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September 11, 1991, Vol 266, No. 10 >
ARTICLE | September 11, 1991

Clinical and Laboratory Features of Murine Typhus in South Texas, 1980 Through 1987 FREE

J. Stephen Dumler, MD; Jeffery P. Taylor, MPH; David H. Walker, MD
[+] Author Affiliations

Reprint requests to Department of Pathology, University of Texas Medical Branch, 101 Keiller Bldg. F09, Galveston, TX 77550 (Dr Dumler).


JAMA. 1991;266(10):1365-1370. doi:10.1001/jama.1991.03470100057033
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References

Objective.  —The clinical and laboratory features of patients with murine typhus have not been extensively reviewed since 1946. We have updated these findings in patients from south Texas who were examined by modern clinical and laboratory methods from 1980 through 1987.

Design.  —Patients were identified by serological methods in this case series, and clinical, epidemiologic, laboratory, and therapeutic data were compiled and analyzed.

Setting.  —The majority of patients (77 of 80) were identified in a primary care community hospital setting; the remainder (3 of 80) were ambulatory hospital outpatients.

Patients.  —From 1980 through 1987, a total of 345 patients were diagnosed with murine typhus; 90 of these patients were seen at four hospitals in south Texas; of these, 80 had clinical and laboratory data available for review.

Main Outcome Measures.  —The frequency of common clinical manifestations (eg, headache, fever, and rash) and laboratory findings (eg, leukocyte and platelet counts and serum chemistry abnormalities) of patients with infectious diseases was tabulated. Clinical severity was semiquantitatively assessed and was correlated with clinical, laboratory, and therapeutic results.

Results.  —Most cases (69%) occurred from April through August. Rash occurred in 54%; the triad of fever, headache, and rash was observed in only 12.5% of patients when first examined by a physician; respiratory and gastrointestinal symptoms were also frequent. Multiple organ involvement was documented by frequent abnormal laboratory findings of the hematologic, respiratory, hepatic, and renal systems. Disease severity was related to older patient age, the presence of renal dysfunction, leukocytosis, and hypoalbuminemia, and previous therapy with sulfa antibiotics.

Conclusions.  —Infection by Rickettsia typhi causes a systemic illness with clinical and laboratory abnormalities not previously recognized or described. Early clinical diagnosis and treatment are needed to avoid undue morbidity and mortality.(JAMA. 1991;266:1365-1370)

