rickettsiaceae dr.t.v.rao md t dr.t.v.rao md1. zinsser, lice and history in 1935, harvard medical...
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RICKETTSIACEAEDr.T.V.Rao MD
T
Dr.T.V.Rao MD 1
Zinsser, Lice And History
• In 1935, Harvard Medical School physician and researcher Hans Zinsser wrote the brilliant and original Rats, Lice and History in which he traced the effects of vermin-borne disease on armies, cities and populations. From his extensive research on head and body lice, Zinsser stated unequivocally that "the body and head louse carry the infection [typhus] from one human to another.
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Zinsser, Lice And History
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General Characteristics• Small obligate intracellular coccobacilli • Gram negative (poorly), better stained with
Giemsa (Blue)• Have cell wall, bigger than virus but smaller
than bacteria• Have DNA and RNA• Have an ATP transport system that allows
them to use host ATP • Arthropod reservoirs and vectors ( e.g.,
ticks, mites, lice or fleas). • Sensitive to antibiotics
Dr.T.V.Rao MD 4
Category of rickettsia• Genus Rickettsia, Coxiella ,Orientia,Ehrlichia
Bartonella• Species Rickettsia prowazekii (epidemic typhus),
Rickettsia typhi (endemic typhus), Rickettsia rickettsii (spotted fever), Rochalimaea quintana (trench fever), Coxiella burnetii (Q fever)
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Dr.T.V.Rao MD
History• 17th-19th century
– Epidemics in Europe as a result of war, disaster, or in prisoners
• 1909: Transmission by lice• 1917-1925: Russia
– Estimated 25 million cases • End of WWII
– DDT used for control – Vaccine developed
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Historical Photograph on Typhus
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Structure: of Bacteria Similar with Gram negative bacteria Cell wall: outer membrane peptidoglycan lipopolysaccharide (LPS) Microcapsule and polysaccharide
Two antigenically distinct groups: LPS: heat-stable, cross-reactive with somatic antigens of non-motile Proteus species (Weil-Felix test) Outer membrane protein: heat-unstable, species-specific
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Rickettsia• Small gram negative Bacilli• Obligate intracellular pathogens.• Parasites on - Lice, Fleas, Ticks Mites colonizes the Gut. In vertebrates colonizes Vascular
endothelium and Reticuloendothelial system.
T.V.Rao MD
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Five genera in this class cause human diseases:
Rickettsia Bartonella
Coxiella (does NOT cause skin rash) Ehrlichia
Orientia
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Replication
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Five genera in this class cause human diseases:
Rickettsia Bartonella
Coxiella (does NOT cause skin rash) Ehrlichia
Orientia
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Genera•1.Rikettsia,•2.Orientia•3.Ehrcichia
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Typhus Group• Murine typhus (also known as endemic• typhus and flea borne typhus)• – Rickettsia mooseri (typhi)• • Epidemic typhus (also known as Brill-• Zinsser disease and louse borne typhus)• – Rickettsia prowazekii• • Scrub typhus (or Chigger fever)• – Rickettsia tsutsugamushi
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The Others
• Q Fever• – Coxiella burnetii• • Ehrlichiosis• – Ehrlichia canis• – Ehrlichia equi• – Ehrlichia chafeensis• – Several others now identified
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RICKETTSIAL INFECTIONS• Fever, headache, malaise, prostration, skin
rash & Hepatosplenomegaly• Classified into groups:
1. Typhus Group – Epidemic typhus, Murine typhus, Scrub typhus2. Spotted Fever Group – RMSF, Rickettsia pox3. Q Fever4. Trench fever5. Ehrlichiosis
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Disease Organism Vector Reservoir
Rocky Mountain spotted fever
R. Rickettsii Tick Tick, wild rodents
Scrub typhus
R. Tsutsugamushi
Laval Mite (chiggers)
Mites, wild rodents
Epidemic typhus
R. Prowazekii Louse Humans, squirrel fleas, flying squirrels
Murine typhus
R. Thphi Flea Wild rodents
Q fever Coxiella Burnetii
None Cattle, sheep, goats, cats
Diseases Caused by the Rickettsia
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DISEASES RICKETTSIAL AGENT
INSECT VECTOR
MAMMALIAN RESERVOIR
TYPHUS GROUP
a) Epidemic typhus
R. prowazekii Louse Human
b) Murine typhus (Endemic typhus)
R. typhi Flea Rodents
c) Scrub typhus)
R. tsutsugamushi
Mite Rodents
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Rickettsia Prowazekii( Von Prowazekii )
• Humans natural vertebrate hosts• Vector - Human body louse,( Pediculus
humans corporis )• Lice get infected from patients.• Life cycle – get multiplied in gut 1 week• Person – person contact.• Lice bite causes itching and scratching• Enters through respiratory tract / Conjunctivae• Incubation 5- 15 days
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Genus -Rickettsia• Two groups Typhus fevers, Spotted fever.Morphology Rickettsia pleomorphic Coco bacillary, Size 0.3 to 0.6 micron x 0.8 - 2 microns.Gram negative, non motileNon capsulate not stained easily Giemsa and Gimenez staining methods.
