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Archive Number 20110417.1205
Published Date 17-APR-2011
Subject PRO/AH/EDR> Murine typhus - Japan ex Thailand
MURINE TYPHUS - JAPAN ex THAILAND
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A ProMED-mail post
<http://www.promedmail.org>
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International Society for Infectious Diseases
<http://www.isid.org>
Date: Sat 16 Apr 2011
From: Fukumi Nakamura-Uchiyama [edited]
<fukumi821290@bokutoh-hp.metro.tokyo.jp>
A previously healthy 56-year-old Japanese man who returned from
Thailand was diagnosed with murine typhus on 16 Apr 2011. He is being
managed in an intensive care unit after developing shock and ARDS.
He worked as a Japanese-language teacher in Payao, one of the
northern cities of Thailand. He was admitted to our hospital on 13 Apr
2011. He complained of 6 days of fever, headache and fatigue. The
physical examination revealed a small erythematous rash on his chest.
Thrombocytopenia, liver and renal impairment, hypotension and pleural
effusion were seen on admission. Since we suspected dengue shock
syndrome, rickettsiosis, especially scrub typhus, or septic shock, we
started fluid replacement and administration of minocycline and
ceftriaxone. He did not respond to fluid replacement and developed
ARDS.
We asked the Japanese National Institute for Infectious Diseases
(NIID) to test his blood specimens for dengue and rickettsia.
Surprisingly, not _Orientia tsutsugamushi_ [the cause of scrub
typhus], but _Rickettsia typhi_ [the cause of murine typhus] DNA was
detected his blood.
The northern part of Thailand is a well-known endemic area of dengue
and scrub typhus, while murine typhus is distributed worldwide. Most
of murine typhus cases present as a self-limited illness without
complications. The mortality rate for murine typhus is low with use of
appropriate antibiotics. Physicians should be aware of the possibility
of murine typhus when they see acutely febrile patients returning from
the northern part of Thailand.
Authors: Nakamura-Uchiyama F, Sakamoto N, Kobayashi K, Iwabuchi S and
Ohnishi K.
--
Communicated by:
Fukumi Nakamura-Uchiyama, MD, PhD
Department of Infectious Diseases,
Tokyo Metropolitan Bokutoh General Hospital
4-23-15 Kotobashi, Sumida-ku, Tokyo 130-8575, Japan
<fukumi821290@bokutoh-hp.metro.tokyo.jp>
[Rickettsia are small obligate intracellular parasites that are
maintained in animal and arthropod reservoirs and transmitted by
arthropod vectors (ticks, fleas, lice or mites) to humans. Murine
typhus, which occurs throughout the world, is a flea-borne rickettsial
disease caused by the _Rickettsia typhi_. Rats are the primary animal
reservoir of _R. typhi_; however, other mammals, such as free-ranging
cats, dogs, and opossums and their fleas can maintain this
microorganism in areas where rats and rat fleas are absent (Azad AF,
Radulovic S, Higgins JA, Noden BH, Troyer JM. Flea-borne
rickettsioses: ecologic considerations. Emerg Infect Dis
1997;3:319-27).
Humans are usually infected by contact with infected flea feces,
either by inoculation into excoriated fleabites, inhalation, or
ingestion. Symptoms include fever, headache, chills, vomiting, nausea,
myalgias, and rash. The illness usually resolves within 3 weeks, even
if untreated. However some patients are sick enough to be hospitalized
in an intensive care unit and up to 4 percent of hospitalized patients
will die from the infection. Treatment is doxycycline. Prevention is
directed at control of flea vectors and animal reservoirs.
The city of Payao, also spelled Phayao, is located in a mountainous
region on the watershed between the Mekong and Chao Phraya river
systems (<http://www.britannica.com/EBchecked/topic/455410/Phayao>) in
the province of Phayao on Thailand's northern border with Laos. For a
map of Thailand that shows the location of Phayao, see
<http://en.wikipedia.org/wiki/File:Thailand_Phayao_locator_map.svg>.
The HealthMap/ProMED-mail interactive map of Japan is available at
<http://healthmap.org/r/008U>, and a map of Japan prefectures is
available at <http://www.digi-promotion.com/pics/map_japan.gif>. -
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