Rickettsiae

Prof. (Dr.) Rajeswar Reddy Kasarla

Professor & Head
Microbiology Department
Universal College of Medical Sciences
Bhairahawa, Nepal
[email protected]
 Introduction

• The rickettsiae are a diverse collection of obligately

intracellular Gram negative bacteria found in ticks,
lice, fleas, mites, chiggers, and mammals
• They include the genera Rickettsia, Orientia, Ehrlichia,
and Coxiella
• zoonotic pathogens
• They infect vascular endothelium & Reticuloendothelial
cells, disseminate in the blood to many organs in
humans & other vertebrate animals
 Named after Howard Taylor Ricketts who discovered
spotted fever rickettsia in 1906 & died of typhus fever
contracted during his study
Rickettsiae share the properties of both viruses & bacteria

 Like viruses-
 1. obligate intracellular parasites
 2. cannot be cultivated in bacteriological media;
 3. grow only in cell cultures & embryonated eggs
 4. and different in genetic properties
But, rickettsiae are considered to be true bacteria,
adapted to obligate intracellular parasitism
 Like bacteria
 1. Gram negative bacilli
 2. possess cell wall
 3. multiply by binary fission
 4. susceptible to antibiotics
 5. possess both RNA and DNA
 6. held back by bacterial filters
 Classification

 Phylogenetically occupy a position between bacteria

and viruses
 Order Rickettsiales
 Tribe Rickettsiae
 Family Rickettsiaceae
 Family Rickettsiaceae comprises 3 genera-
1. Rickettsia
2. Orientia
3. Ehrlichia
 genus Coxiella (Coxiella burnetii) has been excluded
from family Rickettsiaceae & included in order
Legionallales and family Coxiellaceae as it is not
arthropod borne
 genus Rochalimaea (Rochalimaea quintana) has been
excluded from family Rickettsiaceae, as they are not
obligate intracellular parasites & can grow in cell-free
bacteriological media (blood agar)
 Included in family Bartonellaceae and renamed as
Bartonella quintana

 Also differ in genetic properties (16S RNA analysis)

 Fam: Rickettsiaceae

Rickettsia Orientia Ehrlichia

O.tsutsugamushi – 1. Infectious
scrub typhus mononucleosis
Typhus fevers - E. sennetsu
Spotted fevers 2. human monocytic
ehrlichiosis
1. Epidemic typhus – 1. Tick typhus fever - E. chaffeensis
R. prowazekii - R.conori 3. human granulocytic
2. Brill-Zinsser i) Rocky mountain ehrlichiosis
disease spotted fever - E. phagocytophila
(Recrudescent typhus) ii) Siberian tick typhus (E. equi)
3. Endemic typhus – iii) S. African tick typhus
R.mooseri or R. typhi iv) Kenyan tick typhus
v) Mediterranean tick typhus
vi) Indian tick typhus
2. Rickettsial pox – R.akari
Fam: Coxiellaceae

Coxiella
Coxiella burnetti
Q fever
Fam: Bartonellaceae

Bartonella (Rochalimaea
quintana)
Trench fever
Genus Rickettsia
 Morphology

 Gram negative (do not take stain well)

 Coccobacilli (0.3 – 0.6 µ width, 0.8 – 2 µ length)
 pleomorphic
 nonmotile & nonsporing
Red stained Rickettsia rickettsi
visible in cells of Ixodid vector tick
 Cultivation

• cannot grow on bacteriological media

• can be grown in
• 1. yolk sac of embryonated eggs
• 2. continuous cell lines-mouse fibroblast, HeLa, HEp-2,
Detroit-6
• But tissue cultures are not satisfactory for primary
isolation
• 3. Lab animals - Mice, Guinea pigs
• Growth occurs in cytoplasm of infected cells
• In case of spotted fever rickettsia, growth also occurs
in nucleus as well
• Can be propagated in arthropod vectors
(xenodiagnosis)
 Antigenic structure

• possess 3 types of antigens

• 1. Surface Protein antigens (SPA)- group-specific
• 2. Outer Membrane Proteins (OMP-A and OMP-B)
species specific)
• 3. Surface antigen - an alkali-stable polysaccharide
found in some rickettsiae and in Proteus vulgaris OX19
and OX2, Proteus mirabilis OXK strains
• This sharing of antigen between Rickettsiae & Proteus
is the basis of Weil-felix reaction (heterophile
agglutination test) used for the serodiagnosis of
rickettsial infections, by the demonstration of
antibodies to Proteus strains
 Pathogenesis

