Scrub typhus

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Scrub typhus
SynonymsBush typhus
Orientia tsutsugamushi.JPG
Orientia tsutsugamushi
Specialty Infectious disease

Scrub typhus or bush typhus is a form of typhus caused by the intracellular parasite Orientia tsutsugamushi , a Gram-negative α-proteobacterium of family Rickettsiaceae first isolated and identified in 1930 in Japan. [1] [2]

Typhus group of infectious diseases

Typhus, also known as typhus fever, is a group of infectious diseases that include epidemic typhus, scrub typhus and murine typhus. Common symptoms include fever, headache, and a rash. Typically these begin one to two weeks after exposure.

Intracellular parasites are microparasites that are capable of growing and reproducing inside the cells of a host. Some parasites can cause disease.

<i>Orientia tsutsugamushi</i> species of prokaryote

Orientia tsutsugamushi is a mite-borne bacterium belonging to the family Rickettsiaceae and is responsible for a disease called scrub typhus in humans. It is a natural and an obligate intracellular parasite of mites belonging to the family Trombiculidae. With a genome of only 2.4–2.7 Mb, it has the most repeated DNA sequences among bacterial genomes sequenced so far. The disease, scrub typhus, occurs when infected mite larvae accidentally bite humans. Primarily indicated by undifferentiated febrile illnesses, the infection can be complicated and often fatal.

Contents

Although the disease is similar in presentation to other forms of typhus, its pathogen is no longer included in genus Rickettsia with the typhus bacteria proper, but in Orientia . The disease is thus frequently classified separately from the other typhi.

In biology, a pathogen is also known as an infectious agent, or a germ. In the oldest and broadest sense, a pathogen is anything that can produce disease; the term came into use in the 1880s. Typically the term pathogen is used to describe an infectious microorganism or agent, such as a virus, bacterium, protozoan, prion, viroid, or fungus. Small animals, such as certain kinds of worms and insect larvae, can also produce disease but such animals are usually, in common parlance, referred to as parasites rather than pathogens. The scientific study of microscopic, pathogenic organisms is called microbiology, while the study of disease that may include these pathogens is called pathology. Parasitology, meanwhile, is the scientific study of parasites and the organisms that host them.

A genus is a taxonomic rank used in the biological classification of living and fossil organisms, as well as viruses, in biology. In the hierarchy of biological classification, genus comes above species and below family. In binomial nomenclature, the genus name forms the first part of the binomial species name for each species within the genus.

<i>Rickettsia</i> type of bacteria that causes typhus, among other diseases

Rickettsia is a genus of nonmotile, Gram-negative, nonspore-forming, highly pleomorphic bacteria that may occur in the forms of cocci 0.1 μm in diameter, rods 1–4 μm long, or threads of up to about 10 μm long. The term "rickettsia" has nothing to do with rickets, which is a deficiency disease resulting from lack of vitamin D; the bacterial genus Rickettsia was named after Howard Taylor Ricketts, in honour of his pioneering work on tick-borne spotted fever.

Signs and symptoms

Signs and symptoms include fever, headache, muscle pain, cough, and gastrointestinal symptoms. More virulent strains of O. tsutsugamushi can cause hemorrhaging and intravascular coagulation. Morbilliform rash, eschar, splenomegaly, and lymphadenopathies are typical signs. Leukopenia and abnormal liver function tests are commonly seen in the early phase of the illness. Pneumonitis, encephalitis, and myocarditis occur in the late phase of illness. It has particularly been shown to be the most common cause of acute encephalitis syndrome in Bihar, India. [3]

Fever common medical sign characterized by elevated body temperature

Fever, also known as pyrexia and febrile response, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using values between 37.5 and 38.3 °C. The increase in set point triggers increased muscle contractions and causes a feeling of cold. This results in greater heat production and efforts to conserve heat. When the set point temperature returns to normal, a person feels hot, becomes flushed, and may begin to sweat. Rarely a fever may trigger a febrile seizure. This is more common in young children. Fevers do not typically go higher than 41 to 42 °C.

