Typhus

Typhus
Rash caused by epidemic typhus
Classification and external resources
Specialty	Infectious disease
ICD-10	A75
ICD-9-CM	080–083
DiseasesDB	29240
MedlinePlus	001363
eMedicine	med/2332
Patient UK	Typhus
MeSH	D014438

Typhus is any of several similar diseases caused by Rickettsia bacteria.^[1] The name comes from the Greek typhus (τύφος) meaning smoky or hazy, describing the state of mind of those affected with typhus. The causative organism Rickettsia is an obligate intracellular parasitic bacterium that cannot survive for long outside living cells. It is transmitted to humans via external parasites such as lice, fleas, and ticks. While "typhoid" means "typhus-like", typhus and typhoid fever are distinct diseases caused by different genera of bacteria.

Signs and symptoms

The following signs/symptoms refer to epidemic typhus as it is the most important of the typhus group of diseases.^[2]

Signs and symptoms begin with sudden onset of fever, chills, headache, and other flu-like symptoms about 1 to 2 weeks after being infected.^[3] Five to nine days after the symptoms have started, a rash typically begins on the trunk and spreads to the extremities. This rash eventually spreads over most of the body, sparing the face, palms, and soles. Signs of meningoencephalitis begin with the rash and continue into the second or third weeks. Other signs of meningoencephalitis include sensitivity to light (photophobia), altered mental status (delirium), or coma. Untreated cases are often fatal.

Causes

Multiple diseases include the word "typhus" in their description.^[4] Types include:

Condition	Bacteria	Reservoir/vector	Notes
Epidemic Louse-borne Typhus Fever	Rickettsia prowazekii	Human Body louse	When the term "typhus" is used without clarification, this is usually the condition described. Historical references to "typhus" are now generally considered to be this condition.
Murine typhus or "endemic typhus"	Rickettsia typhi	Fleas on rats
Scrub typhus	Orientia tsutsugamushi	Harvest mites on humans or rodents	Unlike the two conditions above, though it has the word "typhus" in the name, it is currently usually not classified in the typhus group, but in the closely related spotted fever group.[5]
Queensland tick typhus[6] or "Australian tick typhus" (and a spotted fever[7])	Rickettsia australis	Ticks

Prevention

The most effective way to prevent typhus is inoculation with the typhus vaccine series before travelling to endemic areas, and to avoid contact with lice.

Treatment

The American Public Health Association recommends treatment based upon clinical findings and before culturing confirms the diagnosis.^[8] Without treatment, death may occur in 10 to 60 percent of patients with epidemic typhus, with patients over age 60 having the highest risk of death. In the antibiotic era, death is uncommon if doxycycline is given. In one study of 60 hospitalized patients with Epidemic Typhus, no patient died when given doxycycline or chloramphenicol.^[9] Some patients also may need oxygen and intravenous (IV) fluids

Epidemiology

According to the World Health Organization, the current death rate from typhus is about one out of every 5,000,000 people per year.^[10]

Only a few areas of epidemic typhus exist today. Since the late 20th century, cases have been reported in Burundi, Rwanda, Ethiopia, Algeria, and a few areas in South and Central America.^{[11][12][13][14]}

Except for two cases, all instances of epidemic typhus in the United States have occurred east of the Mississippi River. An examination of a cluster of cases in Pennsylvania concluded the source of the infection was flying squirrels.^[15] Sylvatic cycle (diseases transmitted from wild animals) epidemic typhus remains uncommon in the US. The Centers for Disease Control and Prevention have documented only 47 cases from 1976 to 2010.^[16]

History

Middle Ages

Civilian Public Service worker distributes rat poison for typhus control in Gulfport, Mississippi, c. 1945.

The first reliable description of the disease appears during the Spanish siege of Moorish Granada in 1489. These accounts include descriptions of fever and red spots over arms, back, and chest, attention deficit, progressing to delirium, gangrenous sores, and the stink of rotting flesh. During the siege, the Spaniards lost 3,000 men to enemy action, but an additional 17,000 died of typhus.