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Typhus Fever
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Typhus Fever group
• 1. Epidemic Typhus•2. Recrudescent typhus ( Brill Zinsser’ disease )
•3. Endemic typhusDr.T.V.Rao MD 23
EPIDEMIC TYPHUS (LOUSEBORNE TYPHUS)
• Etiology: R. prowazekii• severe systemic infection &
prostration • more fatal• Brill-Zinsser Disease
recrudescent diseaseDr.T.V.Rao MD 24
Epidemic Typhus - 1• Also known as louse borne typhus because it• is spread human-to-human via the body louse• (which dies of its infection with Rickettsia• prowazekii after about three weeks)• • This is a serious disease consisting of fever,• severe headache, myalgia, and central rash• • Untreated, the mortality ranges from 20-
40%• • Major killer in concentration camps of WW IIDr.T.V.Rao MD 25
Cultivation• Needs cell culture lines• Grows in the Cytoplasm • Grows at 32 to 350 c• Grows in yolk sac of developing
chick embryo• Grows in mouse fibroblasts,
Hela,Hep2
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Cultivation• Rickettsia can not be grown in
bacteriological media, Obligate intracellular pathogens.
• In continuous cell lines, Guinea pig, Mice
• Infect the endothelial cells of vascular system.
• Can synthesize ATPDr.T.V.Rao MD 27
Life Cycle of Rickettsia
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Replication
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Dr.T.V.Rao MD
Transmission• Human body louse
– Pediculus humanus corporis– Infective for 2-3 days– Infection acquired by feeding on infected
person– Excrete R. prowazekii in feces at
time of feeding– Lice die within 2 weeks
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Dr.T.V.Rao MD
Transmission• Louse feces rubbed into bite or
superficial abrasions• Inhalation of feces • Sylvatic typhus
– Flying squirrel– 30 human cases in eastern and central U.S.
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PATHOLOGYMultiply in endothelial cells of small blood vessels
Vasculitis
(skin – rashes;other organs – DIC & vascular occlusion)
Swollen & necrotic
Thrombosis of the vessels
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Antigenic structure
• Species differ with Group specific antigens.
• Sharing of antigens between Rickettsia and Proteus basis of Weil – Felix Heterophile agglutination Test.
