RICKETTSIAL%20INFECTION:%20DIVERSITIES,%20DILEMMA%20AND%20CHALLENGES - PowerPoint PPT Presentation

About This Presentation
Title:

RICKETTSIAL%20INFECTION:%20DIVERSITIES,%20DILEMMA%20AND%20CHALLENGES

Description:

Title: EECP-Role in management of heart failure Author: User Last modified by: User Created Date: 2/20/2013 7:18:22 AM Document presentation format – PowerPoint PPT presentation

Number of Views:257
Avg rating:3.0/5.0
Slides: 61
Provided by: medic122
Category:

less

Transcript and Presenter's Notes

Title: RICKETTSIAL%20INFECTION:%20DIVERSITIES,%20DILEMMA%20AND%20CHALLENGES


1
RICKETTSIAL INFECTION DIVERSITIES, DILEMMA AND
CHALLENGES
  • Dr. Moniruzzaman Ahmed
  • Associate Professor, Dept of Medicine
  • MAG Osmani Medical College, Sylhet

2
  • Rickettsial diseases - 4 distinct genera
  • Rickettsia, Orientia, Ehrlichia (Ehrlichia
    chaffeensis, the agent of human monocytic
    ecrlichiosis) and Anaplasma (Anaplasma
    phagocytophilium, the agent of human granulocytic
    anaplasmosis)
  • Diseases caused by Rickettsia and Orientia
    species often reffered to as rickettsioses
  • Coxiella burnetii, the agent of Q fever and
    Bartonella spp. were recently removed from the
    order Rickettsiales

Parola P, Paddock CD, Raoult D. Tick-borne
rickettsioses around the world emerging diseases
challenging old concepts. Clin Microbiol Rev.
20051871956
3
RICKETTSIAL SPECIES-BIOVARS
  • SPOTTED FEVER GROUP RICKETTSIOSES (SFGR) / TICK
    BORN RICKETTSIAL DISEASE (TBRD)
  • TYPHUS GROUP (TG)
  • SCRUB TYPHUS GROUP

4
RICKETTSIA- BIOLOGY
  • Small obligate intracellular parasites
  • Gram-negative bacteria
  • Stain poorly with Gram stain (Giemsa)
  • Energy parasites but not obligate, have
    capacity to make ATP
  • Parasite of arthropods fleas, lice, ticks and
    mites
  • Reservoirs - animals, insects and humans