Gaol Fever

In historical times "Gaol Fever", or "Aryotitus fever" was common in English prisons, and is believed by modern authorities to have been Typhus. It often occurred when prisoners were crowded together into dark, filthy rooms where lice spread easily. Thus "Imprisonment until the next term of court" was often equivalent to a death sentence. Prisoners brought before the court sometimes infected members of the court itself.^[17] Following the assizes held at Oxford in 1577, later deemed the Black Assize, over 300 died from gaol fever, including Sir Robert Bell, Lord Chief Baron of the Exchequer. The Black Assize of Exeter 1586 was another notable outbreak. During the Lent assizes court held at Taunton in 1730, gaol fever caused the death of the Lord Chief Baron, as well as the High Sheriff, the sergeant, and hundreds of others. During a time when persons were executed for capital offenses, more prisoners died from 'gaol fever' than were put to death by all the public executioners in the British realm. In 1759, an English authority estimated that each year a quarter of the prisoners had died from gaol fever.^[17] In London, gaol fever frequently broke out among the ill-kept prisoners of Newgate Prison and then moved into the general city population. In May 1750, the Lord Mayor of London, Sir Samuel Pennant, and a large number of court personnel were fatally infected in the courtroom of the Old Bailey, which adjoined Newgate Prison.^[18]

A US soldier is demonstrating DDT hand-spraying equipment. DDT was used to control the spread of typhus-carrying lice.

Epidemics occurred routinely throughout Europe from the 16th to the 19th centuries, including during the English Civil War, the Thirty Years' War, and the Napoleonic Wars.^[19] Pestilence of several kinds raged among combatants and civilians in Germany and surrounding lands from 1618 to 1648. According to Joseph Patrick Byrne, "By war's end, typhus may have killed more than 10 percent of the total German population, and disease in general accounted for 90 percent of Europe's casualties."^[20]

19th century

During Napoleon's retreat from Moscow in 1812, more French soldiers died of typhus than were killed by the Russians.^[21]

A major epidemic occurred in Ireland between 1816 and 1819, during the famine caused by a world-wide reduction in temperature known as the Year Without a Summer. An estimated 100,000 Irish perished. Typhus appeared again in the late 1830s, and yet another major typhus epidemic occurred during the Great Irish Famine between 1846 and 1849. The Irish typhus spread to England, where it was sometimes called "Irish fever" and was noted for its virulence. It killed people of all social classes, as lice were endemic and inescapable, but it hit particularly hard in the lower or "unwashed" social strata.

In the United States, a typhus epidemic broke out in Philadelphia in 1837 and killed the son of Franklin Pierce (14th President of the United States) in Concord, New Hampshire in 1843. Several epidemics occurred in Baltimore, Memphis and Washington, D.C. between 1865 and 1873. Typhus was also a significant killer during the US Civil War, although typhoid fever was the more prevalent cause of US Civil War "camp fever". Typhoid fever, caused by the bacterium Salmonella typhii (not to be confused with Salmonella enterica, the cause of salmonella food poisoning), is a completely different disease from typhus.

In Canada alone, the typhus epidemic of 1847 killed more than 20,000 people from 1847 to 1848, mainly Irish immigrants in fever sheds and other forms of quarantine, who had contracted the disease aboard the crowded coffin ships in fleeing the Great Irish Famine. Officials did not know how to provide sufficient sanitation under conditions of the time, nor understood how the disease spread.^[22]

20th century

Charles Nicolle received the 1928 Nobel Prize in Medicine for his identification of lice as the transmitter of epidemic typhus.

Delousing stations were established for troops on the Western Front during World War I, but the disease ravaged the armies of the Eastern Front, with over 150,000 dying in Serbia alone. Fatalities were generally between 10 and 40 percent of those infected, and the disease was a major cause of death for those nursing the sick.

In 1922, the typhus epidemic reached its peak in Soviet territory, with some 25 to 30 million cases in Russia. Although typhus had ravaged Poland with some 4 million cases reported, efforts to stem the spread of disease in that country had largely succeeded by 1921 through the efforts of public health pioneers such as Hélène Sparrow and Rudolf Weigl.^[23] In Russia, during the civil war between the White and Red Armies, typhus killed 3 million people,^[24][25] mainly civilians.

During World War II, many German POWs after the loss at Stalingrad died of typhus. Typhus epidemics killed those confined to POW camps, ghettos, and Nazi concentration camps who were held in unhygienic conditions. Pictures of typhus victims' mass graves can be seen in footage shot at Bergen-Belsen concentration camp.^[26]

Among thousands of prisoners in concentration camps such as Theresienstadt and Bergen-Belsen who died of typhus^[26] were Anne Frank, age 15, and her sister Margot, age 19. Major epidemics in the post-war chaos of Europe were averted only by widespread use of the newly discovered DDT to kill the lice on millions of refugees and displaced persons.