• Used Proteus strains 0X 19, OX2 OXK
T.V.Rao.MD
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Epidemic TyphusAlso called as Louse borne Typhus Classical TyphusRussia Eastern Europe Devastating Epidemics
in warsNapoleons retreatRussia 3 million deaths 1917 – 1921India - Kashmir
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R. Prowazekii
Louse
Human Human
Louse
Epidemic typhus
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R. Typhi Rodent Flea Rat Tick Flea Human
Rodent
Murine typhus (much milder than epidemic
typhus)Dr.T.V.Rao MD 36
Lesions in Epidemic Typhus
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Rickettsia Prowazekii( Von Prowazekii )
• Humans - natural vertebrate hosts• Vector - Human body louse,( Pediculus
humans corporis )• Lice get infected from patients.• Life cycle – get multiplied in gut 1 week• Person – person contact.• Lice bite causes itching and scratching• Enters through respiratory tract / Conjunctivae• Incubation 5- 15 days
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Pediculus humanus corporis is the Vector
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Dr.T.V.Rao MD
Clinical Symptoms• Incubation: 7-14 days• High fever, chills, headache, cough, severe
myalgia– May lead to coma
• Macular eruption – 5-6 days after onset– Initially on upper trunk, spreads to entire body
• Except face, palms and soles of feet
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Clinical Features• Fever, chills• Rash on 4 th day Spread from Trunk to Limbs Not face palms,
sole.• In 2 nd week may into stuporous,delirious
state May reach 40 % fatality• Bacteria remain latent in Lymphoid tissue,
cloudy state. Because of called as Typhus• May cause Recrudescent Typhus ( Called as Brill Zinser Disease.)
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Dr.T.V.Rao MD
Brill-Zinsser Disease• Occurs years after primary attack
– Person previously affected or lived in endemic area
– Viable retained organisms reactivated– Milder symptoms
• Febrile phase 7-10 days– Rash often absent– Low mortality rate
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Brill- Zinser DiseaseRecrudescent typhus fever
• Earlier recovery from typhus fever• Latency of the organism in lymphoid
tissue• Reactivation leads to recrudescence.• Even louse get infected from
patients.• Clinically similar but mild.
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Pattern of Temperature chart in Typhus Fever
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Endemic TyphusR.mooseri
• Also called as Murine or Flea borne typhus• From Rats -Transmitted by Rat flea• Rickettsia multiplies in Gut and shed in feces• Humans bitten by infected Rat flees.• Saliva or feces rubbed on bitten area, may
lead to infection.• R.typhi R. Prowazekii similar, Biological and
Immunological tests.
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Clinical features• Mild disease • Rat act as reservoir.• Vector – Rat flea -Xenopsylla – cheopsis• Rat flea bites rat• Multiplies in the gut of the rat• Fleas un affted.• Man gets infected accidentally• Mexico Kashmir - china T.V.Rao MD
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Experiments on Animals Neill-Mooser Reaction
• Male guinea pig inoculated intra peritioneally with blood of patients, or isolates of S.typhi produce – Fever, and scrotal swelling, enlarged tests, and cannot be pushed back.-due inflammation and adhesions between layers of Tunica vagina
• Test positive in R.typhi
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Dr.T.V.Rao MD
Treatment• Chloramphenicol • Tetracycline
–Doxycycline 200mg• Response within 48 hrs. usually• Vaccine
– Developed after World War II – Not commercially available
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Spotted Fever Group• Rickets 1906• Rickettsia of this
group, multiplies in Nucleus and Cytoplasm
• Ticks transmit
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DISEASES RICKETTSIAL AGENT
INSECT VECTOR
MAMMALIAN RESERVOIR
SPOTTED FEVER GROUP
a) Indian tick typhus
R. conorii Tick Rodent, Dog
b) Rocky mountain spotted fever
R. rickettsii Tick Rodents, Dogs
c) Rickettsial pox
R. akari Mite Mice
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Tick Typhus• R.rickettsii Rock mountain spotted
fever• R.siberica• R.conori• R.australis. Ticks transmits bite- Trans ovarian
spreadT.V.Rao MD Dr.T.V.Rao MD 51
Rocky Mountain spotted fever
• Ticks in North / South America• Tick type R.conori.• Rickettsial Pox Resembles like chicken pox R. akari by mite Mouse reservoir host.