Headache pain in the head or neck

Headache is the symptom of pain anywhere in the region of the head or neck. It occurs in migraines, tension-type headaches, and cluster headaches. Frequent headaches can affect relationships and employment. There is also an increased risk of depression in those with severe headaches.

Cough medical symptom, reflex to clear large breathing passages

A cough is a sudden, and often repetitively occurring, protective reflex which helps to clear the large breathing passages from fluids, irritants, foreign particles and microbes. The cough reflex consists of three phases: an inhalation, a forced exhalation against a closed glottis, and a violent release of air from the lungs following opening of the glottis, usually accompanied by a distinctive sound.

Causes

Scrub typhus is transmitted by some species of trombiculid mites ("chiggers", particularly Leptotrombidium deliense ), [4] which are found in areas of heavy scrub vegetation. The bite of this mite leaves a characteristic black eschar that is useful to the doctor for making the diagnosis.

Leptotrombidium deliense is a species of mite.

Eschar slough or piece of dead tissue that is cast off from the surface of the skin

An eschar is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, spotted fevers and exposure to cutaneous anthrax. The term "eschar" is not interchangeable with "scab". An eschar contains necrotic tissue, whereas a scab is composed of dried blood and exudate.

Scrub typhus is endemic to a part of the world known as the tsutsugamushi triangle (after O. tsutsugamushi ). [2] This extends from northern Japan and far-eastern Russia in the north, to the territories around the Solomon Sea into northern Australia in the south, and to Pakistan and Afghanistan in the west. [5] It may also be endemic in parts of South America. [6]

Solomon Sea A sea in the Pacific Ocean between Papua New Guinea and the Solomon Islands

The Solomon Sea is a sea located within the Pacific Ocean. It lies between Papua New Guinea and the Solomon Islands. Many major battles were fought there during World War II.

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 subtropics. In rural Thailand and Laos, murine and scrub typhus account for around a quarter of all adults presenting to hospital with fever and negative blood cultures. [7] [8] The incidence in Japan has fallen over the past few decades, probably due to land development driving decreasing exposure, and many prefectures report fewer than 50 cases per year. [9] [10]

It affects females more than males in Korea, but not in Japan, [11] and which may be because sex-differentiated cultural roles have women tending garden plots more often, thus being exposed to vegetation inhabited by chiggers. The incidence is increasing in the southern part of the Indian subcontinent and in northern areas around Darjeeling.[ citation needed ]

Diagnosis

In endemic areas, diagnosis is generally made on clinical grounds alone. However, overshadowing of the diagnosis is quite often as the clinical symptoms overlap with other infectious diseases such as dengue fever, paratyphoid, and pyrexia of unknown origin (PUO). If the eschar can be identified, it is quite diagnostic of scrub typhus, but this is very unreliable in the native population who have dark skin, and moreover, the site of eschar which is usually where the mite bites is often located in covered areas. Unless it is actively searched for, the eschar most likely would be missed. History of mite bite is often absent since the bite does not inflict pain and the mites are almost too small to be seen by the naked eye. Usually, scrub typhus is often labelled as PUO in remote endemic areas, since blood culture is often negative, yet it can be treated effectively with chloramphenicol. Where doubt exists, the diagnosis may be confirmed by a laboratory test such as serology. Again, this is often unavailable in most endemic areas, since the serological test involved is not included in the routine screening tests for PUO, especially in Burma (Myanmar).[ citation needed ]

The choice of laboratory test is not straightforward, and all currently available tests have their limitations. [12] The cheapest and most easily available serological test is the Weil-Felix test, but this is notoriously unreliable. [13] The gold standard is indirect immunofluorescence, [14] 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, a modification of the standard IFA method, can be used with a light microscope, [15] and the results of these tests are comparable to those from IFA. [13] [16] Rapid bedside kits have been described that produce a result within one hour, but the availability of these tests is severely limited by their cost. [13] Serological methods are most reliable when a four-fold rise in antibody titre is found. If the patient is from a nonendemic area, then diagnosis can be made from a single acute serum sample. [17] In patients from endemic areas, this is not possible because antibodies may be found in up to 18% of healthy individuals. [18]

Other methods include culture and polymerase chain reaction, but these are not routinely available [19] and the results do not always correlate with serological testing, [20] [21] [22] and are affected by prior antibiotic treatment. [23] The currently available diagnostic methods have been summarised. [12]

Treatment

Without treatment, the disease is often fatal. Since the use of antibiotics, case fatalities have decreased from 4–40% to less than 2%.