5
The genus Rickettsia is named after Howard Taylor
Ricketts (18711910), who studied Rocky Mountain
spotted fever in the Bitterroot Valley
From 1906 to 1910, Howard T Ricketts isolated the
pathogen and showed that it circulated among
ticks and mammals in the wild. Tragically, this
talented rickettsiologist was affected by
epidemic typhus and died in 1910, at the age of
39 years.
6
TRANSMISSION, PATHOGENESIS PATHOPHYSIOLOGY
7
SPOTTED FEVER GROUP RICKETTSIOSES (SFGR)/ TICK
BORN RICKETTSIAL DISEASE(TBRD)
8
PROTYPICAL DISEASES
(SFGR)/(TBRD)
ORGANISM DISEASE DISTRIBUTION
R.Rickettsii Rocky Mountain spotted fever Western hemisphere
R. akari Rickettsialpox USA, former Soviet Union
R. conorii Boutonneuse fever, Kenya tick typhus, Israeli tick typhus, Mediterranean spotted fever(MSF), Indian tick typhus, Astrakhan tick typhus, Marseilles fever Mediterranean countries, Africa, India, Southwest Asia
R. sibirica Siberian tick typhus Siberia, Mongolia, northern China
R. australia Australian tick typhus Australia
R. japonica Oriental spotted fever Japan
9
GEOGRAPHICAL DISTRIBUTION
Update on Tick-Borne Rickettsioses around the
World a GeographicApproachPhilippe Parola,a
Christopher D. Paddock,b Cristina Socolovschi,a
Marcelo B. Labruna,c Oleg Mediannikov,a Tahar
Kernif,dMohammad Yazid Abdad,e John Stenos,e
Idir Bitam,f Pierre-Edouard Fournier,a Didier
RaoultaOctober 2013 Volume 26 Number 4 Clinical
Microbiology Reviews p. 657702
10
GEOGRAPHICAL DISTRIBUTION (South America)
Update on Tick-Borne
Rickettsioses around the World a
Geographic ApproachPhilippe Parola,a Christopher
D. Paddock,b Cristina Socolovschi,a Marcelo B.
Labruna,c Oleg Mediannikov,a Tahar
Kernif,dMohammad Yazid Abdad,e John Stenos,e
Idir Bitam,f Pierre-Edouard Fournier,a Didier
RaoultaOctober 2013 Volume 26 Number 4 Clinical
Microbiology Reviews p. 6577
11
GEOGRAPHICAL DISTRIBUTION (EUROPE)
Update on Tick-Borne
Rickettsioses around the World a
Geographic ApproachPhilippe Parola,a Christopher
D. Paddock,b Cristina Socolovschi,a Marcelo B.
Labruna,c Oleg Mediannikov,a Tahar
Kernif,dMohammad Yazid Abdad,e John Stenos,e
Idir Bitam,f Pierre-Edouard Fournier,a Didier
RaoultaOctober 2013 Volume 26 Number 4 Clinical
Microbiology Reviews p. 6577
12
GEOGRAPHICAL DISTRIBUTION
Update on Tick-Borne Rickettsioses around the
World a Geographic ApproachPhilippe Parola,a
Christopher D. Paddock,b Cristina Socolovschi,a
Marcelo B. Labruna,c Oleg Mediannikov,a Tahar
Kernif,dMohammad Yazid Abdad,e John Stenos,e
Idir Bitam,f Pierre-Edouard Fournier,a Didier
RaoultaOctober 2013 Volume 26 Number 4 Clinical
Microbiology Reviews p. 6577
13
GEOGRAPHICAL DISTRIBUTION
Update on Tick-Borne Rickettsioses around the
World a Geographic ApproachPhilippe Parola,a
Christopher D. Paddock,b Cristina Socolovschi,a
Marcelo B. Labruna,c Oleg Mediannikov,a Tahar
Kernif,dMohammad Yazid Abdad,e John Stenos,e
Idir Bitam,f Pierre-Edouard Fournier,a Didier
RaoultaOctober 2013 Volume 26 Number 4 Clinical
Microbiology Reviews p. 6577
14
GEOGRAPHIC DISTRIBUTION
  • Geographic and temporal distribution of
    rickettsioses is largely determined by their
    vectors
  • One continent, one pathogenic tick-born
    rickettsia an anachronism
  • Prevalent throughout the world except Antarctica

15
Summary of prevalent Rickettsiae in Southeast
Asia,their reservoirs and vectors for disease
transmission
Rickettsiae Main reservoirs Main vectors
Typhus group Murine typhus (R.typhi) Rats(Rattus rattus, Rattus norvegicus, other Rattus sp.) Xenopsylla cheopis
Scrub typhus (O. tsutsugamushi) Rats (Rattus sp. and Bandicota sp.) Trombiculid mites (Larval stage )
Spotted fever group R.Honei Rats ( Rattus sp. And Bandicota indica.) Ixodes granulatus, Ixodes sp., Rhipicephalus sp.
R. felis Rats(Rattus sp) and shrews (Suncus murinus) Domestic cats, dogs, cows and pigs. Ctenocephalides orientis, C. felis felis, X. cheopis
R. Conorii subsp. indica Rats ( Rattus sp.) R. sanguineus
R. helvetica Unknown Ixodes spp
R. japonica Rats ( Rattus sp. And B. indica.) Various species of animal ticks.
Am. J. Trop. Med. Hyg., 91(3),
2014, pp. 451460Review Article Rickettsial
Infections in Southeast Asia Implications for
Local Populaceand Febrile Returned TravelersAr
Kar Aung, Denis W. Spelman, Ronan J. Murray, and
Stephen Graves
16
Short Report Serosurveillance of Orientia
tsutsugamushi and Rickettsia typhi in Bangladesh