REFERENCES

1 +
Farhang-Azad A, Traub R.  Transmission of murine typhus rickettsiae by Xenopsylla cheopis, with notes on experimental infection and effects of temperature. Am J Trop Med Hyg . 1985;;34:555-563.
2 +
Traub R, Wisseman CL Jr, Farhang-Azad A.  The ecology of murine typhus: a critical review. Trop Dis Bull . 1978;;75:237-317.
3 +
Love GJ, Smith WM.  Murine typhus investigations in southwestern Georgia. Pub Health Rep . 1960;;75:429-440.
4 +
Centers for Disease Control.  Summary of notifiable diseases—United States, 1989. MMWR . 1990;;38:47-59.
5 +
Older JJ.  The epidemiology of murine typhus in Texas, 1969. JAMA . 1970;;214:2011-2017.
6 +
Taylor JP, Betz TG, Rawlings JA.  Epidemiology of murine typhus in Texas, 1980 through 1984. JAMA . 1986;;255:2173-2176.
7 +
Fan MY, Walker DH, Yu SR, Liu Q.  Epidemiology and ecology of rickettsial diseases in the People's Republic of China. Rev Infect Dis . 1987;;9:823-840.
8 +
Al-Awadi AR, Al-Kazemi N, Ezzat G, et al.  Murine typhus in Kuwait in 1978. Bull World Health Organ . 1982;;60:283-289.
9 +
Gross EM, Arbelli Y, Bearman JB, et al.  Spotted fever and murine typhus in the Negev desert region of Israel, 1981. Bull World Health Organ . 1984;;62:301-306.
10 +
Brown AE, Meek SR, Maneechai N, Lewis GE.  Murine typhus among Khmers at an evacuation site on the Thai-Kampuchean border. Am J Trop Med Hyg . 1989;;92:373-378.
11 +
Botros BA, Soliman AK, Darwish M, el Said S, Morrill JC, Ksiazek TG.  Seroprevalence of murine typhus and fievre boutonneuse in certain human populations in Egypt. Am J Trop Med Hyg . 1989;;92:373-378.
12 +
Woodruff PW, Morrill JC, Burans JP, Hyams KC, Woody JN.  A study of viral and rickettsial exposure and causes of fever in Juba, southern Sudan. Trans R Soc Trop Med Hyg . 1988;;82:761-766.
13 +
Tselentis Y, Edlinger E, Alexious G, Chrysantis D, Levendis A.  An endemic focus of murine typhus in Europe. J Infect . 1986;;13:91-92.
14 +
Miller ES, Beeson PB.  Murine typhus fever. Medicine . 1946;;25:1-15.
15 +
Smadel JE.  Status of the rickettsioses in the United States. Ann Intern Med . 1959;;51:421-435.
16 +
Quinby GE, Schubert JH.  Epidemiologic and serologic appraisal of murine typhus in the United States, 1948-1951. Am J Public Health . 1953;;43:160-164.
17 +
Betz TG, Rawlings JA, Taylor JP, Davis BL.  Endemic typhus in Texas. Tex Med . 1983;;79:48-53.
18 +
Buttery CMG, Magnuson LW, McLerran G, Villareal T.  Endemic (murine) typhus in Corpus Christi. Tex Med . 1984;;80:53-54.
19 +
Farhang-Azad A.  Relationship of vector biology and epidemiology of louse- and flea-borne rickettsioses.  In: Walker DH, ed. Biology of Rickettsial Diseases , I. Boca Raton, Fla: CRC Press Inc; 1988;:51-62.
20 +
Burgdorfer W.  Murine (flea-borne) typhus.  In: Hunter GW, ed. Tropical Medicine . 5th ed. Philadelphia, Pa: WB Saunders Co; 1976;:110-111.
21 +
Stuart BM, Pullen RI.  Endemic (murine) typhus fever: clinical observations of 180 cases. Ann Intern Med . 1945;;23:520-536.
22 +
Maxcy KF.  An epidemiologic study of endemic typhus (Brill's disease) in the southeastern United States. Public Health Rep . 1926;;41:2967-2995.
23 +
Woodward TE.  Murine typhus fever: clinical signs, symptoms, and pathophysiology.  In: Walker DH, ed. Biology of Rickettsial Diseases , I. Boca Raton, Fla: CRC Press Inc; 1988;:79-92.
24 +
Irons JV, Bohls SW, Thurman DC, McGregor T.  Probable role of the cat flea, Ctenocephalides felis, in transmission of murine typhus. Am J Trop Med . 1944;;24:359-362.
25 +
Farhang-Azad A, Traub R, Sofi M, Wisseman CL Jr.  Experimental murine typhus infection in the cat flea, Ctenocephalides felis (Siphonaptera:pelucidae). J Med Entomol . 1984;;21:675-680.
26 +
Helmick CG, Bernard KW, D'Angelo LJ.  Rocky Mountain spotted fever: clinical, laboratory, and epidemiological features of 262 cases. J Infect Dis . 1984;;150:480-488.
27 +
Kirk JL, Fine DP, Sexton DJ, Muchmore HG.  Rocky Mountain spotted fever: a clinical review based on 48 confirmed cases, 1943-1986. Medicine Baltimore . 1990;;69:35-45.
28 +
Binford CH, Ecker HD.  Endemic (murine) typhus: report of autopsy findings in three cases. Am J Clin Pathol . 1947;;17:797-806.
29 +
Stasko T, Devillez RL.  Murine typhus: a case report and review. J Am Acad Dermatol . 1982;;7:377-381.
30 +
Walker DH, Parks FM, Betz TG, Taylor JP, Muehlberger JW.  Histopathology and immunohistologic demonstration of the distribution of Rickettsia typhi in fatal murine typhus. Am J Clin Pathol . 1989;;91:720-724.
