8. Burden..
• 24% of PUO in South Indian children
• 70% cases in June-December
17 Feb 2016
Scrub typhus,
62.8%
spotted fever,
32.6%
murine typhus,
4.7%
Magnitude and Features of Scrub Typhus and Spotted Fever in Children in India
J Trop Pediatr (June 2006) 52 (3): 228-229 doi:10.1093/tropej/fmi096
8
17. Exposure to Mite Islands..
• Highest incidence –
o Military soldiers
o farmers
• Military operations -brush & jungle areas
• Epidemics affecting 20% to 50% of the troops
17 Feb 2016 17
29. Boutonneuse Fever
17 Feb 2016
1. clinical presentation = mild - very severe
2. fatality =highly virulent rickettsiae 2–6%
3. clinical signs :
I. fever;
II. headache;
III. rash maculopapular or vesicular;
IV.inoculation eschars at site of tick bite;
V. localized lymphadenopathy
32
30. • Early empirical treatment
• doxycycline
• no vaccines available
• Prevention -minimizing exposure to ticks
17 Feb 2016
Indian tick typhus
33
31. Prevention
• Ticks are prevalent-control is not feasible
• No vaccine available
• Avoidance of tick bite
o Tick repellant
o Protective clothing
• Regular inspection & removal of ticks from
body
• Removal of ticks prior to inoculation of
rickettsia
17 Feb 2016 34
32. Candidatus Rickettsia kellyi
• New species
• Vector undetermined
• Thirupattur ,Tamil Nadu
• 2006
• Fever & Maculopapular Lesion
• Dramatic recovery with Doxycycline
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 3, March 200617 Feb 2016 35
34. • Agent -Rickettsia typhi
• Mode - rat and flea population
• clinical characteristics:
o Fever
o Headache
o Rash
o Systemic inflammatory vasculitis
17 Feb 2016
Murine typhus
37
41. Epidemiological Triad –Q fever
17 Feb 2016
Host
Cattle/Pets/Human
Agent
Coxiella burnetti
As a spore
Environment
Aerosol/tick borne/food
borne/fomite/
not human to human
Q-fever
44
42. Clinical features-
• Clinical manifestations –
o pneumonia
o hepatitis
o prolonged fever
o Endocarditis
• In pregnant women
o placentitis
o premature birth
o growth retardation
o spontaneous abortion/ fetal death
• mortality 1 to 11% of patients of chronic Q fever
17 Feb 2016 45
46. • Presentation-
o Acute febrile illness
o Headache
o Myalgia.
o Neurologic manifestations
o Rash
o Vasculitis
o Gangrene
If Untreated??
high mortality
17 Feb 2016
Epidemic louse-borne typhus
49
47. • Diagnosis
• -based on clinical suspicion with Serology
• Treatment
• -a single 200-mg dose/ short course of
doxycycline
• Relapses
• -Brill-Zinsser disease -mild
• Control
• -de-lousing & hygiene
17 Feb 2016
Epidemic louse-borne typhus
50
49. Epidemic louse borne T.
Q-fever
Murine typhus
Scrub typhus
Distribution of Different Rickettsial diseases in India (ref- Manson’s)
17 Feb 2016 52
50. When you Suspect sooner ..
Treatment is easier …
• 1.Clinically
• 2.Tick exposure
• 3.Epidemiological data
• 4.Lab features
• 5.Rapid defervescence with proper antibiotics
17 Feb 2016Rickettsial Infections: Indian Perspective :Narendra Rathi And Akanksha Rathi
Indian Pediatrics Volume 47__february 17, 2010
53
Howard Ricketts discovered that ticks cause rocky mountain spotted fever RMSF by a mysterious organism…circulated between pigs n mammals.later discovered
Time=reported outbreaks and trends….place =
World burden v/s india burden …like bharath slide
WHO factsheets….
In the picture Rickettsia rickettsii (red dots) in the cell of a deer tick…from wikipedia
The common threads that hold the rickettsiae into a group are their epidemiology, their obligate intracellular lifestyle, and the laboratory technology required to work with them
DD-dengue, Dengue, Kawasaki Disease, Leptospirosis,
Malaria, Measles, Meningococcal
Infections, Rubella , Streptococcal
Infection, Group A, Syphilis, Toxic Shock
Syndrome, Vasculitis and
Thrombophlebitis
measles, rubella, meningococcal infection,
malaria, leptospirosis and other viral
exanthemslow index of suspicion, nonspecific signs and symptoms, and absence of widely available sensitive and specific diagnosic test, these infections are notoriously difficult to diagnose.
