Rickettsiosis (overview) A75-79

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

ache noire; Bush spot fever; Rock Mountain Fever American; Scrub typhus group; Spotted Fever; Tick-bite fever, Spotted fever Group; Typhus group Rickettsiosis

Definition
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Infectious diseases caused by rickettsia (bacteria-like pleomorphic cocci), transmitted by various arthropods (e.g. ticks, lice, fleas) and occurring worldwide, see Table 1.

Etiopathogenesis
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Some rickettsiosis is transmitted by ticks, mites or mite larvae, others by lice or fleas (see table).

In the case of tick-borne infections, the pathogen is transmitted to humans with the bite via the salivary glands.

In the case of rickettsialpox caused by lice or fleas, the pathogen is found in the faeces of the animals and enters skin lesions, for example via scratching.

In the case of ticks or mite-transmitted infections, a primary lesion (eschar) and lymphadenitis occur after inoculation of the pathogen.

Clinical features
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The incubation period is 1 to 2 weeks. With appropriate exposure prophylaxis, rickettsiosis should be considered in the differential diagnosis of fever, eschar and exanthema. Clinically, rickettsialgiosis is manifested by sometimes high fever, myalgia, arthralgia, exanthema and swelling of the lymph nodes. Typical complications are thromboses and thrombophilia, which is manifested by petechiae and gastrointestinal bleeding. Other complications are encephalitis, myocarditis, nephritis, haemorrhages and gangrene. Rickettsiosis must also be ruled out in cases of fever of uncertain origin (FUO).

Laboratory
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Early detection by the Weil-Felix reaction. Today, more specific serological tests such as molecular biological techniques are available to identify the pathogens from blood and tissue. Detection of IgM and IgG antibodies by ELISA, immune peroxidase techniques.

Therapy
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Remember! Start therapy already with clinical suspicion of rickettsialpox (serology takes 2 weeks)!

External therapy
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Control of the arthropods that have transmitted the disease, such as lice, ticks, etc.; see pediculosis below

Internal therapy
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Drug of the 1st choice is tetracycline p.o. (e.g. Tetracycline Wolff 500) 250 mg every 6 hours (or 25-50 mg/kg bw/day) for 8-12 days, approx. 5 days beyond fever and appearance. Doxycycline (e.g. Doxy-Wolff) is also highly effective: 100 mg p.o. 2 times/day for 8-10 days. Alternatively: Ciprofloxacin 2 times/day 500-750 mg p.o. or 2 times/day 100-200 mg i.v.

In the most severe cases with beginning haematogenous spread or generalization, glucocorticoids i.v. to absorb the toxic side symptoms caused by the decomposition of the bacteria. Prednisolone (e.g. Decortin H) 100-125 mg/day for 2-3 days.

Notice! Especially in cases of classic typhus and Rocky Mountains Spotted Fever, life-threatening situations can occur which require intensive medical care.

Progression/forecast
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Healing to complete remission with antibiotic therapy appropriate to the stage of the disease. Nevertheless, the lethality rate under adequate treatment is about 1-2%.

Tables
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Classification of rickettsialpox:

Disease

Pathogen

Transmitter

Occurrence

Skin and other symptoms

Epidemic ty phus (classical typhus)

R. prowazekii

Lice (Pediculosis corporis)

Epidemic, ubiquitous

4th-6th day of fever Exanthema on the trunk (axilla, upper body), spreading with ecchymosis, vasculitis to gangrene. High fever, delirium, severe course of the disease.

Endemic typhus

(Murine typhus, rat typhoid)

R. typhi (moseri)

Lice, rat fleas

Endemic in subtropics and tropics; man is a false host (alternate host)

Rather discreet early hexanthemum, skin symptoms otherwise as above. Conjunctivitis, dry cough, fever.

Rickettsialpox

R. acarii

Mice and rat mites

America, South Africa, Russia, Korea

1-1.5 cm large papulovesicle at the site of the puncture with regional lymphadenopathy, shortly followed by maculopapular and vesicular, varicelliform exanthema on the 3rd - 5th day of fever.

