SCRUB TYPHUS

Dr.T.V.Rao MD

DR.T.V.RAO MD

SCRUB TYPHUS
Scrub typhus or Bush typhus is a form of typhus caused by the intracellular parasite Orientia tsutsugamushi, a Gram-negative proteobacterium of family Rickettsiaceae first isolated and identified in 1930 in Japan
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DR.T.V.RAO MD

INCIDENCE OF SCRUB TYPHUS

The precise incidence of the disease is unknown, as diagnostic facilities are not available in much of its large native range which spans vast regions of equatorial jungle to the sub-tropics. In rural Thailand and in Laos, murine and scrub typhus accounts for around a quarter of all adults presenting to hospital with fever and negative blood cultures The incidence in Japan has fallen over the past few decades, probably due to land development driven decreasing exposure, and many prefectures report fewer than 50 cases per year.
DR.T.V.RAO MD

SCRUB TYPHUS
Scrub typhus caused by Orientia tsutsugamushi Mild to fatal 6-18 days after bite of Mite An Escher is formed at the site of bite With enlargement of Lymph nodes, Interstitial pneumonitis ,lymphadenopathy,spleenomegaly Encephalitis, Respiratory failure, circulatory failure
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RICKETTSIA TSUTSUGAMUSHI.
Causative agent is Rickettsia tsutsugamushi. Found in areas where

they harbour the infected chiggers

particularly vegetation's.
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areas

of

heavy

scrub

 RESERVOIR: Trombiculid mite which feeds on small mammals.

MODE OF TRANSMISSION: By bite of infected larval mites. Infection occurs during wet season when the mites lay their eggs. It is the larva (chigger) that feeds on vertebrate hosts.

TRANSMISSION CYCLE
MITE------RATS AND MICE-----MITE----RATS AND MICE

MAN
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SCRUB TYPHUS
Etiology: Orientia tsutsugamushi
Resembles Epidemic typhus except for the ESCHAR generalized lymphadenopathy & lymphocytosis cardiac & cerebral involvement may be severe

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EPIDEMIOLOGY
Source of infection--------Rat

Route of transmission-----Trombiculid mites

Susceptible population----All susceptible

Epidemic features----------Tsutsugamushi

triangle

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DR.T.V.RAO MD

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MODE OF TRANSMISSION
Rats & Mice Mite

Mite

Humans (Accidental host)

No direct person to person transmission Mite Islands

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CHIGGER
reservoir

Larval stage
vector

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Scrub Typhus
An important vector-borne disease, first described in 1899 in Japan. During World War II, this disease killed thousands of soldiers who were stationed in rural or jungle areas of the Pacific theatre. The disease occurred and threatened people throughout Asia & Australia. The range stretches from the Far-east to the Middle-east (from Japan and Korea, Southeast Asia, Pakistan, India, to Arab countries and Turkey). There are approx. 1 million cases each year world-wide, & over 1 billion people at risk.
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CLINICAL FEATURES
Incubation period : 1-3 wks. (usually6-21 days)
Fever(104-105F) with chills,malaise,conjunctival Irritation.

Maculopapular rash
Lymphadenopathy,Lymphocytosis Headache, Cough, Myalgia

Gastrointestinal symptoms
Typical Eschar formation(5th day of illness)
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DR.T.V.RAO MD

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Scrub Typhus: A Rickettsial Disease

Pathogen: Orientia tsutsugamushi Rickettsial bacteria

Vector: Leptotrombidium

An acute febrile, rickettsial disease caused by a gram-negative, rodshaped (cocco-bacillus) bacterium, known as Orientia (Rickettsia) tsutsugamushi.
O. tsutsugamushi is transmitted to vertebrate hosts (rodents-primary host & humanssecondary or accidental host) by the bite of larval mites (chiggers) of the genus Leptotrombidium, e. g. L. deliense, L. dimphalum, etc.

Chigger-Mite

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SCRUB TYPHUS

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Eschar
Probability: Higher than 60%. Location: Axillary fossa, inguinal region, perianal region, scrotum, buttocks and the thigh. Appearance: an ulcer surrounded by a red areola, is often covered by a dark scab.

The most specific manifestation of scrub typhus.

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CLINICAL MANIFESTATION
Incubation period is 4~21
Sudden onset with a fever

1st week, systemic toxic symptoms

2nd week, get worse, complication

3th week, convalesce

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COMPLICATIONS
Pneumonitis
Hepatitis Myocarditis Meningoencephalitis Disseminated intravascular coagulation Multi organ failure
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Eschar
Probability: Higher than 60%. Location: Axillary fossa, inguinal region, perianal region, scrotum, buttocks and the thigh. Appearance: an ulcer surrounded by a red areola, is often covered by a dark scab.

The most specific manifestation of scrub typhus.

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INVESTIGATIONS
Weil-feilx test positive-proteus strain oxk Indirect immunofluorescence. PCR for Orientia tsutsugamushi from blood of feverish patients.
Some studies have used PCR (polymerase chain reaction) on specimens obtained from eschars.

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DIAGNOSIS OF SCRUB TYPHUS

The cheapest and most easily available serological test is the Weil-Felix test, but this is notoriously unreliable. The gold standard is indirect immunofluorescence, but the main limitation of this method is the availability of fluorescent microscopes, which are not often available in resource-poor settings where scrub typhus is endemic. Indirect immunoperoxidase (IIP) is a modification of the standard IFA method that can be used with a light microscope, and the results of these tests are comparable to those from IFA.
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MANAGEMENT
Drug of choice: Tetracycline
Doxycycline orally or Chloramphenicol in more severe cases. Azithromycin has been used in resistant cases and may be better than doxycycline - especially in children and pregnant women.
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TREATMENT
The drug most commonly used is doxycycline; but chloramphenicol is an alternative. Strains that are resistant to doxycycline and to chloramphenicol are common in northern Thailand.Rifampin and azithromycin are alternatives. Azithromycin is an alternative in children and pregnant women with scrub typhus, and when doxycyclineresistance is suspected. Ciprofloxacin cannot be used safely in pregnancy and is associated with stillbirths and miscarriage. Combination therapy with doxycycline and rifampicin is not recommended due to possible antagonism.
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PREVENTION
Vector control:
Application of insecticides eg: lindane or chlordane to ground and vegetation. Environmental control Personal protection
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 Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World
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