• Rickettsiae are transmitted to man by the bite or feces

of an arthropod vector, scratched into skin
• Following inoculation into dermis, the organism
multiply locally & spread via lymphatics & blood stream
• It binds to the vascular endothelial cells by means of
the outer membrane protein-A (OMP-A) and induces its
uptake by the endothelial cells in a vesicle
• Subsequently, it escapes from vesicle & multiplies in
cytoplasm by binary fission & spreads from cell to cell
• This leads to damage of vascular endothelial cells
resulting in increased permeability, inflammation,
hemorrhage, necrosis & causing thrombus formation,
with partial or complete occlusion of vascular lumen
• Incubation period is about one week
• Overall clinical features are – acute febrile illness
characterized by septicemia, maculopapular rash, fever
• Occasional hemorrhages may occur
• Fatality rate 20% in untreated cases (due to damage to
vascular endothelium)
• Rickettsiae cause
• 1. typhys fevers
• 2. spotted fevers
 Typhus fever group

This group consists of: a) epidemic typhus

b) brill-zinsser disease
c) endemic typhus
 Epidemic typhus/ Classical typhus/ Gaol fever/
Louse borne typhus
• caused by R. prowazekii, named after Von Prowazek,
who died of typhus fever while investigating disease
• Humans – natural hosts
• Vector is human body louse (Pediculus humanus
corporis)
• Lice may be transferred from person to person
• Infection is transmitted
- When louse feces is rubbed through minute
abrasions
- Occasionally, by aerosols of dried louse feces
through inhalation or through conjunctiva
• Incubation period 5-15 days
• Disease starts with fever & chills with maculopapular
rash appearing on 4th or 5th day
• Patient will have a cloudy state of consciousness
(typhos=smoke or cloud)
Bite by human body louse
Bite by human body louse
Human body louse
Maculopapular rash in
epidemic typhus patient
 Brill-Zinsser disease / Recrudesecnt typhus
• In some patients who recover from epidemic typhus,
rickettsiae may remain latent in lymphoid tissues or
organs for many years
• Such latent infection may at times be reactivated
leading to recrudescent typhus (Brill-Zinsser disease)
• R. prowazekii has been isolated from such patients
 Endemic typhus/
murine flea-borne typhus
• caused by R.mooseri or R. typhi, milder than epidemic
typhus
• maintained in nature as mild infection of rats
(reservoirs)
• Rickettsiae multiply in gut of flea & shed in feces
• Humans acquire infection
- by infected flea bite
- by inhalation through aerosols of dried feces
- by ingestion of food contaminated with rat urine or flea
feces
 Murine typhus symptoms
Rat flea
 Neill-Mooser Reaction / Tunica Reaction
• R.mooseri & R.prowazekii are similar but can be
differentiated by biological & immunological tests
• When male guinea pigs are inoculated intraperitoneally
with blood from a case of endemic typhus or with a
culture of R.mooseri (R.typhi)
• they develop fever & scrotal inflammation
• scotrum becomes enlarged & testes cannot be pushed
back into abdomen because of inflammatory adhesions
between the layers of tunica vaginalis
• known as Neill-Mooser reaction or tunica reaction
• Positive with blood from endemic typhus or R.mooseri
(R. typhi) culture
• Negative with blood from epidemic typhus or
R.prowazekii culture
• Other methods used IFA, ELISA, PCR
 Spotted fever group

This group consists of: a) Tick typhus fever

b) Rickettsial pox
• Rickettsiae of this group possess a common soluble Ag
• They multiply in nucleus as well in cytoplasm
• Transmitted by ticks, except R.akari, which is mite-
borne
 a) Tick typhus fever

• Ticks acts as reservoirs & vectors

• Rickettsiae are transmitted trans-ovarially in ticks
• Rickettsiae shed in tick feces
• Transmission to humans primarily by tick bite
i) Rocky mountain spotted fever
• Caused by R.rickettsii
• Transmitted by ticks (Dermacentor andersoni)
ii) Siberian tick typhus
• Caused by R.siberica
• Transmitted by ticks
iii) S. African tick typhus
• Diseases indistinguishable
iv) Kenyan tick typhus • Caused by R.conori (named
v) Mediterranean tick typhus after Conor)
vi) Indian tick typhus • Transmitted by ticks
Tick
Rocky mountain spotted fever
Rocky mountain
spotted fever
 Rickettsiae and diseases caused by them