Short Report Serosurveillance of Orientia
tsutsugamushi and Rickettsia typhi in Bangladesh
Rapeephan R. Maude, Richard J. Maude, Aniruddha
Ghose, M. Robed Amin, M. Belalul Islam, Mohammad
Ali, M. Shafiqul Bari, M. Ishaque Majumder, Ampai
Tanganuchitcharnchai, Arjen M. Dondorp, Daniel H.
Paris, Robin L. Bailey, M. Abul Faiz, Stuart D.
Blacksell, and Nicholas P. J. Day Am. J. Trop.
Med. Hyg., 91(3), 2014, pp. 580583
17
An ongoing study in Mymensingh Medical College

A total of 155 clinically suspected febrile
patients were enrolled in the study. Out of them,
136 (88), 31 (23) and 61 (43) were positive by
Weil-Felix test, ELISA and PCR respectively.Out
of the 61 PCR positive products, 16 were
sequenced in Sapporo Medical University, Japan
where 13 were found to be 99.9 consistent with
Rickettsia felis.
A case series of 40 rickettsial infection in MMCH
found 60 positive for scrub typhus by using
Weil-Felix test (Miah MT, Rahman S, Sarker CN,
Khan GK, Barman TK, 2007. Study on 40 cases of
Rickettsia. Mymensingh Med J 16 8588)
18
Association of tick genera and rickettsial species
19
(No Transcript)
20
(No Transcript)
21
CLINICAL MANIFESTATIONS
  • Clinical symptoms of tick-borne SFG rickettsioses
    begin 4 to 10 days after a bite and typically
    include fever, headache, muscle pain, rash, local
    lymphadenopathy, and, for most of these
  • diseases, a characteristic inoculation eschar at
    the bite site
  • Life-threatening manifestations prolonged
    fever, renal failure, myocarditis,
    meningoencephalitis, hypotension, ARDS, multiple
    organ failure

22
ESCHAR (TACHE NOIRE)
A crusty necrotic lesion with or without a
surrounding erythematous halo which suggests the
location of the vector bite
23
(No Transcript)
24
(No Transcript)
25
LAR
Lymphangitis may be present in several
rickettsioses Half of the cases of R. sibirica
subsp. mongolitimonae infection present this sign
(rope-like lymphangitis between the inoculation
eschar and lymphadenitis) the infection being
termed lymphangitis-associated rick-ettsiosis
(LAR) also present in infections caused by R.
heilongjiangensis and R. africae
26
DEBONEL / TIBOLA /SENLAT
  • Two dominant signs characterize this syndrome an
    inoculation eschar and regional lymphadenopathy
  • The occurrence of fever and rash is rare.
  • DEBONEL/TIBOLA (Dermacentor-borne necrosis
    erythema lymphadenopathy/tick-borne
    lymphadenopathy), also called SENLAT (scalp
    eschar and neck lymphadenopathy after tick bite)
    when the tick bite affects only the scalp
  • Produced by different species of Rickettsia. The
    main etiological agent is Rickettsia slovaca