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Ticks acts as vectors and reservoirs of Infection
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Rocky Mountain spotted fever
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Rocky mountain spotted fever
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Rocky Mountain spotted fever
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Rocky Mountain spotted fever
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Genus - Ehrlichia• Small – Gram negative , obligate intracellular
pathogens,• Can infected Phagocytic cells.• Called as Glandular fever• Ehrlichia sennetsu causative agent.• Cause atypical lymphocytosis• No arthropod vector,• Eating fish infected with flukes infected by
these bacteria.Dr.T.V.Rao MD 59
Monocytic Ehrlichiosis• Caused by Ixodid ticks, E.chaffensis.• Deer, cattle, Sheep reservoirs• Leucopenia Thrombocytopenia• Liver is involved.• Doxycycline effective in Ehrlichosis• Human granulocytic Ehrlichosis E.equi.
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Laboratory Diagnosis of Rickettsial diseases
• Isolation• Serology• Isolations can be dangerous if not
well protected.• R.typhi R.conori, R.akari causes
tunica reaction• R.prowazeki only fever
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Diagnosis and Prevention Microscopy Serological Test (Weil-Felix reaction, ELISA, IF, PCR) Breaking the infection chain ( controlling and killing the intermediate hosts and reservoir hosts) Inactivated vaccine has protective effect Chloromycetin, tetracycline are helpful for therapy, Sulphonamides are not administered (increasing the penetrating of the vessel).
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Laboratory Diagnosis
• Tissue cultures
• In Vero cells,• MRC – 5
cells.
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SerologyWeil – Felix Test
Test based on principle of Hetrophile agglutination tests
• Non motile strains of Proteus are selected.• OX19,OX2,OXK• Sharing alkali stable carbohydrate antigen by
some Rickettsia X certain strains of Proteus vulgaris OX19,OX2, and Proteus mirabilis OXK.
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Laboratory Diagnosis• Weil – Felix is simple to perform but of
Historical importance• Other tests Complement fixation tests, Agglutination, Passive hem agglutination.
PCRDr.T.V.Rao MD 65
DISEASE WEIL-FELIX
OX19 OX2 OXK
Epidemic typhus ++ +/- -
Endemic typhus ++ - -
Scrub typhus - - ++
RMSF + + -
Rickettsial pox - - -
Q fever - - -
Trench fever ? ? ?Dr.T.V.Rao MD 66
Different Methods of Diagnosis
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1. Giemsa Staining Technique:- utilizes peritoneal scrapings of infected mice.
Older Techniques:to detect O. tsutsugamushi
2. Weil-Felix Proteus Agglutination Test:-is a test which relies on the fact that Rickettsia and Proteus OX strains have common antigens. :-is a test for the presence & type of rickettsial disease based on the agglutination of X-strain Proteus vulgaris with suspected Rickettsia in a patient’s blood serum sample.:-is commonly used in hospitals & clinics:-This test is now being replaced by a complement-fixation test.
Weil-Felix Proteus Agglutination TestDr.T.V.Rao MD 68
2. Indirect Immuno-Peroxidase (IIP)
Control Infected
IIP= is a modification of IFA technique that replaces the fluorochrome with peroxidase.
Slide is observed using a bright-field microscope.
Staining reaction is positive when O. tsutsugamushi particles stain light brown.
Immunological Assays
Newer Techniques:to detect O. tsutsugamushi
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4. Enzyme-linked Immuno-Sorbant Assay (ELISA)
1. Add antigens
Ag-coated well
3. Add anti-Ab2. Add mouse serum
Ag-Ab complex
Optical Density
(OD) Reading
4. Add enzyme-substrate mix
5.Let colorize
ELISA test is a technique for detecting & measuring antigen or antibody. :-It is one of the most reliable techniques to detect antibody
against scrub typhus infection.:-Its procedure is the principal for development of recent
rapid diagnostic kits.:-This technique is widely used in laboratories & hospitals.
