FLEA- AND LOUSE-BORNE TYPHUS GROUP RICKETTSIOSES is a topic covered in the Harrison's Manual of Medicine.

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Etiology and Epidemiology

Caused by R. typhi, endemic murine typhus has a rat reservoir and is transmitted by fleas.

  • Humans become infected when Rickettsia-laden flea feces are scratched into pruritic bite lesions; less often, the flea bite itself transmits the organisms or aerosolized rickettsiae from flea feces are inhaled.
  • In the United States, endemic typhus occurs mainly in southern Texas and southern California; globally, it occurs in warm (often coastal) areas throughout the tropics and subtropics.
  • Flea bites often are not recalled by pts, but exposure to animals such as cats, opossums, raccoons, skunks, and rats is reported by ~40%.
  • Risk factors for severe disease include older age, underlying disease, and treatment with a sulfonamide drug.

Clinical Manifestations

Prodromal symptoms 1–3 days before the abrupt onset of chills and fever include headache, myalgia, arthralgia, nausea, and malaise; nausea and vomiting are nearly universal early in illness.

  • Rash is apparent at presentation (usually ~4 days after symptom onset) in 13% of pts; 2 days later, half of the remaining pts develop a maculopapular rash that involves the trunk more than the extremities, is seldom petechial, and rarely involves the face, palms, or soles.
  • Pulmonary disease is common, causing a hacking, nonproductive cough in 35% of pts. Almost one-fourth of pts who undergo CXR have pulmonary densities due to interstitial pneumonia, pulmonary edema, and pleural effusions.
  • Laboratory abnormalities include anemia, leukopenia early in the course, leukocytosis late in the course, thrombocytopenia, hyponatremia, hypoalbuminemia, mildly increased hepatic aminotransferase levels, and prerenal azotemia.
  • Complications may include respiratory failure, hematemesis, cerebral hemorrhage, and hemolysis.
  • The duration of untreated disease averages 12 days (range, 9–18 days).


The diagnosis can be based on culture, PCR, serologic studies of acute- and convalescent-phase sera, or immunohistology, but most pts are treated empirically.


Doxycycline (100 mg PO bid for 7–15 days) is effective. Ciprofloxacin provides an alternative if doxycycline is contraindicated.

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