27
TYPHUS GROUP
28
HISTORY AND HISTORICAL IMPACT OF TYPHUS
Europian history has been affected by Typhus
epidemics from the the 15th through the 20th
centuries, Pediculus humanus corporis as having a
more profound effect on human history than any
other animal Rickettsia prowazeki is isolated and
identified by Da Rocha-Lima in 1916. Named in
honor of H. T. Ricketts and L. von Prowazek, both
of whom contracted typhus in the course of their
investigations and died In 1829, the French
clinician Louis clearly differentiated Typhus
Fever from Typhoid Fever (Wolback et al.,
1922) Transmission of Epidemic Typhus by the body
louse was first demonstrated experimentally by
Nicolle and others (1909) Early History. The
first pestilence attributed to louse-borne
typhus was the Athenian Plague of 430 B.C. The
Fifteen Century. An epidemic of louse-borne
typhus struck the besieging army of Spanish and
within a month had killed 17,000 of the original
25,000 soldiers. The Sixteen Century. Western
civilizations at that time regarded their God as
a somewhat capricious tyrant, who either gave
life or took it. Having no recourse to medicine
as a means of explaining their devastations,
medieval man turned to spiritual and metaphysical
sources. A number of so-called "Assize
Epidemics" occurred in England at this time, most
notably at Oxford in 1577 and Exeter in 1589. The
Oxford epidemic was of such import that the
University there was closed for 30 years
afterward. The Seventeenth Century. In the
Thirty Years War of 1618-1648 along with Plague
and starvation, typhus was responsible for the
loss of 10,000,000 people in which only 350,000
men died in combat . The Eighteenth Century. The
18th century was marred by many small epidemics
of typhus The Nineteenth Century. Napoleon
Bonaparte's campaign against the Russians in 1812
Napoleon had organized his "Grande Armee",
numbering 600,000 well-seasoned troops -Only
90,000 French soldiers reached Moscow out of the
original army of 600,000. The great majority,
possibly as high as 300,000, had died of Epidemic
Typhus and dysentery. Epidemic Typhus had helped
defeat Napoleon and end his dreams of a
French-ruled world. Typhus was endemic in Russia
with some 82,000 cases a year recorded before
1914 Either socialism will defeat the louse,
or the louse will defeat socialism All
attention to this problem comrades! Lenin
observed The Twentieth Century. Nicolle's proof
of the transmission of typhus by body lice in
1910 Insurance Company as saying that as many as
twenty-five million cases of typhus occurred
during the years 1918-1922 with upwards of three
million deaths. To dehumanise the Jews the Nazi
Propaganda Minister Joseph Goebbels declared
These are no longer peopleThe task is not
humanitarian but surgical. Steps have to be taken
here, and really radical ones tool. Otherwise
Europe will perish from the Jewish disease.
29
HISTORY AND HISTORICAL IMPACT OF TYPHUS
  • Rickettsia prowazeki is isolated and identified
    by Da Rocha-Lima in 1916. Named in honor of H. T.
    Ricketts and L. von Prowazek, both of whom
    contracted typhus in the course of their
    investigations and died
  • In 1829, the French clinician Louis clearly
    differentiated Typhus Fever from Typhoid Fever
    (Wolback et al., 1922)
  • Transmission of Epidemic Typhus by the body louse
    was first demonstrated experimentally by Nicolle
    and others (1909). Nicolle received the Nobel
    Prize for his work on typhus in 1928.

30
Henrique da Rocha Lima and Stanislas von Prowazeck
31
Charles Jules Henri Nicolle
32
HISTORY AND HISTORICAL IMPACT OF TYPHUS
  • 15th-19th century Epidemics in Europe as a result
    of war, disaster, or in prisoners
  • The Sixteen Century The Oxford was closed for 30
    years
  • The Seventeenth Century. In the Thirty Years War
    of 1618-1648 along with Plague and starvation,
    typhus was responsible for the loss of 10,000,000
    people in which only 350,000 men died in combat
  • The Nineteenth Century. Only 90,000 French
    soldiers reached Moscow out of the original army
    of 600,000. Epidemic Typhus had helped defeat
    Napoleon and end his dreams of a French-ruled
    world

33
HISTORY AND HISTORICAL IMPACT OF TYPHUS
  • Either socialism will defeat the louse, or the
    louse will defeat socialism All attention to
    this problem comrades! Lenin observed
  • To dehumanise the Jews the Nazi Propaganda
    Minister Joseph Goebbels declared These are no
    longer Steps have to be taken here, and really
    radical ones tool. Otherwise Europe will perish
    from the Jewish disease.
  • End of WWII, DDT for control
  • Discovery of Tetracycline and Chloramphenicol in
    late 1940

