0521779407-20 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:22
1474 Typhus Fevers■Endemic (murine) Typhus: History of flea bite or exposure to cats,
opposums, rabbits, skunks 1–2 weeks before the onset of symptoms,
especially during late spring-summer in southern Texas or southern
California.
■Scrub Typhus: Chigger bite 1–3 weeks before onset of illness. Travel
to endemic areas in eastern Asia or western Pacific.Symptoms:
■Epidemic Typhus: Abrupt onset of fever, severe headache, chills,
myalgias+/−nonproductive cough.
■Endemic typhus: Abrupt onset of fever (100%), severe headache
(45%), chills (44%), myalgias (33%), nausea (33%).
■Scrub Typhus: Abrupt onset of fever (100%), severe headache (100%),
and myalgias.
Physical Signs:
■Epidemic Typhus: Fever (102–104◦F), maculopapular rash begins
in axillary folds and upper trunk 3–5 days after onset of illness
and becomes progressively petechial and confluent, nonproductive
cough with diffuse rales/rhonchi. Conjunctival injection, eye pain,
skin necrosis, digit gangrene.
■Endemic Typhus: Macular/maculopapular rash beginning 3–5 days
after disease onset on arms/axillae and spreading to trunk, extrem-
ities, occasionally including palms and soles, eventually 50%
have rash, 35% nonproductive cough, 23% abnormal CXR, hep-
atosplenomegaly in 1–45%. Neurologic symptoms and signs may
occur.
■Scrub Typhus: Eschar at site of tick bite, tender generalized or
regional lymphadenopathy (85%), conjunctival injection, macu-
lar/maculopapular rash on trunk and extremities 5 days after onset
of symptoms (34%), splenomegaly. Neurologic findings in <10%
(ataxia, slurred speech, tremor, delirium, nuchal rigidity, deafness),
fever to 40–40.5◦C.
tests
Laboratory
■Basic Blood Tests:
■Early: Low Hematocrit and WBC
■Later: low platelets, elevated WBC (may be lymphocytic predomi-
nance), hyponatremia, low albumin and mild LFT abnormalities.
■Specific Diagnostic Tests: Clinical diagnosis. Treat while awaiting lab
confirmation.