Immunological Assays
Newer Techniques:to detect O. tsutsugamushi
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Prophylaxis
•Control of vectors.•Destruction animal reservoirs,
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Scrub Typhus• Scrub typhus caused by• Mild to fatal• 6-18 days after bite of Mite• An Escher is formed at the site of bite• With enlargement of Lymph nodes,
Interstitial pneumonitis ,lymphadenopathy,spleenomegaly Encephalitis, Respiratory failure, circulatory failure
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SCRUB TYPHUSEtiology: Orientia tsutsugamushi• resembles Epidemic typhus except for
the ESCHAR • generalized lymphadenopathy &
lymphocytosis• cardiac & cerebral involvement may be
severe
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Epidemiology
Source of infection--------Rat
Route of transmission-----Trombiculid mites
Susceptible population----All susceptible
Epidemic features----------Tsutsugamushi
triangle
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Epidemiology
Infectedanimal
Egg
Larva
Egg
Larva
Nymph
NymphAdul
t
Adult
Human
• Natural cycle-natural focalization • Natural focus disease-zoonosis-borne diseases
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An important vector-borne disease, first described in 1899 in Japan.
During World War II, this disease killed thousands of soldiers who were stationed in rural or jungle areas of the Pacific theatre.
Scrub Typhus
The disease occurred and threatened people throughout Asia & Australia. The range stretches from the Far-east to the Middle-east (from Japan and Korea, Southeast Asia, Pakistan,
India, to Arab countries and Turkey). There are approx. 1 million cases each year world-wide, & over 1 billion people at risk.
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R. Tsutsugamushi Eggs Adult stage Nymphal stage
Nymphal stage Adult stage Eggs
Rats Nymphal stage Nymphal stage Human
Scrub typhus
Chigger
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Scrub typhus
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Pathogen: Orientia tsutsugamushi
Rickettsial bacteria
Vector: Leptotrombidium
Chigger-Mite
An acute febrile, rickettsial disease caused by a gram-negative, rod-shaped (cocco-bacillus) bacterium, known as Orientia (Rickettsia) tsutsugamushi.
Scrub Typhus: A Rickettsial Disease
O. tsutsugamushi is transmitted to vertebrate hosts (rodents-primary host & humans-secondary or accidental host) by the bite of larval mites (chiggers) of the genus Leptotrombidium, e. g. L. deliense, L. dimphalum, etc.
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Pathogenesis and pathology
InoculationInvade Local lymph node
Spread byBlood stream
Invade Vascular endothelium
Papule maculoppularescharulcer
Enlargement of locallymph node
General symptoms of intoxication
General organ hyperaemia.Systemic lyphadenopath
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R. Tsutsugamushi Eggs Adult stage Nymphal stage
Nymphal stage Adult stage Eggs
Rats Nymphal stage Nymphal stage Human
Scrub typhus
Chigger
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Scrub typhus
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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 Dr.T.V.Rao MD 83
Specific 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.
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Ricketisial pox• Transmitted by mites,• Similar other spotted fever• Head ache ,fever• Escher at the site of bite by mite.• Maculopapular rash, can be
vesicular,• Fever lasts for 1 week
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Skin Lesion Mite
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Q Fever• Occurs in veterinarians, ranchers, and animal
researchers who are in contact with infected placenta from sheep, cattle, or goats (no arthropod vector for C. burnetii)
• • Incubation period is 10-28 days• • Fever and headache are common; 50% will
develop pneumonia after inhaling the organism; hepatitis & endocarditis are rare
• • Specific serology establishes the diagnosis• • Bioterrorist threat?Dr.T.V.Rao MD 87
Coxiella Burnetii • Q fever（ query fever ）• Self-limiting flu-like syndrome with high
fever (40 )℃• Primary reservoirs are wild (cattle,
sheep, goat etc.)• Non-cross reactive antigen with non-
motile Proteus (Weil-Felix reaction negative)
• Live in macrophages of vertebrate hostDr.T.V.Rao MD 88
Genus – CoxiellaQ Fever
• Etiological agent ?• Small in size called Coxiella burnetti• Ixodid tick spread the disease• Domestic live stock get infected.• Coxiella abundant in Tick feces,• Survive in dried feces, Milk too infective• Cause Human infection.
