Pathogenic Ricketttsiae & Borreliae

Causative agents of epidemic typhus and other

rickettsioses
The Rickettsiae are small (0.3-0.5 x 0.8-2.0 um),
Gram-negative, aerobic, coccobacilli that are obligate
intracellular parasites of eukaryotic cells. They may
reside in the cytoplasm or within the nucleus of the cell
that they invade. They divide by binary fission and they
metabolize host-derived glutamate via aerobic
respiration and the citric acid (TCA) cycle. They have
typical Gram-negative cell walls, and they lack flagella.
They can be stained by Zdrodowsky stain because they
are weak acid fast. The rickettsiae frequently have a
close relationship with arthropod vectors that may
transmit the organism to mammalian hosts.
Taxonomy

order Rickettsiales
family Rickettsiaceae
genus Rickettsia
This genus includes many species associated
with human disease, including those in the
spotted fever group and the typhus group. The
rickettsiae that are pathogens of humans are
subdivided into three major groups based on
clinical characteristics of disease: 1. spotted
fever group; 2. typhus group; and 3. scrub
typhus group.
• The Rickettsia human pathogens are generally grouped as follows:
• 1. Spotted fever group
• R. rickettsii (Western hemisphere)
• Rocky Mountain spotted fever
• R. akari (USA, former Soviet Union)
• Rickettsialpox
• R. conorii (Mediterranean countries, Africa, Southwest Asia, India)
• Boutonneuse fever
• R. sibirica (Siberia, Mongolia, northern China)
• Siberian tick typhus
• R. australis (Australia)
• Australian tick typhus
• R. japonica (Japan)
• Oriental spotted fever
• R. africae (South Africa)
• African Tick Bite Fever
• 2. Typhus group
• R. prowazekii (Worldwide)
• Epidemic, recrudescent and sporadic
typhus
• R. typhi (Worldwide)
• Murine (endemic) typhus
• 3. Scrub typhus group
• The causative agent of scrub typhus
formerly known as R. tsutsugamushi has
been reclassified into the genus Orientia.
 Obligate intracellular parasites, the
Rickettsia depend on entry, growth, and
replication within the cytoplasm of
eukaryotic host cells (typically endothelial
cells). Because of this, Rickettsia cannot
live in artificial nutrient environments and
are grown either in tissue or embryo
cultures (typically, chicken embryos are
used), or inside susceptible animals. The
majority of Rickettsia bacteria are
susceptible to antibiotics of the
tetracycline group.
Description: Following the release from the phagosomes,
rickettsia grow free in the cytoplasm of cultured cells,
dividing by binary fission (seen at arrows). Inset highlights
the outer and inner membranes of rickettsia
 Zdrodowsky stain of tick hemolymph cells infected with R.
rickettsii. Rickettsia rickettsii, is a very small bacterium that must
live inside the cells of its hosts.
Immunofluorescent test of a positive human serum on
Rickettsia rickettsii grown in chicken yolk sacs, 400X
Direct fluorescent staining of the frozen sections of midguts
of X. cheopis fleas showing R. typhi-infected epithelial cells
 Virulence of Rickettsiae
• Adherence to the Host Cell
Rickettsiae are inoculated into the dermis of the skin by
a tick bite or through damaged skin from the feces of lice
or fleas. The bacteria spread through the bloodstream
and infect the endothelium. Adherence to the host cell is
the first step of rickettsial pathogenesis. The adhesins
are presumed to be outer membrane proteins. The outer
membrane protein OmpA has been implicated in
adherence of R. rickettsii because antibodies to OmpA
have been shown to block adherence.
• The host cell receptor for any Rickettsia has yet to be
identified. Although the main target cells of Rickettsia in
vivo are endothelial cells, rickettsiae can infect virtually
every cell line in vitro. Thus, either the receptor for
Rickettsia is ubiquitous among cells, or rickettsiae can
bind to different receptors.
 Virulence of Rickettsiae
Invasion of Host Cells
Upon attaching to the host cell membrane,
rickettsiae are phagocytosed by the host cell.
The rickettsiae are believed to induce host cell
phagocytosis because they can enter cells that
normally do not phagocytose particles. Once
phagocytosed by the host cell, rickettsiae are
observed to quickly escape from the phagosome
membrane and enter the cytoplasm. The
mechanism of escape from the phagosome
membrane is not well understood, but it is
thought to be mediated by a rickettsial enzyme,
phospholipase A2.
 Virulence of Rickettsiae
• Movement within and Release from the Host Cell
Observations in cell culture systems suggest that the
mechanisms of intracellular movement and destruction
of the host cells differ among the spotted fever group
and typhus group rickettsiae.
• Typhus group rickettsiae are released from host cells by
lysis of the cells. After infection with R. prowazekii or R.
typhi, the rickettsiae continue to multiply until the cell is
packed with organisms and then bursts. Phospholipase
A2 may be involved in cell lysis. Typhus group rickettsia-
infected host cells have a normal ultrastructural
appearance.
 Virulence of Rickettsiae
Spotted fever group rickettsiae seldom accumulate
in large numbers and do not lyse the host cells. They
escape from the cell by stimulating polymerization of
host cell-derived actin tails, which propel them through
the cytoplasm and into tips of membranous extrusions,
from which they emerge. Infected cells exhibit signs of
membrane damage associated with an influx of water,
but the means by which rickettsiae damage host cell
membranes is uncertain. There is evidence to suggest a
role for free radicals of oxygen, phospholipase, and a
protease.
 Pathogenesis
All rickettsial infections begin with
introduction of the organisms into the skin, either
through a tick bite or cutaneous abrasions
contaminated by flea or louse feces. Rickettsiae
enter dermal cells including endothelium and
proliferate locally intracellularly with endothelial
cell-to-cell spread for most rickettsioses
resulting in an eschar, a zone of dermal and
epidermal necrosis approximately 1 cm in
diameter with a surrounding zone of erythema.
Eschars do not occur in epidemic and murine
typhus and are rarely observed in Rocky
Mountain spotted fever.
 Pathogenesis (continuation)

