Doctors Revision

Infectious Diseases

Typhus Fever

A group of febrile infectious diseases caused by Rickettsia species, transmitted by arthropod vectors (lice, fleas, mites).

Also known as: Epidemic Typhus, Louse-borne Typhus, Murine Typhus, Endemic Typhus, Scrub Typhus

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Referral and warning signs

When to refer

Refer to Hospital (HC4/H) if: Severe illness (confusion, respiratory distress, shock). Complications suspected. Diagnosis uncertain. Patient requires IV antibiotics or close monitoring.

Red flags

  • Altered mental status / Confusion / Coma.
  • Signs of shock.
  • Respiratory distress.
  • Severe rash / Purpura.
  • Signs of end-organ damage (renal failure, myocarditis).

Signs and symptoms

  • General Features (common to types, severity varies):
  • - Abrupt onset of fever, chills.
  • - Severe headache.
  • - Myalgia (muscle pains), arthralgia.
  • - Malaise, profound weakness.
  • - Rash: Typically macular or maculopapular, appears around day 5. Distribution varies:
  • - Epidemic Typhus (Louse-borne): Starts trunk -> spreads peripherally (spares face, palms, soles).
  • - Murine Typhus (Flea-borne): Similar to epidemic but less severe rash, often more sparse.
  • - Scrub Typhus (Mite-borne): Maculopapular rash; often an eschar (dark scab) at mite bite site.
  • - Cough (dry).
  • - Nausea, vomiting.
  • - Confusion, delirium, stupor (especially in severe epidemic typhus - 'typhus nodule' pathology).
  • - Conjunctival injection.
  • - Hepatosplenomegaly, Jaundice (less common).

Risk factors

  • Epidemic Typhus (R. prowazekii): Infestation with body lice (Pediculus humanus corporis). Associated with overcrowding, poor hygiene, poverty, war, famine, refugee camps.
  • Murine Typhus (R. typhi): Contact with rats/rodents and their fleas (Xenopsylla cheopis). Often urban/port areas.
  • Scrub Typhus (Orientia tsutsugamushi): Exposure to infected larval mites (chiggers) in grassy/brushy areas (farmers, hikers in endemic zones - Asia, Pacific, N. Australia).

Diagnosis

Clinical assessment

Suspicion based on acute febrile illness with headache, rash, and relevant epidemiological exposure (lice, fleas/rats, mites/environment). Epidemic typhus often occurs in outbreaks.

Differential diagnosis

  • Typhoid fever.
  • Malaria.
  • Meningococcaemia.
  • Measles / Other viral exanthems.
  • Dengue fever.
  • Leptospirosis.
  • Brucellosis.
  • Relapsing fever.

Investigations

  • Serology: Mainstay of diagnosis. Detection of specific antibodies (IgM/IgG) using IFA (Indirect Fluorescent Antibody) test or ELISA. Requires acute and convalescent samples (4-fold rise in titre).
  • Weil-Felix Test: Older agglutination test using Proteus antigens. Non-specific and unreliable, cross-reacts with other conditions. NOT recommended for definitive diagnosis.
  • PCR on blood or tissue biopsy (eschar): Can provide early diagnosis (specialized labs).
  • FBC (may show thrombocytopenia, normal/low WBC).

Diagnostic criteria

Clinical suspicion + Epidemiological link + Serological confirmation (IFA/ELISA). Weil-Felix is unreliable.

Management

Non-pharmacological management

  • Supportive care (hydration, rest).
  • Fever control (paracetamol).
  • Delousing: For epidemic (louse-borne) typhus - treat patient, clothing, and bedding with appropriate insecticide (e.g., Permethrin, Malathion) to prevent spread.

Pharmacological treatment

  • Antibiotic Therapy (Highly effective if started early): (LOC: HC2+)
  • - First line: Doxycycline 100mg PO Q12H for 5-7 days (or until 3 days after fever resolves). (Child >8y: 2 mg/kg/dose Q12H).
  • - Single dose Doxycycline 200mg PO may be effective for epidemic typhus but higher relapse risk.
  • - Alternative: Chloramphenicol 500mg PO/IV Q6H for 5-7 days. (Child: 15 mg/kg/dose Q6H). Use if doxycycline contraindicated (e.g., young children <8y, pregnancy - weigh risk/benefit). (LOC: HC4)
  • - Azithromycin may be alternative for scrub typhus.

Monitoring

Monitor fever resolution and clinical improvement. Monitor for complications.

Complications

  • Severe disease (esp. epidemic typhus): Pneumonia, Myocarditis, Encephalitis, Renal failure, Gangrene, Vascular collapse, Death.
  • Relapse (Brill-Zinsser disease - reactivation of epidemic typhus years later).

Prevention

  • Epidemic Typhus: Louse control (personal hygiene, washing clothes/bedding, insecticides during outbreaks).
  • Murine Typhus: Rodent and flea control.
  • Scrub Typhus: Avoid mite-infested areas, use insect repellent (DEET), wear protective clothing.
  • Prompt treatment of cases.

Patient education

  • Explanation of the infection and vector (lice, fleas, mites).
  • Importance of completing antibiotic course (Doxycycline highly effective).
  • Delousing measures if epidemic typhus.
  • Prevention strategies relevant to the type of typhus.

Uganda-specific notes

Epidemic (louse-borne) typhus is the type historically reported in Uganda, often linked to conditions favouring louse infestation. Murine/Scrub typhus less recognized but possible. Diagnosis often presumptive based on clinical picture and response to Doxycycline. Weil-Felix test still sometimes used but unreliable.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.1.10

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