As antimicrobials effective for rickettsial disease are usually not included in empirical
therapy of nonspecific febrile illnesses, treatment of rickettsial disease is not provided unless they are suspected.
Knowledge of geographical distribution, evidence of exposure to vector, clinical features like fever, rash, eschar, headache
and myalgia along with high index of suspicion are crucial factors for early diagnosis.
The greatest challenge is the difficult diagnostic dilemma posed by these infections early in their clinical course, when antibiotic therapy is most effective. Early signs and symptoms of these illnesses are notoriously nonspecific or mimic benign viral illnesses, making diagnosis difficult
http://medind.nic.in/ibv/t10/i2/ibvt10i2p157.pdf
#Q fever is excluded from the rickettsiaceae family as it doesn’t have an arthropod vector(ananthanarayan paniker microbiology 2008 edition)
Rickettsia are classically classified into 2 groups the SFG and typhus group on the basis of antigenic differences in their cell wall
Reference- Tropical Infectious Diseases: Principles, Pathogens and Practice
By Richard L. Guerrant, David H. Walker, Peter F. Weller chapter-53-55
commonly reported diseases in India are scrub typhus, murine flea-borne typhus, Indian Tick Typhus and Q fever
H. R. Somashekar,
Prabhakar D. Moses,
Sreeja Pavithran,
Leni Grace Mathew,
Indira Agarwal,
Jean Marc Rolain,
Didier Raoult,
George M. Varghese,
and Elizabeth Mathai
Magnitude and Features of Scrub Typhus and Spotted Fever in Children in India
J Trop Pediatr (June 2006) 52 (3): 228-229 doi:10.1093/tropej/fmi096
Done by cmc
Spotted fevers & typhus fever in Tamil Nadu
Indian J Med Res 126, August 2007, pp 101-103
Nicd.nic.in
Common clinical manifestations of ????scrub typhus
Vaidya VM, Malik SVS, Kaur S, Kumar S, Barbuddhe SB.
Comparison of PCR, immunoflorescence assay, and
pathogen isolation for diagnosis of Q fever in humans
with spontaneous abortions. J Clin Microbiol 2008;
46:2038-2044.
C. burnetii infection of pregnant women can provoke placentitis and often lead to premature birth, growth retardation, spontaneous abortion, or fetal death (29). The disease is usually benign, but mortality occurs in 1 to 11% of patients with chronic Q fever
The bite caused by a
"strikingly big" engorged tick was almost
uniformly located on the occipital scalp
region. The infection occurred most
commonly in young children: the larger
half of the patients were less than 10 years
of age.
Insecticides have been used to control chiggers,
both in high-risk habitats and on blankets and clothes, but neither are currently practical in rural Asia for farmers (who are at most risk
of scrub typhus). For short-term adult visitors, weekly 200 mg doxycycline
reduces the risk of contracting scrub typhus. There is currently
no safe and effective vaccine available.
Chiggers article. Dangerous bug
Figure. The locations of typical eschars in 2 representative patients with scrub typhus. A) An eschar on the neck of a patient (03PE1). B) An eschar on the waist of a patient...
Orientia tsutsugamushi in Eschars from Scrub Typhus Patients
Yun-Xi Liu*, Wu-Chun Cao* , Yuan Gao†, Jing-Lan Zhang†, Zhan-Qing Yang†, Zhong-Tang Zhao‡, and Janet Foley§
Author affiliations: *Beijing Institute of Microbiology and Epidemiology, Beijing, People's Republic of China;†Center for Disease Control and Prevention of Jinan, Jinan, People's Republic of China; ‡Shandong University, Jinan, People's Republic of China; §University of California, Davis, Davis, California, USA
http://wwwnc.cdc.gov/eid/article/12/7/05-0827_article
ONE OUTBREAK OF SCRUB TYPHUS REPORTED BETWEEN 2008-2014
IDSP-DIAGNOSIS OF SCRUB TYPHUS BY ELISA
Clinical profile and improving mortality trend of scrub typhus in South India.cmc
International Journal of Infectious Diseases
Volume 23, June 2014, Pages 39–43
A patient with fever, headache, and myalgia with an eschar in an endemic area is likely to have scrub typhus.