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Coxiella burnetti
• Q fever• Cow and sheep• tick• High resistance
abrupt onset ,fever,headache,chills,myalgia,granulomatous hepatitis
chronic diaease with subacute onset ,endocarditis,hepatic dysfunction
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Q - Fever
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Q Fever• Wool hides, Meat, Milk• Enters through abrasions• System infection through Intestine,
pulmonary,• All organs are involved• Can cause serious infection, Hepatitis and meningitis, May last for 2 – 3 years as chronic conditionInfects Monocytes and Macrophages,Dr.T.V.Rao MD 92
Q Fever
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Pasteurization of Milk Which method is better ?
• Pasteurization by holders method not effective
• Flash method effective.
• Phase variation applicable
Phase I and Phase II
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Clinical features
• Present with head ache, chills, Pneumonia
• Endocarditis, Meningitis, Encephalitis
• Can cause latent infections.
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Q Fever
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Laboratory Diagnosis
• Indirect Immunofluorescence methods
• Polymerase chain reaction,• Genus specific applications in
progress.• Isolation of the organism is
dangerous. Dr.T.V.Rao MD 97
Treatment• Doxycycline is effective.• Tetracycline are highly
effective• Nursing care• May need blood transfusion.
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Ehrlichiosis• Ehrlichia chaffeensis most common
– Human monocytotropic ehrlichiosis (HME)
• E. ewingii has also been identified• Transmitted by lone star tick (Amblyomma
americanum)• White-tailed deer major host for tick
species and natural reservoir for bacteria• Infections in coyotes, dogs, and goats
have been documented
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Proposed life cycle for the agent of Human Granulocytic Ehrlichiosis
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Ehrlichiosis Clinical Information
• Onset occurs 5–10 days after tick bite• Infects leukocytes
– E. chaffeensis prefers monoctyes– E. ewingii prefers granuloctyes– Morulae can be identified
• Rash observed ~33% of patients with HME– Vary from petechial or maculopapular to diffuse
erythema– Occurs later in disease
• Rash rarely seen with E. ewingii infections101
E. Chaffeensis Laboratory Criteria
• Confirmed– Fourfold change in IgG by IFA in paired serum samples– Detection of DNA by PCR– Demonstration of antigen by IHC in biopsy or autopys
sample– Isolation of bacteria by cell culture
• Supportive– Elevated IgG or IgM by IFA, ELISA, dot-ELISA or other
formats– Morulae identification by blood smear microscopic
examination
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Bartonella• Gram – ve bacilli/Anthropoids• B.bacilliform, B.quintana,B henselae• Bartonella bacilliform• Also called as Oroya fever,• A Medical student – Peruvian Daniel Carrion Credited for isolation. Called as Carrions Disease
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Bacterial Morphology
• B.bacilliform• Pleomorphic
gram negative bacteria
• Carries a tuft of polar flagella.
T.V.Rao MD
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Clinical features• Progressive Anemia,• Bacterial invasion of
Erythrocytes• Carries high mortality
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Bartonella ( Rochalimia )• Bartonella Quintana• Called as trench fever• Called as five day fever.• Grows in cell free culture media.• Chronic/Latent infections• Infection may lost > 20 yearsT.V.Rao MD
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Bartonella Henselae • Cat scratch disease (CSD)• Weil-Felix reaction negative• Infection by cats or dogs• “Parinaud” Eye-Lymph node
syndrome The eye looks red, irritated, and
painful, similar to conjunctivitis.
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Bartonella henselae• Also called s cat scratch disease• Caused by B.henselae• Needs lymph node biopsy• Staining sections with Warthim
Starry sating• Associated in AIDS patients.
T.V.Rao MD
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Prevention• Use of repellents in endemic areas• • Protective clothing in endemic areas• • Careful inspection & quick removal of ticks• • Useful vaccine for RMSF is available for high
risk groups such as forest rangers that work in endemic areas
• • Weekly doxycycline may prevent scrub typhus infection in field workers
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• Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in
the Developing World • Email
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