31 +
Peterson JC, Overall JC, Shapiro JL.  Rickettsial diseases of childhood: a clinical pathologic study of tick typhus, 'Rocky Mountain spotted fever,' and murine typhus, 'endemic typhus.' J Pediatr . 1947;;30:495-525.
32 +
Samra Y, Shaked Y, Maier MK.  Delayed neurologic display in murine typhus: report of two cases. Arch Intern Med . 1989;;149:949-951.
33 +
Raoult D, Weiller PJ, Chagnon A, Chaudet H, Gallais H, Casanova P.  Mediterranean spotted fever: clinical, laboratory and epidemiological features of 199 cases. Am J Trop Med Hyg . 1986;;35:845-850.
34 +
Philip RN, Casper EA, Ormsbee RA, Peacock MG, Burgdorfer W.  Microimmunofluorescence test for the serologic study of Rocky Mountain spotted fever and typhus. J Clin Microbiol . 1976;;3:51-61.
35 +
Hechemy KE, Osterman JV, Eisemann CS, Elliott LB, Sasowski SJ.  Detection of typhus antibodies by latex agglutination. J Clin Microbiol . 1981;;13:214-216.
36 +
Hechemy KE, Stevens RW, Sasowski S, Michaelson EE, Casper EA, Philip RN.  Discrepancies in Weil-Felix and microimmunofluorescence test results for Rocky Mountain spotted fever. J Clin Microbiol . 1979;;9:292-293.
37 +
Walker DH, Kirkman HN.  Rocky Mountain spotted fever and deficiency in glucose-6-phosphatase dehydrogenase. J Infect Dis . 1980;;142:771.
38 +
Snyder JC.  The treatment of the rickettsial diseases of man.  In: Moulton FR, ed. Rickettsial Diseases of Man . Washington, DC: Thomas Adams and Davis Inc; 1946;:169-177.
39 +
Beltran RR, Herrero-Herrero JI.  New quinolones in the treatment of Mediterranean spotted fever (MSF): a comparison study with other antibiotic regimens.  In: Kazar J, Raoult D, eds. Rickettsiae and Rickettsial Diseases: Proceedings of the IVth International Symposium . Bratislava, Czechoslovakia: Publishing House of the Slovak Academy of Sciences; 1991;:714-717.
40 +
Raoult D, Zuchelli P, Weiller PJ, et al.  Incidence, clinical observations and risk factors in the severe form of Mediterranean spotted fever among patients admitted to hospital in Marseilles, 1983-1984. J Infect . 1986;;12:111-116.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Farhang-Azad A, Traub R.  Transmission of murine typhus rickettsiae by Xenopsylla cheopis, with notes on experimental infection and effects of temperature. Am J Trop Med Hyg . 1985;;34:555-563.
2 +
Traub R, Wisseman CL Jr, Farhang-Azad A.  The ecology of murine typhus: a critical review. Trop Dis Bull . 1978;;75:237-317.
3 +
Love GJ, Smith WM.  Murine typhus investigations in southwestern Georgia. Pub Health Rep . 1960;;75:429-440.
4 +
Centers for Disease Control.  Summary of notifiable diseases—United States, 1989. MMWR . 1990;;38:47-59.
5 +
Older JJ.  The epidemiology of murine typhus in Texas, 1969. JAMA . 1970;;214:2011-2017.
6 +
Taylor JP, Betz TG, Rawlings JA.  Epidemiology of murine typhus in Texas, 1980 through 1984. JAMA . 1986;;255:2173-2176.
7 +
Fan MY, Walker DH, Yu SR, Liu Q.  Epidemiology and ecology of rickettsial diseases in the People's Republic of China. Rev Infect Dis . 1987;;9:823-840.
8 +
Al-Awadi AR, Al-Kazemi N, Ezzat G, et al.  Murine typhus in Kuwait in 1978. Bull World Health Organ . 1982;;60:283-289.
9 +
Gross EM, Arbelli Y, Bearman JB, et al.  Spotted fever and murine typhus in the Negev desert region of Israel, 1981. Bull World Health Organ . 1984;;62:301-306.
10 +
Brown AE, Meek SR, Maneechai N, Lewis GE.  Murine typhus among Khmers at an evacuation site on the Thai-Kampuchean border. Am J Trop Med Hyg . 1989;;92:373-378.
11 +
Botros BA, Soliman AK, Darwish M, el Said S, Morrill JC, Ksiazek TG.  Seroprevalence of murine typhus and fievre boutonneuse in certain human populations in Egypt. Am J Trop Med Hyg . 1989;;92:373-378.
12 +
Woodruff PW, Morrill JC, Burans JP, Hyams KC, Woody JN.  A study of viral and rickettsial exposure and causes of fever in Juba, southern Sudan. Trans R Soc Trop Med Hyg . 1988;;82:761-766.
13 +
Tselentis Y, Edlinger E, Alexious G, Chrysantis D, Levendis A.  An endemic focus of murine typhus in Europe. J Infect . 1986;;13:91-92.
14 +
Miller ES, Beeson PB.  Murine typhus fever. Medicine . 1946;;25:1-15.
15 +
Smadel JE.  Status of the rickettsioses in the United States. Ann Intern Med . 1959;;51:421-435.
16 +
Quinby GE, Schubert JH.  Epidemiologic and serologic appraisal of murine typhus in the United States, 1948-1951. Am J Public Health . 1953;;43:160-164.