Tick fever (Mediterranean, North Asian, African, Australian)

R. conorii, R. australis

Ticks

Europe, Africa, India, South and East Asia, Australia

At the site of the puncture possibly small ulcer, possibly with blackish crusts (tache noir) and regional lymphadenopathy. On the 4th day of fever generalized maculopapular exanthema. Sudden fever.

Q fever

R. burneti

Ticks (in wild animals); from person to person: aerogenic

Ubiquitous

At the site of the puncture possibly small ulcer, possibly with blackish crusts (tache noir) and regional lymphadenopathy. Sudden fever, severe feeling of illness, conjunctivitis, cough, atypical pneumonia.

Tsutsugamushi fever (bush spotted fever)

R. tsutsugamushi

Running mites (rats, field mice, forest and field rodents)

South and East Asia, North Australia, Islands in the Indian and Pacific Ocean

1-1.5 cm large papulovesicle or ulcer at the site of the puncture with regional lymphadenopathy. On 5-8 fever day generalized maculopapular exanthema. Conjunctivitis, sudden fever, generalized swelling of the lymph nodes.

Rocky Mountain spotted fever

R. rickettsii

Ticks (Ixodes dammini)

America

A small ulcer may be present at the site of the puncture, possibly with blackish crusts (tache noir) and regional lymphadenopathy. On the 4th-5th day of fever petechial or haemorrhagic exanthema (more rarely also ulcerations) on the periphery (hands, feet, ankles, neck, face). Sudden fever, chills, headache, muscle or joint pain. U.U. Delirium, coma, severe course of disease.

Note(s)
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The pathogens were named after the pathologist Howard Taylor Ricketts (1871-1910), who, among other things, researched the Rocky Mountain spotted fever, whose pathogen he was able to detect in the blood of infected people (vector = tick species). In 1909 he travelled to Mexico City with the aim of researching typhoid fever. In the process he became infected with Rickettsia and died in 1910.

Case report(s)
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Infection by Reckiettsia conori:

3 days after a holiday stay in South Africa a 46 years old patient fell ill with flu-like symptoms with fatigue, medium fever and catarrhal symptoms. At the same time a rather discreet, not itchy, bright red, truncated, maculo-papular (0.1-0.2 cm large efflorescences) exanthema developed.

Findings: A 0.5 cm large ulcer with blackish crusts (tache noir) was found on the extensor lower leg. A slightly painful regional lymphadenopathy was striking. The blood count showed clear leukopenia (2,200/ul) and monocytosis (15.5%). On admission no positive rickettsial serology. Only 5 weeks later clearer IgG-titer (1:320) on R. conori.

Therapy: Doxycycline 2 times/day 100 mg p.o. for 10 days. Immediate clinical improvement. Ulcer healed under usual wound treatment after 6 weeks.

Literature
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  1. Baumann D et al (2003) Fever after a tick bite: clinical manifestations and diagnosis of acute tick bite-associated infections in northeastern Switzerland. Dtsch Med Weekly 128: 1042-1047
  2. Diaz IA et al (2003) Rickettsiosis caused by Rickettsia conorii in Uruguay. Ann N Y Acad Sci 990: 264-266
  3. Lee HC et al (2002) Clinical manifestations and complications of rickettsiosis in southern Taiwan. J Formos Med Assoc 101: 385-392
  4. Murray KO et al (2017) Typhoid Group Rickettsiosis, Texas, USA, 2003-2013 Emerg Infect Dis 23:645-648 .
  5. Orfanos CE et Garbe C: Rare infections of the skin. In: Therapy of skin diseases. Orfanos CE (Ed.). Springer-Verlag Berlin Heidelberg New York. S. 173–176
  6. Oteo JA et al (2003) Epidemiological and clinical differences among Rickettsia slovaca rickettsiosis and other tick-borne diseases in Spain. Ann N Y Acad Sci 990: 355-356
  7. Raoult D et al (2002) Spotless rickettsiosis caused by Rickettsia slovaca and associated with Dermacentor ticks. Clin Infect Dis 34: 1331-1336
  8. Toutous-Trellu L et al (2003) African tick bite fever: not a spotless rickettsiosis! J Am Acad Dermatol 48: S18-19

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020