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Referral and warning signs
When to refer
Refer to Hospital (HC4/H) if: Severe illness (confusion, respiratory distress, shock). Complications suspected. Diagnosis uncertain. Patient requires IV antibiotics or close monitoring.
Red flags
- Altered mental status / Confusion / Coma.
- Signs of shock.
- Respiratory distress.
- Severe rash / Purpura.
- Signs of end-organ damage (renal failure, myocarditis).
Signs and symptoms
- General Features (common to types, severity varies):
- - Abrupt onset of fever, chills.
- - Severe headache.
- - Myalgia (muscle pains), arthralgia.
- - Malaise, profound weakness.
- - Rash: Typically macular or maculopapular, appears around day 5. Distribution varies:
- - Epidemic Typhus (Louse-borne): Starts trunk -> spreads peripherally (spares face, palms, soles).
- - Murine Typhus (Flea-borne): Similar to epidemic but less severe rash, often more sparse.
- - Scrub Typhus (Mite-borne): Maculopapular rash; often an eschar (dark scab) at mite bite site.
- - Cough (dry).
- - Nausea, vomiting.
- - Confusion, delirium, stupor (especially in severe epidemic typhus - 'typhus nodule' pathology).
- - Conjunctival injection.
- - Hepatosplenomegaly, Jaundice (less common).
Risk factors
- Epidemic Typhus (R. prowazekii): Infestation with body lice (Pediculus humanus corporis). Associated with overcrowding, poor hygiene, poverty, war, famine, refugee camps.
- Murine Typhus (R. typhi): Contact with rats/rodents and their fleas (Xenopsylla cheopis). Often urban/port areas.
- Scrub Typhus (Orientia tsutsugamushi): Exposure to infected larval mites (chiggers) in grassy/brushy areas (farmers, hikers in endemic zones - Asia, Pacific, N. Australia).
Diagnosis
Clinical assessment
Suspicion based on acute febrile illness with headache, rash, and relevant epidemiological exposure (lice, fleas/rats, mites/environment). Epidemic typhus often occurs in outbreaks.
Differential diagnosis
- Typhoid fever.
- Malaria.
- Meningococcaemia.
- Measles / Other viral exanthems.
- Dengue fever.
- Leptospirosis.
- Brucellosis.
- Relapsing fever.
Investigations
- Serology: Mainstay of diagnosis. Detection of specific antibodies (IgM/IgG) using IFA (Indirect Fluorescent Antibody) test or ELISA. Requires acute and convalescent samples (4-fold rise in titre).
- Weil-Felix Test: Older agglutination test using Proteus antigens. Non-specific and unreliable, cross-reacts with other conditions. NOT recommended for definitive diagnosis.
- PCR on blood or tissue biopsy (eschar): Can provide early diagnosis (specialized labs).
- FBC (may show thrombocytopenia, normal/low WBC).
Diagnostic criteria
Clinical suspicion + Epidemiological link + Serological confirmation (IFA/ELISA). Weil-Felix is unreliable.
Management
Non-pharmacological management
- Supportive care (hydration, rest).
- Fever control (paracetamol).
- Delousing: For epidemic (louse-borne) typhus - treat patient, clothing, and bedding with appropriate insecticide (e.g., Permethrin, Malathion) to prevent spread.
Pharmacological treatment
- Antibiotic Therapy (Highly effective if started early): (LOC: HC2+)
- - First line: Doxycycline 100mg PO Q12H for 5-7 days (or until 3 days after fever resolves). (Child >8y: 2 mg/kg/dose Q12H).
- - Single dose Doxycycline 200mg PO may be effective for epidemic typhus but higher relapse risk.
- - Alternative: Chloramphenicol 500mg PO/IV Q6H for 5-7 days. (Child: 15 mg/kg/dose Q6H). Use if doxycycline contraindicated (e.g., young children <8y, pregnancy - weigh risk/benefit). (LOC: HC4)
- - Azithromycin may be alternative for scrub typhus.
Monitoring
Monitor fever resolution and clinical improvement. Monitor for complications.
Complications
- Severe disease (esp. epidemic typhus): Pneumonia, Myocarditis, Encephalitis, Renal failure, Gangrene, Vascular collapse, Death.
- Relapse (Brill-Zinsser disease - reactivation of epidemic typhus years later).
Prevention
- Epidemic Typhus: Louse control (personal hygiene, washing clothes/bedding, insecticides during outbreaks).
- Murine Typhus: Rodent and flea control.
- Scrub Typhus: Avoid mite-infested areas, use insect repellent (DEET), wear protective clothing.
- Prompt treatment of cases.
Patient education
- Explanation of the infection and vector (lice, fleas, mites).
- Importance of completing antibiotic course (Doxycycline highly effective).
- Delousing measures if epidemic typhus.
- Prevention strategies relevant to the type of typhus.
Uganda-specific notes
Epidemic (louse-borne) typhus is the type historically reported in Uganda, often linked to conditions favouring louse infestation. Murine/Scrub typhus less recognized but possible. Diagnosis often presumptive based on clinical picture and response to Doxycycline. Weil-Felix test still sometimes used but unreliable.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.1.10