The drug most commonly used is doxycycline or tetracycline, but chloramphenicol is an alternative. Strains that are resistant to doxycycline and chloramphenicol have been reported in northern Thailand. [24] [25] Rifampicin [26] and azithromycin [27] are alternatives. Azithromycin is an alternative in children [28] and pregnant women with scrub typhus, [29] [30] [31] and when doxycycline resistance is suspected. [32] Ciprofloxacin cannot be used safely in pregnancy and is associated with stillbirths and miscarriage. [31] [33] Combination therapy with doxycycline and rifampicin is not recommended due to possible antagonism. [34]

Vaccine

No licensed vaccines are available. [35]

An early attempt to create a scrub typhus vaccine occurred in the United Kingdom in 1937 (with the Wellcome Foundation infecting around 300,000 cotton rats in a classified project called "Operation Tyburn"), but the vaccine was not used. [36] The first known batch of scrub typhus vaccine actually used to inoculate human subjects was dispatched to India for use by Allied Land Forces, South-East Asia Command in June 1945. By December 1945, 268,000 cc had been dispatched. [37] The vaccine was produced at Wellcome′s laboratory at Ely Grange, Frant, Sussex. An attempt to verify the efficacy of the vaccine by using a placebo group for comparison was vetoed by the military commanders, who objected to the experiment. [38]

Enormous antigenic variation in Orientia tsutsugamushi strains is now recognized, [39] [40] and immunity to one strain does not confer immunity to another. Any scrub typhus vaccine should give protection to all the strains present locally, to give an acceptable level of protection. A vaccine developed for one locality may not be protective in another, because of antigenic variation. This complexity continues to hamper efforts to produce a viable vaccine. [41]

History

An Australian soldier, Private George "Dick" Whittington, is aided by Papuan orderly Raphael Oimbari, near Buna on 25 December 1942. Whittington died in February 1943 from the effects of bush typhus. (Picture by Life photographer George Silk) Wounded Australian soldier led by a Papuan orderly at Buna.jpg
An Australian soldier, Private George "Dick" Whittington, is aided by Papuan orderly Raphael Oimbari, near Buna on 25 December 1942. Whittington died in February 1943 from the effects of bush typhus. (Picture by Life photographer George Silk)

Severe epidemics of the disease occurred among troops in Burma and Ceylon during World War II. [42] Several members of the U.S. Army's 5307th Composite Unit (Merrill's Marauders) died of the disease, and before 1944, no effective antibiotics or vaccines were available. [43] [44]

World War II provides some indicators that the disease is endemic to undeveloped areas in all of Oceania in the Pacific theater, although war records frequently lack definitive diagnoses, and many records of "high fever" evacuations were also likely to be other tropical illnesses. In the chapter entitled "The Green War", General MacArthur's biographer William Manchester identifies that the disease was one of a number of debilitating afflictions affecting both sides on New Guinea [45] in the running bloody Kokoda battles over extremely harsh terrains under intense hardships fought during a six-month span [46] all along the Kokoda Track in 1942-43, and mentions that to be hospital-evacuated, Allied soldiers (who cycled forces) had to run a fever of 102 °F, and that sickness casualties outnumbered weapons-inflicted casualties 5:1. [45] Similarly, the illness was a casualty producer in all the jungle fighting of the land battles of the New Guinea campaign and the Guadalcanal campaign. Where the Allies had bases, they could remove and cut back vegetation, or use DDT as a prophylaxis area barrier treatment, so mite- and tick-induced sickness rates in forces off the front lines were diminished.

The disease was also a problem for US troops stationed in Japan after WWII, and was variously known as "Shichitō fever" (by troops stationed in the Izu Seven Islands) or "Hatsuka fever" (Chiba prefecture). [47]

See also

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