The first typhus vaccine was developed by the Polish zoologist Rudolf Weigl in the period between the two world wars.^[27] Better, less-dangerous and less-expensive vaccines were developed during World War II. Since then, some epidemics have occurred in Asia, Eastern Europe, the Middle East, and parts of Africa.

References

1. "Typhus" at Dorland's Medical Dictionary
2. Levinson, Warren (2010). Review of Medical Microbiology and Immunology (11 ed.). McGraw Hill. ISBN 9780071700283.
3. Gary R. Mullen; Lance A. Durden (27 September 2002). Medical and Veterinary Entomology. Academic Press. pp. 58–. ISBN 978-0-08-053607-1.
4. Eremeeva, Marina E; Gregory A Dasch. "Rickettsial (Spotted & Typhus Fevers) & Related Infections (Anaplasmosis & Ehrlichiosis)". CDC Centers for Disease Control and Prevention. Retrieved 15 May 2014.
5. Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease. St. Louis, Mo: Elsevier Saunders. p. 396. ISBN 0-7216-0187-1.
6. Ticks Factsheet NSW Department of Health
7. Spotted Fevers Department of Medical Entomology, University of Sydney
8. Heymann, David (2015). Control of communicable diseases manual : an official report of the American Public Health Association. Washington, DC: APHA Press, an imprint of the American Public Health Association. pp. 661–668. ISBN 9780875530185.
9. "Outbreak of epidemic typhus in the northern region of Saudi Arabia". Am J Trop Med Hyg. 12: 82–90. 1963. PMID 13933690.
10. WHO Statistical Information System (WHOSIS)
11. Raoult, D (1997). "Jail fever (epidemic typhus) outbreak in Burundi.". Emerg Infect Dis. 3 (3): 357–60. doi:10.3201/eid0303.970313. PMID 9284381.
12. Mokrani (2004). "Reemerging threat of epidemic typhus in oAlgeria.". J Clin Microbiol. 42 (8): 3898–900. doi:10.1128/jcm.42.8.3898-3900.2004. PMID 15297561.
13. "Epidemic typhus risk in Rwandan refugee camps.". Wkly Epidemiol Rec. 69 (34): 259. 1994. PMID 7947074.
14. Perine, PL (1992). "A clinico-epidemiological study of epidemic typhus in Africa.". Clin Infect Dis. 14 (5): 1149–58. doi:10.1093/clinids/14.5.1149. PMID 1600020.
15. Chapman, A (2009). "Cluster of sylvatic epidemic typhus cases associated with flying squirrels, 2004-2006". Emerg Infect Dis. 15 (7): 1005–11. doi:10.3201/eid1507.081305. PMID 19624912.
16. McQuiston, JH (2010). "Brill-Zinsser disease in a patient following infection with sylvatic epidemic typhus associated with flying squirrels.". Clin Infect Dis. 51 (6): 712–5. doi:10.1086/655891. PMID 20687836.
17. Ralph D. Smith, "Comment, Criminal Law—Arrest—The Right to Resist Unlawful Arrest," 7 NAT. RESOURCES J. 119, 122 n.16 (1967) (hereinafter Comment) (citing John Howard, The State of Prisons 6–7 (1929)) (Howard's observations are from 1773 to 1775). Copied from State v. Valentine (May 1997) 132 Wn.2d 1, 935 P.2d 1294
18. Gordon, Charles The Old Bailey and Newgate pp.331–2. T. Fisher Unwin, London, 1902
19. War and Pestilence. Time magazine
20. Byrne, Joseph Patrick (2008). Encyclopedia of Pestilence, Pandemics, and Plagues: A—M. ABC-CLIO. p. 732. ISBN 0-313-34102-8.
21. The Historical Impact of Epidemic Typhus. Joseph M. Conlon.
22. "M993X.5.1529.1 | The government inspector's office". McCord Museum. Montreal. Retrieved 22 January 2012.
23. Paul Weindling. International Health Organisations and Movements, 1918–1939. Cambridge University Press 1995, p. 99.
24. Andrew W. Artenstein. Vaccines: A Biography. Springer 2010, p. 250
25. David G. Rempel. A Mennonite Family in Tsarist Russia and the Soviet Union, 1789–1923. University of Toronto Press 2011, p. 249
26. "Trials of War Criminals Before the Nurenberg Military Tribunal" (PDF). Volumn 1. US. Government Printing Office. 1949. pp. 508–511. Retrieved 19 May 2015.
27. Naomi Baumslag, Murderous Medicine: Nazi Doctors, Human Experimentation, and Typhus, Greenwood Publishing Group, 2005, page 133