). In a retrospective case series of 30 children diagnosed with murine typhus, 80% experienced rash (Fergie et al, 2000).
2) INCIDENCE/CHARACTERISTICS: In a retrospective case series of pediatric patients diagnosed with murine typhus in Texas from 1979 to 1996, 59 (63%) of 94 patients developed a rash during the course of their illness (median time to onset was 6 days). A triad of symptoms including fever, headache and rash was present in 43 (49%) of 87 children. The characteristics of the rash found in 94 exposures were: macular (24/48) 50%, maculopapular (12/48) 25%, erythematous (5/48) 10%, petechial and macular (3/48) 6%, papular (2/48) 4%, and petechial (2/48) 4% (Whiteford et al, 2001).
c) SCRUB TYPHUS 1) Macular and maculopapular rashes generally appear within 2 days after the chigger feeds and progresses to an eschar at the site of inoculation during a 6 to 18 day incubation period. An eschar appearing at the site of a mite bite is pathognomonic (Dupon et al, 1992) (Yi et al. 1993) (Kato et al, 1997). An ulcer may occur at the eschar site (Ghorbani et al, 1997). The rash, when present, typically spreads from the trunk to the extremities, and begins as a macular eruption which may become papular. a) Adenopathies of scrub typhus may be more common than either eschar or rash, and are usually palpable, ranging from small kernels to large spongy glands (Berman & Kundin, 1973; Baxter, 1996). Generally, only those that drain the eschar are tender or suppurative (Baxter, 1996). Eschars are generally found near tender lymph nodes when present (Yi et al, 1993; Chien et al, 1995).
b) A case of scrub typhus, transmitted by a needle stick to a nurse during the care of a scrub typhus patient, is reported. Erythematous swelling developed at the tip of her finger, the site of the needle stick, 7 days later. Ten days after the needle stick, fever and headache developed, and her skin lesion became vesicular. A rising indirect immunofluorescent antibody titer gave a positive diagnosis for scrub typhus, which improved following therapy with doxycycline (Jee et al, 1996).
B) PURPURA FULMINANS 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 74-year-old man presented with a fever of 5 days duration along with headache, myalgia, and productive cough. Upon examination the patient was disoriented and irritable with a fever (38.8 degrees C) and hypotension (90/60 mm Hg). Pedal edema was also noted. Antibiotic therapy was initiated for probable sepsis. Laboratory studies were significant for severe thrombocytopenia (INR 1.6, platelet count 18 x 10(9)/L, aPTT prolongation 10 seconds, and D-dimer 400 ng/mL) and renal insufficiency. By day 2, he developed a symmetrical purpuric rash found on the palms, soles of the feet, arms and legs which became black and necrotic within 48 hours. Further serological testing was performed. By day 4, a serology test was positive for scrub typhus. Doxycycline was initiated and other antibiotic therapies were discontinued. Systemic symptoms gradually improved and his skin lesions resolved without sequelae and the patient was discharged to home on day 7 (Jain et al, 2014).
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Musculoskeletal |
3.15.2) CLINICAL EFFECTS
A) MUSCLE PAIN 1) WITH POISONING/EXPOSURE a) Abrupt onset of painful myalgias and arthralgias are common following 1 to 3 days of malaise in epidemic, endemic, and scrub typhus (Whiteford et al, 2001; Perine et al, 1992; Dupon et al, 1992; Yi et al, 1993; Ghorbani et al, 1997; Marschang et al, 1995; Raoult et al, 1998). Up to 32% of scrub typhus patients in one study developed myalgia (Berman & Kundin, 1973).
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Immunologic |
3.19.2) CLINICAL EFFECTS
A) LYMPHADENOPATHY 1) WITH POISONING/EXPOSURE a) Generalized lymphadenopathy is the most common physical finding (approximately 85% of cases) in scrub typhus. Scrub typhus adenopathy is easily palpable, with nodes ranging from small kernels to large spongy glands. Generally, only those that drain the eschar are tender or suppurative (Baxter, 1996; Yi et al, 1993; Chien et al, 1995; Kato et al, 1997; Marschang et al, 1995).
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Reproductive |
3.20.1) SUMMARY
A) Vertical transmission of scrub typhus through the placental barrier from mother to fetus has occurred.
3.20.2) TERATOGENICITY
A) CONGENITAL ANOMALY 1) A male neonate (2,200 grams) was delivered by cesarean section from a 34-week pregnant female with diagnosed scrub typhus. The infant was found to have hepatosplenomegaly and a positive scrub typhus IgM test. His condition deteriorated, with development of anemia, sepsis, and DIC. Treatment with chloramphenicol was begun. He recovered after one month. Residual effects included mildly retarded growth, microcephaly and encephalomalacia, which was seen on CT brain scan (Suntharasaj et al, 1997).
3.20.3) EFFECTS IN PREGNANCY
A) PLACENTAL BARRIER 1) Vertical transmission of scrub typhus through the placental barrier from mother to fetus is reported in a 34-week pregnant female. The diagnosis was confirmed by positive Weil-Felix (OXK titer 1:320) and scrub typhus (titer 1:1600) tests in the mother; vertical transmission was demonstrated by positive scrub typhus IgM in the child. After cesarean section and following 7 days of antibiotic therapy, the mother recovered and was discharged (Suntharasaj et al, 1997).
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