Scrub Typhus

April 15, 2009

Guangzhou

Lecturer: Cai Qingxian

E-mail:
cqx200000@yahoo.com.cn
Why is it called scrub typhus?
How does man get scrub typhus?
What’s the most important characteristic?
How to diagnose it?
How to treat it?
 Definition
 An acute, febrile, infectious disease which is caused by

the organism Orientia tsutsugamushi.

 Eschar, regional lyphadenopathy, fever, Maculopapule rash,

leukopenia
Etiology

Epidemiology

Pathogenesis and pathology

Clinical Manifestation

Laboratory Examinations

Diagnosis and Differential Diagnoses

Treatment & Prevention

 Etiology
 First isolated from patient by Japanese in 1930.

 Named O tsutsugamushi in 1995.

 Obligate intracellular Giemsa-positive.

 0.3 ～ 0.6um×0.5 ～ 1.5um, about the size of bacteria

 a cross immunity with proteus OXk

 Sensitive to Chloramphenicol and

tetracycline
Etiology √
Epidemiology

Pathogenesis and pathology

Clinical Manifestation

Laboratory Examinations

Diagnosis and Differential Diagnoses

Treatment & Prevention

 Epidemiology
 Source of infection--------Rat

 Route of transmission-----Trombiculid mites

 Susceptible population----All susceptible

 Epidemic features----------Tsutsugamushi triangle

 Epidemiology
 Infection with one of these serotypes convey lifelong

immunity to only that serotype.

 No cross-protective immunity from other serotypes.

 Epidemiology

•North: northern Japan and far-eastern

Russia
•South: to northern Australia
•West: to Pakistan and Afghanistan

Infected vector live in jungle, scrub and grassland.

 Epidemiology
Adul
Nymp t Eg
h g

Infected
animal Larva Larva Human

Eg Nymp
g h
Adul
t

•Natural cycle-natural focalization

•Natural focus disease-zoonosis-borne diseases
 Epidemiology
In the South, from May to October with a maximal
peak in June-July

In the North, from September to December with a

maximal peak in October
Etiology √
Epidemiology √

Pathogenesis and pathology

Clinical Manifestation

Laboratory Examinations

Diagnosis and Differential Diagnoses

Treatment & Prevention

 Pathogenesis and pathology
Invade Local Spread by Invade
Inoculation
lymph node Blood stream Vascular
endothelium

Papule Enlargement General General organ

maculoppular of local symptoms of hyperaemia.
eschar lymph node intoxication Systemic
ulcer lyphadenopath
Etiology √
Epidemiology √

Pathogenesis and pathology √

Clinical Manifestation

Laboratory Examinations

Diagnosis and Differential Diagnoses

Treatment & Prevention

 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
Specifc features
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.
Escha
r
Ulcer
Escha
r
 Specifc features
Maculopapular rashes
Onset: Appear at the end of the 1st week, lasts
3~7d.

Location: Chest, abdomen, whole trunk, or upper

and lower limbs. rarely involves the face, palms
and soles. .
 Specifc features
　　－ Lymphadenopathy
 Regional lymphadenopathy:

occur at the end of the 1st week.

localize: the draining lymph node around the primary eschar
characterized by tenderness and enlargement
Generalized lymphadenopathy: appears 2-3 days later.
Etiology √
Epidemiology √

Pathogenesis and pathology √

Clinical Manifestation √
Laboratory Examinations

Diagnosis and Differential Diagnoses

Treatment & Prevention

 Laboratory Examinations
Blood routine:
Leukopenia
Normal of WBC,
Elevation with some complications.
Biochemical examination

Injure of liver fuction

 Laboratory Examinations

－－ Serologic examination
Weil-felix: Can be positive as early as 4th day after onset.
>1:160 or increase 4 times during the course.
Easy for operation but poor for specialization.
IFA: Almost the gold standard.
Positive at the end of the 1st week. Last for years.
IIP: Comparable to those from IFA. More available.
 Laboratory Examinations

－－ Pathogenic examination
Culture: Mouse is usual experimental animal.
spleen and liver are stain with Gimsa.

PCR: Detect the orientia DNA

Not routinely available

Etiology √
Epidemiology √

Pathogenesis and pathology √

Clinical Manifestation √
Laboratory Examinations √

Diagnosis and Differential Diagnoses

Treatment & Prevention

 Diagnosis
Epidemiology data ： Visit the endemic area during the
past 3weeks. working, camping or sitting on grass

Clinical manifestation ： Eschar,regional lyphadenopathy,

fever, maculopapular rash, leukopenia, failed therapy with
common antibiotic drug.

Laboratory examination ： Weil-felix reaction with titers

beyond 1:160 or fourfold rise during the course of disease.
 Differential Diagnoses
Epedemic typhus: occur in winter and spring, bite by louse,
Weil-felix with OX19 is positive.
Typhus: Slow onset, persistent high fever, mental apath,
bradycardia, digestive symptoms, rose rash, no eschar, widal
test positive. Blood culture of typhus bacillus is positive.
Leptospirosis: Tenderness of calf muscle, microsopic
demonstration
Etiology √
Epidemiology √

Pathogenesis and pathology √

Clinical Manifestation √
Laboratory Examinations √

Diagnosis and Differential Diagnoses √

Treatment & Prevention

 Treatment
Sensitive antibiotics decrease fatality from 40% to 2%. 　
　　　　
－ General treatment
Enough bed rest, rich vitamin and plenty of water.
Intensive nursing care and prevent complication
 Treatment
　　　　－ Pathogen treatment
Chloramphenicol : 2g per day for adult, or 25mg/kg of bw per
day for children.
Doxycycline: 0.2g per day for adult.
Roxithromycin: 0.6g per day for adult, 2~3mg/kg/d for child
Azithromycin,tetracycline are also sensitive. Half dose for 7-
10 days after defervescence
 Treatment
 Strains resistant to doxycycline and chloramphenicol

 Combination therapy with doxycycline and rifampicin

should be used
 Prevention
Source of infection: Rat
Routes of transmission: Trombiculid mite
Protect succeptibility: Avoid being bitten

No effective vaccine against scrub typhus

 Summary
 Scrub typhus is caused by orientia tsutsugamushi. People acquire
oriential infection when being bitten by larva of trombiculid mite.

 The clinical manifestation can be characterized by fever, eschar,

regional lymphadenopathy, maculopapular rash and leukopenia.
(Typical eschar is a scrub typhus marker.)

 Organism of scrub typhus is sensitive to chloramphenical and

tetracycline.
Thank You !