Spotted fever group rickettsioses often manifest

regional lymphadenopathy in the drainage of the eschar,
suggesting that rickettsiae may spread via lymphatic
vessels from the tick bite inoculation site early in the
infection. Rickettsiae spread throughout the body and
infect mainly endothelial cells, establishing many foci of
contiguous infected blood vessel-lining cells. Injury in
these local sites causes vascular damage manifesting as
rash, interstitial pneumonia, encephalitis, interstitial
nephritis, and interstitial myocarditis, as well as lesions in
the liver, gastrointestinal wall, pancreas, and potentially
any vascularized tissue of the body.
 Pathogenesis (continuation)

The most important pathophysiologic

effect is increased vascular permeability
with consequent edema, loss of blood
volume, hypoalbuminemia, decreased
osmotic pressure, and hypotension. These
effects can be life threatening resulting in
pulmonary edema and adult respiratory
distress syndrome, shock, or acute tubular
necrosis.
Late (petechial) rash on palm and forearm.
Urban and suburban life cycles of Rickettsia and
mammalian hosts
Pathogenesis Mechanism of Epidemic Typhus

The clinical onset of epidemic typhus is usually abrupt after an

incubation period of about 14 days R. prowazekii is a
coccobacillary obligate intracellular organism that reproduces by
binary fission. After local infection at the site of the louse bite, the
organism infects the endothelial cells of capillaries and small
blood vessels, producing a vasculitis. Platelet and fibrin
deposition results in occlusion of vessels. Tissue biopsy reveals
perivascular infiltration with lymphocytes, plasma cells,
polymorphonuclear leukocytes, and histiocytes, with or without
necrosis of the vessel. Giemsa staining is useful for identifying
the organism in the cytoplasm of cells. The vasculitis is most
prominent in the skin, heart, central nervous system, skeletal
muscle, and kidneys. Gangrene of the skin can occur if local
thrombosis is severe .
Brill-Zinsser disease

