Typhus fevers
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Many species of Rickettsia can cause illnesses in humans (Table 4-18). The term “rickettsiae” conventionally embraces a polyphyletic group of microorganisms in the class Proteobacteria, comprising species belonging to the genera Rickettsia, Orientia, Ehrlichia, Anaplasma, Neo-rickettsia, Coxiella, and Bartonella. These agents are usually not transmissible directly from person to person except by blood transfusion or organ transplantation, although sexual and placental transmission has been proposed for Coxiella. Transmission generally occurs via an infected arthropod vector or through exposure to an infected animal reservoir host. However, sennetsu fever is acquired following consumption of raw fish products. The clinical severity and duration of illnesses associated with different rickettsial infections vary considerably, even within a given antigenic group. Rickettsioses range in severity from diseases that are usually relatively mild (rickettsialpox, cat scratch disease, and African tick-bite fever) to those that can be life-threatening (epidemic and murine typhus, Rocky Mountain spotted fever, scrub typhus and Oroya fever), and they vary in duration from those that can be self-limiting to chronic (Q fever and bartonelloses) or recrudescent (Brill-Zinsser disease). Most patients with rickettsial infections recover with timely use of appropriate antibiotic therapy.
Travelers may be at risk for exposure to agents of rickettsial diseases if they engage in occupational or recreational activities which bring them into contact with habitats that support the vectors or animal reservoir species associated with these pathogens.
Epidemic Typhus and Trench Fever
Epidemic typhus and trench fever, which are caused by Rickettsia prowazkeii and Bartonella quintanta, respectively, are transmitted from one person to another by the human body louse (3-4). Contemporary outbreaks of both diseases are rare in most developed countries and generally occur only in communities and populations in which body louse infestations are frequent, especially during the colder months when louse-infested clothing is not laundered. Foci of trench fever have also been recognized among homeless populations in urban centers of industrialized countries. Travelers who are not at risk of exposure to body lice or to persons with lice are unlikely to acquire these illnesses. However, health-care workers who care for these patients may be at risk for acquiring louse-borne illnesses through inhalation or inoculation of infectious louse feces into the skin or conjunctiva. In the eastern United States, campers, inhabitants of wooded areas, and wildlife workers can acquire sylvatic epidemic typhus if they come in close contact with flying squirrels, their ectoparasites, or their nests, which can be made in houses, cabins, and tree-holes.
Murine Typhus and Cat-Flea Rickettsiosis
Murine typhus, which is caused by infection with Rickettsia typhi, is transmitted to humans by rat fleas, particularly during exposure in rat-infested buildings (3). Flea-infested rats can be found throughout the year in humid tropical environments, especially in harbor or riverine environments. In temperate regions, they are most common during the warm summer months. Similarly, cat-flea rickettsiosis, which is caused by infection with Rickettsia felis, occurs worldwide from exposure to flea-infested domestic cats and dogs, as well as peridomestic animals, and is responsible for a murine typhus-like febrile disease in humans.
Scrub Typhus
Mites (“chiggers”) transmit Orientia tsutsugamushi, the agent of scrub typhus, to humans (5). These mites occur year-round in a large area from South Asia to Australia and in much of East Asia, including Japan, China, Korea, Maritime Provinces and Sakhalin Island of Russia, and Tajikistan. Their prevalence, however, fluctuates with temperature and rainfall. Infection may occur on coral atolls in both the Indian and Pacific Oceans, in rice paddies and along canals and fields, on oil palm plantations, in tropical to desert climates and in elevated river valleys. Humans typically encounter the arthropod vector of scrub typhus in recently disturbed habitat (e.g., forest clearings) or other persisting mite foci infested with rats and other rodents.
Tick-Borne Rickettsioses
Tick-borne rickettsial diseases are most common in temperate and subtropical regions (6). These diseases include numerous well-known classical spotted fever rickettsioses (7) and an expanding group of newly recognized diseases. In general, peak transmission of tick-borne rickettsial pathogens occurs during spring and summer months. Travelers who participate in outdoor activities in grassy or wooded areas (e.g., trekking, camping, or going on safari) may be at risk for acquiring tick-borne illnesses, including those caused by Rickettsia, Anaplasma, and Ehrlichia species.
Rickettsialpox
Rickettsialpox is generally an urban, mite-vectored disease associated with R. akari-infected house mice, although feral rodent-mite reservoirs also have been described (3). Outbreaks of this illness have occurred shortly after rodent extermination programs or natural viral infections that depleted rodent populations and caused the mites to seek new hosts. R. akari-infected rodents have been found in urban centers in the former Soviet Union, South Africa, Korea, Croatia, and the United States. Travelers may be at risk for exposure to rodent mites when staying in old urban hostels and cabins.