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      Murine Typhus in Drug Detoxification Facility, Yunnan Province, China, 2010

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          Abstract

          To the Editor: An outbreak of murine typhus caused by Rickettsia typhi was confirmed among persons attending a 51-acre drug detoxification program 2.5 km from Ruili City in Yunnan Province, People’s Republic of China. Ruili City, with an average altitude of 1,381 km, is located in southwestern China near the Myanmar border (Figure). At the time of the outbreak, the detoxification program had 1,264 inpatients and 96 staff members. The facility is divided into sections A (women), B, C, and D. Residents of each section are housed in a 4-story building; each floor contains 9 rooms (2 m2 per person). During September 4–21, 2010, a total of 76 of the 430 residents of section B were reported with fever of unknown cause. All patients were men 19–38 years of age who worked in clothing manufacture at the facility and were receiving treatment for drug addiction. Before the outbreak, rats and stray cats were frequently observed in a cafeteria in section B. No persons with similar illness were observed in the other 3 sections. Figure A) Location of Ruili City, Yunnan Province, People’s Republic of China (97°51′–98°02′E, 23°38′–24°14′S; altitude 1,381 m). B) Number of murine typhus cases reported from Ruili City Center for Disease Control and Prevention during 2001–2010. To investigate the outbreak, we gathered information about demographics; past medical histories; exposures to vectors, such as ticks, mites, fleas, and lice; and symptoms. Patients frequently reported headache, dizziness, diffuse myalgia, high fever (>39°C), and shivers but did not report a rash or eschar. No patients remembered a flea or louse bite, but they frequently reported seeing rats in the area. The Chinese Center for Disease Control and Prevention (China CDC) Institutional Review Board approved the investigation. Two milliliters of blood was collected from each consenting patient. Separated serum and the remaining blood clots were stored at −70°C and transferred to the Department of Rickettsiology, National Institute of Communicable Disease Control and Prevention, China CDC, for testing. Specimens were tested by indirect immunofluorescence assay ( 1 ) to detect specific IgM and IgG against 10 common rickettsiae: Rickettsia prowazekii, R. typhi, R. heilongjiangensis, Orientia tsutsugamushi types Karp and Kato, Coxiella burnetii, Bartonella henselae, and B. quintana, Ehrlichia chaffeensis, and Anaplasma phagocytophilum. Antigens were prepared by placing the rickettsial stains in L929 cells and HL60 or and DH82 cells, respectively; collecting the culture when Gimenez stain or Wright staining showed positive results; ultrasonically crushing the culture; and purifying the bacteria by density ultracentrifugation. Positive control serum was prepared by inoculating rabbits with the above standard rickettsiae strains. We collected 76 serum samples from patients a median of 4 days (range 1–9 days) after illness onset. Thirty-five (40%) were IgM positive for R. typhi (titer >40, maximum titer 160) and 29 (38%) were IgG positive for R. typhi (titer >80, maximum titer 320). No samples were positive for the other 8 rickettsial antigens, except for 10 (13%) that had weak reactions for R. prowazakii (titer 40). Twelve convalescent-phase serum samples (median interval between acute and convalescent phases 187 days [range 181–192 days]) were IgG positive for R. typhi (titer >80) and 4 had 4-fold increases in titer; 2 reached titers of 1,280 and 2,560. DNA was extracted from acute-phase samples by using a QIAGEN DNA extraction kit (Hilden, Germany) and tested by real-time PCR that targeted the groEL gene of R. prowazekii and R. typhi ( 2 ). Twelve (16%) of the 76 samples were positive. To differentiate between R. prowazekii and R. typhi, we used a previously developed nested PCR targeting the groEL gene of R. prowazekii and R. typhi ( 3 ) and found the expected 218-bp fragments in 11 patients. BLAST analysis (http://blast.ncbi.nlm.nih.gov/Blast.cgi) showed that these sequences (200 bp) were 100% homologous with that of R. typhi strain Wilmington (GenBank accession no. AF017197). Initially, patients were treated with antiviral drugs and Chinese herbal medicine for suspected influenza. Subsequently, murine typhus was suspected and doxycycline was administered. All patients recovered fully. Yunnan Province’s subtropical geographic and climate characteristics are advantageous to the vectors of rickettsial diseases, such as murine typhus, scrub typhus, spotted fever, and Q fever ( 4 – 6 ). Three national murine typhus outbreaks involving >10,000 cases each have been reported since 1949, and each involved Yunnan Province ( 7 ). In the 1970s, an outbreak of louse-borne typhus occurred in northeastern Yunnan Province ( 4 ); since then, louse-borne typhus has been rarely reported. Murine typhus was reported from Baoshan City, east of Ruili City, in 2010. However, the currently reported murine typhus outbreak in Ruili City near the China–Myanmar border was the largest outbreak in China during the previous decade. None of the 76 patients had rash, a finding similar to that reported in previous outbreaks in Myanmar, Thailand, and other Southeast Asia regions ( 8 – 10 ). In addition to the 76 cases reported here, 70 additional sporadic cases of murine typhus were reported to the Ruili CDC in 2010. We conclude that murine typhus should be considered in cases of unexplained fever with nonspecific clinical manifestations in southern Yunnan Province.

