eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Rickettsial Infection: Follow-up

Author: Mobeen H Rathore, MD, CPE, FAAP, FIDSA, Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)
Coauthor(s): Nizar F Maraqa, MD,, Assistant Professor of Pediatrics, Pediatric Infectious Diseases, University of Florida College of Medicine at Jacksonville
Contributor Information and Disclosures

Updated: May 11, 2009

Follow-up

Further Inpatient Care

  • Patients with rickettsial infection may require hospitalization only if they are clinically unstable or have developed complications.

Transfer

  • Rickettsial infections with severe complications may require transfer to tertiary care facilities.

Deterrence/Prevention

Personal avoidance of ticks (wearing proper clothing and use of repellants) remains an integral part of protection against rickettsial infections. In case of bites, prompt removal of ticks might prove extremely beneficial in prevention of infection. Attempting to control the tick reservoir is not usually feasible. Use of antibiotics following tick exposure is not currently indicated to prevent rickettsial infection.

  • Rocky Mountain spotted fever (RMSF): Various vaccines have been developed; however, they have not yet been proven efficacious or safe to recommend for routine use in patients. An improved killed chicken embryo vaccine has shown that it may provide partial protection against RMSF and ameliorate the illness when it occurs.24
  • Rickettsialpox: Avoidance of contact with and control of house mouse infestations is important to prevent acquisition of infection.
  • Boutonneuse fever: Natural immunity occurs following infection. Effective vaccines are not yet available.
  • Typhus group (epidemic and endemic typhus): Delousing of individuals and use of insecticides to treat clothing are effective preventive measures against the spread of louse-borne typhus. Killed vaccines that are no longer available in the United States were shown to reduce mortality rates but were not effective in prevention of disease.
  • Brill-Zinsser disease (ie, relapsing louse-borne typhus): This is analogous to primary louse-borne epidemic typhus.
  • Murine (endemic or flea-borne) typhus: Prevention is primarily by controlling the flea and rat populations. Insecticides should be used before rodenticides to prevent rat fleas from seeking alternate hosts if rats are no longer available. As with louse-borne typhus, a vaccine is no longer available in the United States.
  • Tsutsugamushi disease (ie, scrub typhus): Prevention can be achieved by vector control or chemoprophylaxis. The agent of choice for chemoprophylaxis is doxycycline, given as a weekly dose started before exposure to infection and continued for 6 weeks postexposure.
  • Q fever: A whole-cell vaccine for Q fever has been developed in Australia for clinical use in the occupational setting.5 Control of disease in domestic animal population has been difficult because animals that have no detectable antibodies to C burnetii still shed the organism at parturition. Q fever outbreaks in research laboratories using animals (especially sheep) can be prevented by instituting proper control measures designed to protect the environment from fomite and aerosol transmission.

Complications

  • RMSF: Complications are uncommon, especially if patients receive proper treatment. Acute complications may include a superimposed bronchopneumonia and congestive heart failure (caused by fluid overload). Long-term health problems following acute RMSF infection include partial paralysis of the lower extremities; gangrene requiring amputation of fingers, toes, arms, or legs; hearing loss; loss of bowel or bladder control; movement disorders; and language disorders. These rare complications are usually seen in severely affected individuals.15
  • Rickettsialpox: This is usually a self-limited disease with no complications.
  • Boutonneuse fever: Similarly to RMSF, the disease occasionally may follow a malignant and rapidly fatal course with multiorgan failure, encephalopathy, and coagulopathy.8
  • Louse-borne (epidemic) typhus: Complications are uncommon but include gangrene, parotitis, otitis, myopericarditis, pneumonia, and pleurisy.
  • Brill-Zinsser disease (ie, relapsing louse-borne typhus): Complications are similar to the primary illness; however, relapses usually are less severe.
  • Murine (endemic or flea-borne) typhus: Complications are similar to those observed in louse-borne typhus and are uncommon.
  • Tsutsugamushi disease (scrub typhus): Complications are generally uncommon. Deafness, atypical pneumonia, disease similar to adult respiratory distress syndrome, myocarditis, and disseminated intravascular coagulopathy have been reported.
  • Q fever: Complications include chronic Q fever, endocarditis, myocarditis, meningoencephalitis, glomerulonephritis, and syndrome of inappropriate antidiuretic hormone (SIADH).