34
Delousing and Disinfection
35
In German soilders had to show delousing
certificates when on leave
36
(No Transcript)
37
(No Transcript)
38
Neither the queens nor the kings, the lice
shaped the history of Europe
39
TYPHUS
Disease Group Disease Agent Vector Animal Reservoir Geographical Distribution
Typhus Group Epidemic Typhus Sylvatic typhus R. prowazekii Human body louse Flea Humans, Fleas, flying squirells Mountainous regions of Africa, Asia, and Central, north and South America.
Murine typhus R. typhi Rat flea (Xenopsylla cheopis) Rats, cat, mice Tropical and subtropical areas Worldwide
40
  • Brill-Zinsser Disease
  • The rickettsia can remain latent and reactivate
    months or years later, with symptoms similar to
    or even identical to the original attack of
    typhus, including a maculopapular rash
  • Mild illness and low mortality rate.
  • Rash is rare
  • EPIDEMIC TYPHUS
  • Incubation period approximately 1 week
  • Sudden onset of fever, chills, headache and
    myalgia
  • Rash after one week
  • Maculopapular progressing to petechial or
    hemorrhagic
  • First on trunk and spreads to extremities
    (centrifugal spread)
  • Complications
  • Myocarditis, stupor, delirium (Greek typhos
    smoke)
  • Recovery may take months, debilitating
  • Mortality rate can be high (60-70) but this may
    be because of the situation, such as famine

41
Rickettsia typhi - Murine or endemic typhus
  • Occurs worldwide
  • Vector - rat flea
  • Bacteria in feces
  • Reservoir - rats
  • No transovarian transmission
  • Normal cycle - rat to flea to rat
  • Humans accidentally infected
  • Incubation period 1 - 2 weeks
  • Sudden onset of fever, chills, headache and
    myalgia
  • Rash in most cases begins on trunk and spreads to
    extremities (centrifugal spread)
  • Mild disease - resolves even if untreated

42
SCRUB TYPHUS
43
SCRUB TYPHUS GROUP
Antigenic group Disease Species Vector Animal reservoir Geographic distribution
Scrub typhus Scrub typhus Orientiatsutsugamushi Larval mite(chigger) Rodents Asia-Pacific region from maritime Russia and China to Indonesia and North Australia to Afghanistan
Scrub typhus Scrub Typhus Orientia chuta Unknown Unknown Dubai
44
Isolation of a
Novel Orientia Species (O. chuto sp. nov.) from a
Patient Infected in Dubai Leonard Izzard,1,2
Andrew Fuller,3 Stuart D. Blacksell,4,5 Daniel H.
Paris,4,5 Allen L. Richards,4,6,7 Nuntipa
Aukkanit,4,5 Chelsea Nguyen,1 Ju Jiang,6 Stan
Fenwick,2 Nicholas P. J. Day,4 Stephen Graves,1
and John Stenos1,2 JOURNAL OF CLINICAL
MICROBIOLOGY, Dec. 2010, p. 44044409 Vol. 48,
No. 12
45
Scrub typhus
  • Orientia tsutsugamushi is the causative agent
    transmitted to humans through the bite of
    thrombiculid mites.
  • The chigger (larval) phase is the only stage that
    is parasitic on animals or humans.
  • First described in china 318 AD, isolated in
    Japan in 1930
  • Disease of rural villages and suburban areas.
  • Term scrub is used because of the vegetation
    (terrain between woods and clearing) that
    harbours the vector.
  • Scrub typhus is endemic in tsutsugamushi triangle
    which extends from northern Japan, far eastern
    Russia in the north to the Northern Australia in
    the south and pakistan in the west.
  • Estimated 1 billion people are at risk of scrub
    typhus and estimated 1 million cases occur
    annually.