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          Emerging Rickettsioses of the Thai-Myanmar Border1

          To investigate the presence of rickettsioses in rural residents of the central Thai-Myanmar border, we tested the blood of 46 patients with fever. Four patients had murine typhus, three patients had scrub typhus, and eight patients had spotted fever group rickettsioses, including the first case of Rickettsia felis infection reported in Asia.
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            Clinical and laboratory features of murine typhus in south Texas, 1980 through 1987.

            --The clinical and laboratory features of patients with murine typhus have not been extensively reviewed since 1946. We have updated these findings in patients from south Texas who were examined by modern clinical and laboratory methods from 1980 through 1987. --Patients were identified by serological methods in this case series, and clinical, epidemiologic, laboratory, and therapeutic data were compiled and analyzed. --The majority of patients (77 of 80) were identified in a primary care community hospital setting; the remainder (3 of 80) were ambulatory hospital outpatients. --From 1980 through 1987, a total of 345 patients were diagnosed with murine typhus; 90 of these patients were seen at four hospitals in south Texas; of these, 80 had clinical and laboratory data available for review. --The frequency of common clinical manifestations (eg, headache, fever, and rash) and laboratory findings (eg, leukocyte and platelet counts and serum chemistry abnormalities) of patients with infectious diseases was tabulated. Clinical severity was semiquantitatively assessed and was correlated with clinical, laboratory, and therapeutic results. --Most cases (69%) occurred from April through August. Rash occurred in 54%; the triad of fever, headache, and rash was observed in only 12.5% of patients when first examined by a physician; respiratory and gastrointestinal symptoms were also frequent. Multiple organ involvement was documented by frequent abnormal laboratory findings of the hematologic, respiratory, hepatic, and renal systems. Disease severity was related to older patient age, the presence of renal dysfunction, leukocytosis, and hypoalbuminemia, and previous therapy with sulfa antibiotics. --Infection by Rickettsia typhi causes a systemic illness with clinical and laboratory abnormalities not previously recognized or described. Early clinical diagnosis and treatment are needed to avoid undue morbidity and mortality.
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              Murine typhus in Thailand: clinical features, diagnosis and treatment.

              One hundred and thirty-seven patients with murine typhus were reviewed. A history of direct contact with rats was rare, and none gave a history of flea bite. No seasonal trend was observed. Clinical presentations included fever (100%), hepatomegaly (24%), rash (20%) and non-specific signs. Complications were uncommon but included jaundice, pneumonia, renal insufficiency and meningitis. Only two patients died. A single 200 mg dose of doxycycline significantly shortened the duration of fever: 79% were afebrile in 48 h, compared to 15% of the untreated group.
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                Author and article information

                Journal
                Emerg Infect Dis
                Emerging Infect. Dis
                EID
                Emerging Infectious Diseases
                Centers for Disease Control and Prevention
                1080-6040
                1080-6059
                August 2012
                : 18
                : 8
                : 1388-1390
                Affiliations
                [1]Yunnan Institute of Endemic Diseases Control and Prevention, Dali, People’s Republic of China (W.-H. Yang, H.-L. Zhang, Y.-Z. Zhang, Y. Feng);
                [2]People’s Republic of China ICDC, Beijing, People’s Republic of China (T. Dong, S.-W. Wang, H.-L. Yu, J.-G. Xu, L.-J. Zhang);
                [3]Harbin Medical University, Harbin, People’s Republic of China (T. Dong, Z.-Y Qu);
                [4]and Ruili Center for Disease Control and Prevention, Ruili, People’s Republic of China (Y.-H. Liu, Z.-L. Yin)
                Author notes
                Address for correspondence: Li-Juan Zhang, Department of Rickettsiology, National Institute of Communicable Disease Control and Prevention, China CDC, Changping District, Beijing 102206, People’s Republic of China; email: zhanglijuan@ 123456icdc.cn
                Article
                12-0060
                10.3201/eid1808.120060
                3414037
                22840682
                3dbdd3b7-8758-4327-8ac4-3ad0fc6fe830
                History
                Categories
                Letters to the Editor
                Letter

                Infectious disease & Microbiology
                typhus,rickettsia,murine typhus,vector-borne infections,outbreak,china–myanmar border,rickettsia typhi,people’s republic of china

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