17 +
Betz TG, Rawlings JA, Taylor JP, Davis BL.  Endemic typhus in Texas. Tex Med . 1983;;79:48-53.
18 +
Buttery CMG, Magnuson LW, McLerran G, Villareal T.  Endemic (murine) typhus in Corpus Christi. Tex Med . 1984;;80:53-54.
19 +
Farhang-Azad A.  Relationship of vector biology and epidemiology of louse- and flea-borne rickettsioses.  In: Walker DH, ed. Biology of Rickettsial Diseases , I. Boca Raton, Fla: CRC Press Inc; 1988;:51-62.
20 +
Burgdorfer W.  Murine (flea-borne) typhus.  In: Hunter GW, ed. Tropical Medicine . 5th ed. Philadelphia, Pa: WB Saunders Co; 1976;:110-111.
21 +
Stuart BM, Pullen RI.  Endemic (murine) typhus fever: clinical observations of 180 cases. Ann Intern Med . 1945;;23:520-536.
22 +
Maxcy KF.  An epidemiologic study of endemic typhus (Brill's disease) in the southeastern United States. Public Health Rep . 1926;;41:2967-2995.
23 +
Woodward TE.  Murine typhus fever: clinical signs, symptoms, and pathophysiology.  In: Walker DH, ed. Biology of Rickettsial Diseases , I. Boca Raton, Fla: CRC Press Inc; 1988;:79-92.
24 +
Irons JV, Bohls SW, Thurman DC, McGregor T.  Probable role of the cat flea, Ctenocephalides felis, in transmission of murine typhus. Am J Trop Med . 1944;;24:359-362.
25 +
Farhang-Azad A, Traub R, Sofi M, Wisseman CL Jr.  Experimental murine typhus infection in the cat flea, Ctenocephalides felis (Siphonaptera:pelucidae). J Med Entomol . 1984;;21:675-680.
26 +
Helmick CG, Bernard KW, D'Angelo LJ.  Rocky Mountain spotted fever: clinical, laboratory, and epidemiological features of 262 cases. J Infect Dis . 1984;;150:480-488.
27 +
Kirk JL, Fine DP, Sexton DJ, Muchmore HG.  Rocky Mountain spotted fever: a clinical review based on 48 confirmed cases, 1943-1986. Medicine Baltimore . 1990;;69:35-45.
28 +
Binford CH, Ecker HD.  Endemic (murine) typhus: report of autopsy findings in three cases. Am J Clin Pathol . 1947;;17:797-806.
29 +
Stasko T, Devillez RL.  Murine typhus: a case report and review. J Am Acad Dermatol . 1982;;7:377-381.
30 +
Walker DH, Parks FM, Betz TG, Taylor JP, Muehlberger JW.  Histopathology and immunohistologic demonstration of the distribution of Rickettsia typhi in fatal murine typhus. Am J Clin Pathol . 1989;;91:720-724.
31 +
Peterson JC, Overall JC, Shapiro JL.  Rickettsial diseases of childhood: a clinical pathologic study of tick typhus, 'Rocky Mountain spotted fever,' and murine typhus, 'endemic typhus.' J Pediatr . 1947;;30:495-525.
32 +
Samra Y, Shaked Y, Maier MK.  Delayed neurologic display in murine typhus: report of two cases. Arch Intern Med . 1989;;149:949-951.
33 +
Raoult D, Weiller PJ, Chagnon A, Chaudet H, Gallais H, Casanova P.  Mediterranean spotted fever: clinical, laboratory and epidemiological features of 199 cases. Am J Trop Med Hyg . 1986;;35:845-850.
34 +
Philip RN, Casper EA, Ormsbee RA, Peacock MG, Burgdorfer W.  Microimmunofluorescence test for the serologic study of Rocky Mountain spotted fever and typhus. J Clin Microbiol . 1976;;3:51-61.
35 +
Hechemy KE, Osterman JV, Eisemann CS, Elliott LB, Sasowski SJ.  Detection of typhus antibodies by latex agglutination. J Clin Microbiol . 1981;;13:214-216.
36 +
Hechemy KE, Stevens RW, Sasowski S, Michaelson EE, Casper EA, Philip RN.  Discrepancies in Weil-Felix and microimmunofluorescence test results for Rocky Mountain spotted fever. J Clin Microbiol . 1979;;9:292-293.
37 +
Walker DH, Kirkman HN.  Rocky Mountain spotted fever and deficiency in glucose-6-phosphatase dehydrogenase. J Infect Dis . 1980;;142:771.
38 +
Snyder JC.  The treatment of the rickettsial diseases of man.  In: Moulton FR, ed. Rickettsial Diseases of Man . Washington, DC: Thomas Adams and Davis Inc; 1946;:169-177.
39 +
Beltran RR, Herrero-Herrero JI.  New quinolones in the treatment of Mediterranean spotted fever (MSF): a comparison study with other antibiotic regimens.  In: Kazar J, Raoult D, eds. Rickettsiae and Rickettsial Diseases: Proceedings of the IVth International Symposium . Bratislava, Czechoslovakia: Publishing House of the Slovak Academy of Sciences; 1991;:714-717.
40 +
Raoult D, Zuchelli P, Weiller PJ, et al.  Incidence, clinical observations and risk factors in the severe form of Mediterranean spotted fever among patients admitted to hospital in Marseilles, 1983-1984. J Infect . 1986;;12:111-116.

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