The incubation period is approximately 6–14 days. Ten to fifty percent of patients may have an eschar – this variability probably reflects, atleast in part, the extent to which patients are examined. Eschars, which are usually single and in secluded areas such as the axilla and groin, are painless, erythematous papules that develop a central black
scab, resembling a cigarette burn (Fig. 63.3). They are not pathognomonic for scrub typhus, as similar lesions may be produced by spotted
fever group rickettsioses. Chiggers are minute and, unlike ticks, are not normally noticed. Patients may scratch off the characteristic black scab. Lymphadenopathy is more frequent than in sympatric murine typhus [2]. Headache, myalgia, and dry cough frequently occur; a maculopapular erythematous rash occurs in a minority of patients
[1,2]. Deafness, tinnitus, and conjunctival suffusion occur. Severe disease can manifest as pneumonitis, acute respiratory distress
syndrome, jaundice with mildly raised transaminases, meningoencephalitis,coagulopathy, multi-organ failure, acute renal failure, acute
transverse myelitis, myocarditis, and Guillain-Barré syndrome. Why some, and not others, develop severe disease is not understood.
Mortality is positively correlated with blood bacterial load [5]. Orientia
tsutsugamushi DNA has been demonstrated in cerebrospinal fluid
(CSF), with normal glucose, a mild increase in white cell density
(ranging from 11–88% lymphocytes) and raised protein [7]. Scrub
typhus appears to be less severe in children, but there have been no prospective comparisons between children and adults from the same
population. Scrub typhus can cause serious adverse effects for mother
and baby in pregnancy [8]. The majority of scrub typhus patients are not diagnosed or treated. The differential diagnosis
would include spotted fever group rickettsiosis, which would also be
expected to respond to tetracyclines. Scrub typhus eschars could be
confused with the lesions of anthrax, tularemia, chancroid, lymphogranuloma
venereum, and injury. In the absence of an eschar, few
clinical features are helpful. Murine typhus, leptospirosis, Q fever,
dengue, hemorrhagic fever with renal syndrome (HFRS), infectious
mononucleosis, HIV seroconversion, septicemia (especially typhoid),
and malaria are important differential diagnoses . Laboratory diagnosis of scrub typhus is difficult. Culture (requiring
BSL3 facilities) is 100% specific, but has low sensitivity. Immunofluorescence
(IFA) and immunoperoxidase IgM and IgG antibody tests
have been commonly used, but these are expensive, rarely accessible
and are bedevilled by subjectivity of interpretation and uncertainty as
to the most appropriate cut-off titers in different communities [10].
Ideally, they should be interpreted by comparing titers between paired
acute and convalescent samples , The Weil-Felix OXK test is still commonly used
in Asia, but has low sensitivity. Conventional and quantitative realtime
PCR assays for the detection of O. tsutsugamushi in blood, eschar
tissue, and CSF have been developed [11, 12]. However, there remain
great difficulties in the accessibility of the diagnosis of scrub typhus
in rural endemic areas. Mixed infections may occur with, for example,
leptospirosis but, given the persistence of antibodies, distinguishing
these from serial infections without culture or PCR techniques is
difficult. Given the difficulties of making a timely laboratory diagnosis and the
significant minority who develop severe disease, empirical treatment
should be considered for all cases with scrub typhus in the differential
diagnosis. The diversity of O. tsutsugamushi suggests it is unlikely that
one treatment regimen will be appropriate across the wide distribution
of this organism. Chloramphenicol- and doxycycline-resistant
scrub typhus have been described in northern Thailand [13], but there
are no subsequent published data on this clinical problem. Given the difficulties of making a timely laboratory diagnosis and the
significant minority who develop severe disease, empirical treatment
should be considered for all cases with scrub typhus in the differential
diagnosis. The diversity of O. tsutsugamushi suggests it is unlikely that
one treatment regimen will be appropriate across the wide distribution
of this organism. Chloramphenicol- and doxycycline-resistant
scrub typhus have been described in northern Thailand [13], but there
are no subsequent published data on this clinical problem. There are few data to guide the antibiotic treatment of severe disease
– parenteral or nasogastric doxycycline or chloramphenicol are potential
options. Appropriate supportive care is essential. The treatment
of scrub typhus in pregnancy is problematic – chloramphenicol
(although contraindicated in the last trimester), azithromycin, and
rifampicin have been used. In children, the risks of short-course doxycycline
are almost certainly exceeded by the benefit of effective cure.
