1. Scrub Typhus April 15, 2009 Guangzhou Lecturer: Cai Qingxian E-mail: cqx200000@yahoo.com.cn

2. 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?

3. Definition  An acute, febrile, infectious disease which is caused by the organism Orientia tsutsugamushi.  Eschar, regional lyphadenopathy, fever, Maculopapule rash, leukopenia

4.  Etiology  Epidemiology  Pathogenesis and pathology  Clinical Manifestation  Laboratory Examinations  Diagnosis and Differential Diagnoses  Treatment & Prevention

5. 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

6.  Etiology √  Epidemiology  Pathogenesis and pathology  Clinical Manifestation  Laboratory Examinations  Diagnosis and Differential Diagnoses  Treatment & Prevention

7. Epidemiology Source of infection--------Rat Route of transmission-----Trombiculid mites Susceptible population----All susceptible Epidemic features----------Tsutsugamushi triangle

8. Epidemiology Infection with one of these serotypes convey lifelong immunity to only that serotype. No cross-protective immunity from other serotypes.

9. 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.

10. Epidemiology Infected animal Eg g Larva Eg g Larva Nymp h Adul t Human Natural cycle-natural focalizationnatural focalization Natural focus disease-zoonosis-borne diseaseszoonosis-borne diseases

11. 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

12.  Etiology √  Epidemiology √  Pathogenesis and pathology  Clinical Manifestation  Laboratory Examinations  Diagnosis and Differential Diagnoses  Treatment & Prevention

13. Pathogenesis and pathology Inoculation Invade Local lymph node Spread by Blood stream Invade Vascular endothelium Papule maculoppular eschar ulcer Enlargement of local lymph node General symptoms of intoxication General organ hyperaemia. Systemic lyphadenopath

14.  Etiology √  Epidemiology √  Pathogenesis and pathology √  Clinical Manifestation  Laboratory Examinations  Diagnosis and Differential Diagnoses  Treatment & Prevention

15. 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

16. 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.

17. Eschar

18. Ulcer

19. Eschar

20. 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..

21. 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.

22.  Etiology √  Epidemiology √  Pathogenesis and pathology √  Clinical Manifestation √  Laboratory Examinations  Diagnosis and Differential Diagnoses  Treatment & Prevention

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

24. 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.

25. 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

26.  Etiology √  Epidemiology √  Pathogenesis and pathology √  Clinical Manifestation √  Laboratory Examinations √  Diagnosis and Differential Diagnoses  Treatment & Prevention

27. 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.

28. 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

29.  Etiology √  Epidemiology √  Pathogenesis and pathology √  Clinical Manifestation √  Laboratory Examinations √  Diagnosis and Differential Diagnoses √  Treatment & Prevention

30. 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

31. 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

32. Treatment  Strains resistant to doxycycline and chloramphenicol  Combination therapy with doxycycline and rifampicin should be used

33. Prevention Source of infection: Rat Routes of transmission: Trombiculid mite Protect succeptibility: Avoid being bitten No effective vaccine against scrub typhus

34. 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.

35. Thank You !