0521779407-20 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:22
1476 Typhus Fevers■Scrub Typhus: Doxycycline or chloramphenicol 7–15 days. Chlora-
mphenicol- and tetracycline-resistant strains of scrub typhus found
in northern Thailand may respond to ciprofloxacin or azithromycin.
■Contraindications: Sulfa drugs should be avoided since they can
increase the severity of endemic typhus.
■No tetracyclines in children<9years.
■In pregnancy, use chloramphenicol
follow-up
During Treatment
■Fever usually abates rapidly with antibiotics:≤48 hours in epidemic
typhus,≤72 hours in endemic typhus and≤24 hours in scrub typhus.
■Inpatient care for only severely ill. Outpatients should be checked
weekly until clinically improving. Patient education for prevention,
especially for travelers to endemic areas. Effective vaccine available
for those at high risk for epidemic typhus.
■Epidemic typhus may relapse if treated within 48 hours of the onset of
symptoms. Recurrent disease responds to 2nd course of antibiotics.
■Scrub typhus may relapse if treatment given within the first 5 days
of illness; treating for 2 weeks decreases the chance of relapse.
■Epidemic typhus can recrudesce years later from lymph nodes, caus-
ing milder, Brill-Zinsser disease.
complications and prognosis
Complications
■Epidemic Typhus: Renal failure/azotemia, CNS abnormalities/sei-
zures, myocardial failure, deafness and tinnitus, respiratory fail-
ure, electrolyte abnormalities (low sodium, calcium and potassium),
hypoalbuminemia, hypovolemia and shock.
■Endemic Typhus: Respiratory failure requiring mechanical ventila-
tion, cerebral hemorrhage, hemolysis (with G6PD deficiency).
■Scrub Typhus: Heart failure, circulatory collapse and pneumonia
cause mortality.Prognosis
■Epidemic Typhus: Up to 40% mortality without treatment, highest in
elderly. Without treatment, fever will lyse after 2 weeks.
■Endemic Typhus: Worse severity with old age, underlying disease,
treatment with sulfa drug; case fatality 1–4%. Usually mild. May be
fatal if misdiagnosed or inadequately treated.
■Scrub Typhus: Untreated, fever resolves in 2 weeks with mortality
0–30%. No mortality with appropriate treatment.