In a retrospective analysis of children with scrub typhus, no significant
differences in fever clearance times were found between doxycycline,
chloramphenicol, or roxithromycin therapy [21].
Mortality is very variable, ranging from 0–60% in untreated patients,
for reasons that are unclear. Delayed administration of doxycycline
has been associated with major organ dysfunction and prolonged
Jipmer case classical eschar
December 2013 with a history of fever, body aches, and headache since last 15 days. He reported no localizing symptoms. There was no icterus or lymphadenopathy. An eschar was noted on the upper abdomen (Figure). A faint blanching erythema was also apparent on the trunk and proximal limbs
Clinical profile and improving mortality trend of scrub typhus in South India.cmc ,,MODS in34%
International Journal of Infectious Diseases
Volume 23, June 2014, Pages 39–43
Clinical profile and improving mortality trend of scrub typhus in South India.cmc ,,MODS in34%
International Journal of Infectious Diseases
Volume 23, June 2014, Pages 39–43
cdc
increasing trend in proportion of scrub typhus cases to overall admissions from 1% to 2.2% over four year period (2011-2014). More cases were admitted between the months of September and January.
In south american countries,40% pts suspected of dengue but lacking dengue antibodies were diagnosed with SFG rickettsioses
In areas with amblyomma species ticks-antibodies against SFG group are very common in africa
Vaidya VM, Malik SVS, Kaur S, Kumar S, Barbuddhe SB.
Comparison of PCR, immunoflorescence assay, and
pathogen isolation for diagnosis of Q fever in humans
with spontaneous abortions. J Clin Microbiol 2008;
46:2038-2044.
C. burnetii infection of pregnant women can provoke placentitis and often lead to premature birth, growth retardation, spontaneous abortion, or fetal death (29). The disease is usually benign, but mortality occurs in 1 to 11% of patients with chronic Q fever
hunter’s book
J Vector Borne Dis 51, December 2014, pp. 259–270J Vector Borne Dis 51, December 2014, pp. 259–270
Problem of ticks and tick-borne diseases in India with special emphasis on
progress in tick control research: A review
Srikant Ghosh & Gaurav Nagar
Cmc 2006
Synonyms: flea-borne typhus, endemic typhus
Xenopsylla chaeopsis
Disease outcome: usually favorable – low rate of
complications and mortality
World Health Organization (WHO). 1989. Geographical distribution of arthropod-borne diseases and their principal vectors
Vaidya VM, Malik SVS, Kaur S, Kumar S, Barbuddhe SB.
Comparison of PCR, immunoflorescence assay, and
pathogen isolation for diagnosis of Q fever in humans
with spontaneous abortions. J Clin Microbiol 2008;
46:2038-2044.
C. burnetii infection of pregnant women can provoke placentitis and often lead to premature birth, growth retardation, spontaneous abortion, or fetal death (29). The disease is usually benign, but mortality occurs in 1 to 11% of patients with chronic Q fever
The disease is usually benign, chronic Q fever
Raoult, D. 1990. Host factors in the severity of Q fever. Ann. N. Y. Acad. Sci. 590:33-38.
R. prowazekii requires an arthropod vector to infect the human host. In this case, the vector is the body louse, Pediculus humanus humanus (more commonly known as Pediculus humanus corporis):
gangrene of extremities , Untreated cases,
The poor sensitivity and low specificityof the Weil-Felix test is,PCR also low sensitivity .IgM Elisa
now well demonstrated for the diagnosis of Rocky
mountain spotted fever (RMSF)10-13 MSF14, murine
typhus, epidemic typhus15 and scrub typhus16. Although
a good correlation between the results of the Weil-Felix
test and detection of IgM antibodies by an IFA is often
observed, with the development of techniques that are
used to grow rickettsiae, this test should be used only
as a first line of testing in rudimentary hospital
laboratories. the Weil Felix test still serves as a useful and
cheapest available tool for the laboratory diagnosis of
rickettsial diseases. A four-fold rise in agglutinin titres
in paired sera is diagnostic for infection with these
febrile agents.