Brill-Zinsser disease occurs as recrudescence of

previous infection with R. prowazekii. It is believed
that stress or a waning immune system may
reactivate earlier infection which is hidden in bone
marrow. The clinical symptoms are usually milder
than primary epidemic typhus and more closely
resemble those of murine typhus. Patients with
Brill-Zinsser disease lack specific IgM antibody
and have elevated IgG antibody to R. prowazekii.
Treatment is identical to that of primary epidemic
typhus.
Patients with epidemic typhus typically have a 1 to
3 days of malaise before abrupt onset of severe
headache, fevers, chills, and myalgia.
 Diagnosis
Diagnosis of rickettsial infections is often difficult.
The clinical signs and symptoms (e.g., fever, headache,
nausea, vomiting, and muscle aches) resemble many
other diseases during the early stages when antibiotic
treatment is most effective. A history of exposure to the
appropriate vector tick, louse, flea, or mite is helpful but
cannot be relied upon. Observation of a rash, which
usually appears on or after day 3 of illness, should
suggest the possibility of a rickettsial infection but, of
course, may occur in many other diseases also.
Knowledge of the seasonal and geographic
epidemiology of rickettsioses is useful, but is
inconclusive for the individual patient. Except for
epidemic louse-borne typhus, rickettsial diseases strike
mostly as isolated single cases.
 Diagnosis
Because rickettsiae are both fastidious and
hazardous, few laboratories undertake their isolation and
diagnostic identification. Some laboratories are able to
identify rickettsiae by immunohistology in skin biopsies
as a timely, acute diagnostic procedure, but to establish
the diagnosis physicians usually rely on serologic
demonstration of the development of antibodies to
rickettsial antigens in serum collected after the patient
has recovered. Currently, assays that demonstrate
antibodies to rickettsial antigens themselves (e.g., the
indirect fluorescence antibody test or latex agglutination)
are preferable to the nonspecific, insensitive Weil-Felix
test that is based on the cross-reactive antigens of OX-
19 and OX-2 strains of Proteus vulgaris.
 Treatment and prevention
Antibiotic Therapy: Tetracyclines and
chloramphenicol are highly effective in the
treatment of epidemic typhus. Because of a long
half-life, doxycycline has been shown to be
effective against epidemic typhus.
Successful vaccination against R.
prowazekii has been partially achieved with
inoculation of live vaccine strain Espana or
inactivated chemical rickettsial vaccine,
prepared from surface termostable antigen of
R.prowazekii.
 Causative agents of relapsing fever and
Lyme disease
Taxonomy
Order Spirochaetales
Family Spirochaetaceae
Genus Borrelia
Species B.recurrentis causes epidemic
relapsing fever
B.burgdorferi causes Lyme
disease
Structure, Classification, and Antigenic Types
Borrelial cells average 0.2 to 0.5 µm by 4 to 18 µm
and have 3-8 coils. Seven to twenty periplasmic flagella
originate at each end and overlap at the center of the
cell. Basal bodies of periplasmic flagella of borreliae
resemble those in Gram-positive bacteria. Because of
their larger diameter, borreliae are more readily stained
with aniline dyes than are other spirochetes. Their lipid
components are unusual in that they include cholesterol;
this substance has been found in only one other bacterial
genus, Mycoplasma. The nutritional requirements of the
borreliae are complex. Glucose, amino acids, long-chain
fatty acids, N-acetylglucosamine, and several vitamins
are some of their required organic nutrients. The
borreliae are microaerophilic organisms. Borrelia hermsii
has a generation time of 12 hours when cultivated in
artificial media at 35°C compared with only 6 to 10 hours
in the mouse.
Romanowsky-Giemsa stain of Borrelia in
blood
Fluorescent staining of borreliae
 Pathogenesis of relapsing fever
In most cases, borreliae must rely on an insect
vector to transmit the organisms through the epidermis.
The site of entry is usually not prominent as the
organisms are not clinically recognized until they enter
the blood. The mechanisms by which they reach the
bloodstream are unknown. The relapses are due to the
ability of borreliae to undergo multiple cyclic antigenic
variations. As antibodies for the predominant antigenic
type multiplying within the host appear, these organisms
"disappear" from the peripheral blood and are replaced
by a different antigenic variant within a few days. This
process may occur several times in an untreated host,
depending on the infecting Borrelia strain.
 Lyme disease
The mechanism by which borreliae cause Lyme
disease has not been elucidated. Early Lyme disease is
characterized by an expanding annular red rash,
erythema migrans, in approximately 70 percent of
patients, which is frequently accompanied by fever,
fatigue, headache, and muscle and joint pain. Arthritis,
neuritis, and carditis may also be present during early
Lyme disease. Persistent neurologic and arthritic
infections (lasting for months to years) may occur in
some patients. In contrast to the relapsing fevers, there
are very few spirochetes in Lyme disease, but viable B
burgdorferi organisms are necessary for the disease to
manifest itself. Although the disease has the same