Prognosis

  • RMSF
    • The overall mortality rate without specific therapy is approximately 25%; however, the mortality rates are higher for men, elderly persons, and black men with G-6-PD deficiency.
    • In the United States, the overall mortality rate currently is 5-7%.
    • Fatalities are mainly caused by delay in diagnosis and treatment.
    • Solid immunity usually follows recovery from RMSF.
  • Rickettsialpox
    • Rickettsialpox is usually self-limited.
    • Deaths have not been reported.
  • Boutonneuse fever
    • Boutonneuse fever generally runs a benign course.
    • Very rarely, it may follow a rapidly fatal course in otherwise healthy children.
  • Louse-borne (epidemic) typhus
    • The mortality rate in untreated cases correlates with the patient's age.
    • Mortality may be uncommon in children younger than 12 years, but rates rise to as high as 60-70% in individuals older than 50 years.
    • Most patients who recover develop immunity.
  • Brill-Zinsser disease (ie, relapsing louse-borne typhus): This is analogous to primary louse-borne epidemic typhus, except that patients who recover do not develop immunity.
  • Murine (endemic or flea-borne) typhus: This is usually a mild illness without significant sequelae.
  • Tsutsugamushi disease (ie, scrub typhus)
    • Fatalities are rare with use of antibiotics.
    • The heterogeneity of scrub typhus strains accounts for the frequent reinfections.
    • Sporadic short courses of doxycycline or chloramphenicol may be required to prevent relapses.
  • Q fever
    • Patients with uncomplicated Q fever recover within 1-3 months without sequelae.
    • The mortality rate is less than 1%.
    • On the other hand, complicated cases have a higher rate of permanent disabilities and fatalities.

Patient Education

  • Education of patient population regarding effective avoidance of ticks is highly important.
  • Physician education is also important to promote early diagnosis and proper treatment.
  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Ticks.

Miscellaneous

Medicolegal Pitfalls

  • Use of sulfonamides, which usually have a harmful effect and are contraindicated in rickettsial infections
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Nizar F Maraqa, MD, to the original writing and development of this article.



More on Rickettsial Infection

Overview: Rickettsial Infection
Differential Diagnoses & Workup: Rickettsial Infection
Treatment & Medication: Rickettsial Infection
Follow-up: Rickettsial Infection
Multimedia: Rickettsial Infection
References
Further Reading
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References

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  3. Center of Disease Control and Prevention (CDC). Rickettsial Diseases. Infectious Disease Information. Available at http://www.cdc.gov/ncidod/dvrd/branch/vrzb.htm.

  4. Edwards MS, Feigin RD. Rickettsial diseases. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. 5th ed. WB Saunders Co; 2004:2497-2515/Chapter 195.

  5. Tissot-Dupont H, Raoult D. Q Fever. Infect Dis Clin N Am. Sept 2008;22:505-514. [Medline].

  6. Walker DH. Rickettsiae. In: Baron S, ed. Medical Microbiology. 4th ed. University of Texas Medical Branch; 1996:[Full Text].

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Further Reading

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Keywords

Rocky Mountain spotted fever, RMSF, rickettsialpox, boutonneuse fever, Mediterranean spotted fever, Kenya tick-bite fever, African tick typhus, India tick typhus, Israeli spotted fever, Marseille fever, epidemic louse-borne typhus, endemic murine typhus, Tsutsugamushi disease, scrub typhus, Q fever, Brill-Zinsser disease, relapsing louse-borne typhus, rickettsial infection, Rickettsiae, Rickettsia, rickettsialpox, catscratch disease, trench fever, hypoalbuminemia, osteomyelitis, chronic hepatitis, chronic vascular infection, endocarditis, pericarditis, myocarditis, treatment, diagnosis, atelectasis, pulmonary edema

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Contributor Information and Disclosures

Author

Mobeen H Rathore, MD, CPE, FAAP, FIDSA, Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)
Mobeen H Rathore, MD, CPE, FAAP, FIDSA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, European Society for Paediatric Infectious Diseases, Florida Medical Association, Florida Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America, Society for Pediatric Research, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Coauthor(s)

Nizar F Maraqa, MD,, Assistant Professor of Pediatrics, Pediatric Infectious Diseases, University of Florida College of Medicine at Jacksonville
Nizar F Maraqa, MD, is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

José Rafael Romero, MD, Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center
José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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