46
TSUTSUGAMUSHI TRIANGLE

47
(No Transcript)
48
Clinical features-Scrub typhus
  • Incubation period - 1 to 3 weeks
  • Sudden onset of fever, chills, headache and
    myalgia
  • Maculopapular rash (spots and bumps)
  • Begins on trunk and spreads to extremities
    (centrifugal spread)
  • Commonest symptom high grade fever ,headache
    muscle pain ,cough, and GI symptoms
  • Severe disease in 2ND week.
  • Meningitis , meningo-encephalitis , deafness,
    pneumonia, ARDS, MODS myocarditis.
  • Reinfection Relapses are seen due to variable
    immunity to different strains
  • Mortality rates variable (1-15)

49
ESCHAR
50
(No Transcript)
51
SYNDROMIC CLASSIFICATION OF RICKETTSIOSES
Syndromic classification of rickettsioses an
approach for clinical Practicel varo A.
Faccini-Martinez a, Lara Garcia-A lvarez b,
Marylin Hidalgo a, Jose A. Oteo
b, International Journal of Infectious Diseases
28 (2014) e126e139
52
SYNDROMIC CLASSIFICATION OF RICKETTSIOSES
Syndromic classification
of rickettsioses an approach for
clinical Practice lvaro A. Faccini-Martinez a,
Lara Garcia-A lvarez b, Marylin Hidalgo a,
JoseInfectious Diseases 28 (2014) e126e139
53
Laboratory Diagnosis
  • Serologic assays (eg, indirect immunofluorescence,
    complement fixation, indirect hemagglutination,
    latex fixation, enzyme immunoassay,
    microagglutination) are preferable to the
    nonspecific and insensitive Weil-Felix test based
    on the cross-reactive antigens of Proteus
    vulgaris strains
  • Immunofluorescence assay (IFA) is currently
    considered to be the reference serological
    method.

54
  • Polymerase chain reaction (PCR) to detect
    rickettsiae in blood or tissue provides promise
    for early diagnosis. PCR testing and
    immunohistochemical staining of skin specimen
    obtained by performing a biopsy may help confirm
    the clinical diagnosis in patients with rash.
  • The swabs of eschars may be used for molecular
    detection of rickettsial infections when biopsies
    are difficult to perform.

55
(No Transcript)
56
DILEMMA CHALLENGES
57
DIAGNOSIS
  • A thorough history and knowledge of the
    distribution of rickettsial agents and their
    vectors
  • evidence of exposure to vector
  • clinical features like fever, rash, eschar,
    headache and myalgia
  • high index of suspicion are crucial factors

58
TREATMENT
Antibiotic Indication Dosage Treatment
Doxycycline (standard treatment of rickettsosis) Severe rickettsioses (including pregnant women and children) Ideally intravenous Adults or childrengt45kg Adults or childrengt45kg100 mg twice a day pregnant women(last trimester)100 mg twice a day Childrenlt45kg22 mg twice a day Continued for 3 days after symptoms has resolved
Macrolides(josamycin, clarythromycin and azithrothromycin Option for not severe rickettsioses in children and pregnant women Josamycinchildren 50 mg/kg twice a day, pregnant women 1g/8hrly Clarithromycin for children 15mg/kg twice a day Josamycin 5 days Clarithromycin 7 days and Azithromycin 3 days
Chloramphenicol Alternative option in severe rickettsioses Azithromycin in children 10 mg /kg/day in 1 dose Adults and pregnant (first and second trimester) 60-75 mg/kg in4 divided doses Children12-25 mg/kg every 6 hourly 5-10 days
Syndromic classification of
rickettsioses an approach for clinical Practice
lvaro A. Faccini-Martinez a, Lara Garcia-A
lvarez b, Marylin Hidalgo a, JoseInfectious
Diseases 28 (2014) e126e139
59
(No Transcript)
60
  • But however secure and well-regulated civilized
    life may become bacteria, protozoa, viruses,
    infected fleas, lice, ticks, mosquitoes, and
    bedbugs will always lurk in the shadows ready to
    pounce when neglect, poverty, famine, or war lets
    down the defenses. 
  • Hans Zinsser
  • Rats, Lice and History (1934), 13-4. 
Write a Comment
User Comments (0)
About PowerShow.com