general features in the United States and Europe,
arthritis occurs more frequently in the former and
neurologic disease in the latter.
 Epidemiology
Borrelia is transmitted to humans by the body louse
or ticks. Borrelia recurrentis, the cause of louse-borne
(epidemic) relapsing fever, is carried by the human louse
Pediculus humanus. The louse ingests the bacterium
while feeding on a borrelemic host. The organisms
multiply in the hemolymph and central ganglion of the
louse. Because other organs are not invaded,
transovarial transmission does not occur in the louse. In
addition, Borrelia organisms are released when the louse
is injured by host activities such as scratching.
Accordingly, one louse can infect only a single host and
is infective only for its life-span of around 1 month.
Therefore, humans rather than the louse are the
reservoir of this disease. The louse-borne disease is
called epidemic relapsing fever because it can be rapidly
disseminated under conditions of overcrowding and poor
personal hygiene, such as during wars and natural
disasters.
 Epidemiology
The tick-borne relapsing fever is called endemic
relapsing fever because it occurs whenever humans are
exposed to infected ticks. The soft ticks Ornithodoros
hermsi and O turicata. These ticks often obtain their
blood meal at night, and because the tick bite is usually
painless and feedings are short (5 to 20 minutes), people
may not be aware of having been bitten. The designation
of species of these borreliae is based on their vector
(e.g., B hermsii is associated with O hermsi). Genetic
studies have shown that this basis is incorrect. The two
North American species, B hermsii and B turicatae,
actually represent a single species. The ticks usually
become infected by feeding on borrelemic rodents. In
contrast to the louse, all tissues of the tick are invaded,
resulting in transovarial transmission and the presence
of borreliae in salivary and coxal (basal segment of
appendage) secretions. These borreliae in the salivary
and coxal secretions enter the host through the bite
wound while the tick is feeding (less than 1 minute may
be required for transmission).
 Epidemiology
B.burgdorferi, the agent of Lyme
disease, is transmitted by members of the
Ixodes ricinus complex (hard ticks).
Transovarial transmission of the
spirochete is infrequent, with fewer than 1
percent of the larvae infected.
 Immunity
Borrelia appears to be resistant to
nonspecific host defense mechanisms and
elicits an inflammatory response
consisting of mononuclear cells. These
spirochetes are rapidly killed in vitro by the
antibody-complement system. Immunity to
the borrelioses is primarily humoral
(specific IgM and IgG is secreted), and
such immune serum passively protects
experimental animals from infection.
 Diagnosis
Clinical features of the relapsing fevers other than
their recurring pattern are not diagnostic. Diagnosis is
based primarily on demonstration of the spirochetes in
blood during febrile episodes by dark-field examination,
use of stained blood smears, or mouse inoculation.
Antibody detection by indirect immunofluorescence
assay is available. The characteristic
expanding red skin lesion, erythema migrans, is
diagnostic for Lyme disease. However, 30 percent of
patients do not develop this rash. The usual symptoms
of early disease (fever, fatigue, headache, and muscle
and joint pain) are too nonspecific to be diagnostic.
Although B burgdorferi has been isolated from blood,
skin, and cerebrospinal fluid, this is a low yield procedure
and is not recommended. Serologic tests are used most
commonly for diagnosis of Lyme disease.
Erythema Migrans
 Diagnosis
To improve the sensitivity and specificity of
serodiagnosis of Lyme disease, evaluating serum
samples from patients with symptoms of Lyme disease
by a two-step process which includes a sensitive
screening test such as immunofluorescence assay or
enzyme immunoassay is recommended. Samples
judged equivocal or positive by the screening should be
further tested by Western blot. Both IgM and IgG
Western blot should be performed for persons with
suspected Lyme disease who present within the first four
weeks of disease onset. Only IgG Western should be
performed for patients presenting later because
interpretation of IgM band patterns after that time is less
reliable. Serologic testing of a convalescent serum
sample two to four weeks after the first sample is
recommended for patients who have symptoms of early
Lyme disease and negative screening test results.
 Prevention and treatment
Relapsing fevers and Lyme disease are prevented
by avoiding the vectors. It is important to be aware of
endemic areas and to take proper precautions. When in
potential tick habitats, one should wear clothing that
covers as much of the skin as possible and use tick
repellents. Periodic skin inspection and tick removal
prevent Lyme disease. A Lyme disease vaccine may be
available in the near future. The relapsing-fever and
Lyme disease borreliae have similar antibiotic
susceptibilities.
Early Lyme disease can be effectively treated with
oral tetracyclines and semisynthetic penicillins. Arthritic
and neurologic disorders are treated with high-dose
intravenous penicillin G or ceftriaxone. Patients who
have failed to respond to penicillin or tetracycline therapy
have been effectively treated with ceftriaxone.