Rickettsiae Disease Vector Mode of transmission

1. R. prowazekii Epidemic typhus Human body louse louse feces scratched into skin

Brill-Zinsser disease - -
(recrudescent typhus)
2. R.typhi (R.mooseri) Endemic typhus Rat flea flea bite or flea feces scratched
into skin
3. R.rickettsi Rocky mountain spotted Ixodid ticks tick bite
fever
4. R.conori Boutonneuse fever Ixodid ticks tick bite
(African, Kenyan, Indian
tick typhus fever)
5. R.australis Australian tick typhus Ixodid ticks tick bite

6. R.siberica Siberian tick typhus Ixodid ticks tick bite

7. R.akari Rickettsial pox Mites Mite bite

 b) Rickettsial pox

• Rickettsial pox is a self-limited, non-fatal, vesicular

exanthema also called varicelliform rickettsiosis
• The disease resembles chicken pox, hence the name
• The causative agent is Rickettsia akari, (akari = mite)
• the reservoir is mice and the vector is mite
 Disease Vector Mode of transmission
1. Orientia Scrub typhus Trombiculid mite bite
tsutsugamushi mites

Disease Vector Mode of transmission

1. Ehrlichia Sennetsu fever No vector ingestion of raw fish
sennetsu
2. E. chaffeensis Monocytic Tick Tick bite
ehrlichiosis
3. E. phagocytophila Human granulocytic Ixodid ticks Tick bite
ehrlichiosis

Disease Vector Mode of transmission

1. Coxiella burnetii Q fever - Zoonotic
 Genus: ORIENTIA
Orientia tsutsugamushi
Scrub Typhus
 Scrub Typhus

• It is caused by Orientia tsutsugamushi (formerly

R.tsutsugamushi, R.orientalis)
• (Tsutsuga = dangerous; mushi = insect or mite)
• First observed in Japan
• transmitted by mites
• Mites inhabit sharply demarcated areas in soil, where
microecosystem favorable - mite islands
• It is a place disease associated with scrub vegetation
and when man trespasses into these mite islands he
may be bitten by mite larvae (Chiggers)
• Hence, also called chigger borne disease
• Various rodents, birds act as reservoirs & help in spread
of organism to fresh areas
• O.tsutsugamushi contains three major antigen types-
Karp, Gilliam and Kato
Vector: Chigger-Mite
(Leptotrombidium)
 Vesicular rash and eschar in a patient of scrub typhus

Eschar = Clinical Sign of Scrub Typhus

• 4 factors (zoonotic tetrad) essential for establishment
of infection – coexistence & intimate relationship
among i) O.tsutsugamushi ii) chiggers iii) rats
iv) transitional/ secondary forms of vegetation
• Incubation period 1-3 weeks
• Bacteria multiply at the bite site and form a papule tha
t ulcerates & becomes necrotic lesion called eschar
• Regional lymphadenopathy develops & progresses to ge
neralized lymphadenopathy in a few days
• The disease sets in with fever, headache, conjunctival
infection
• In the severe cases, it can lead to
• -Pneumonia with adult respiratory distress syndrome
• -Circulatory failure resulting in death
 Dry Habitats Wet Habitats
Scrub Area The term scrub of RiceField
scrub typhus came
from the type of
vegetations (terrain
between woods &
clearings) that harbor
the vectors.
Areas Around Houses
Moist Areas: Swamp & Bog

Edges of Dense Forest

Genus: EHRLICHIA
• Small Gram negative bacilli
• Obligate intracelluar parasite, with an affinity towards
blood cells
• They grow in cytoplasm of phagocytic cells, within
phagosomes as mulberry-like clusters called Morula
(=mulberry)
• Tick borne
• Similar organisms Anaplasma, Cowdria, Neorickettsia
known as causative agents of tick-borne infections in
cattle & sheep
• Cause 3 infections in humans
• 1. Infectious Mononucleosis/Glandular Fever
• Caused by E. sennetsu (sennetsu=glandular fever)
• 2. human monocytic ehrlichiosis
• Caused by E. chaffeensis
• 3. human granulocytic ehrlichiosis
• Caused by E. equi (E. phagocytophila) an equine
pathogen
Lab diagnosis of Rickettsial diseases
• Lab diagnosis consists of
• demonstration of organism or antigen
• isolation of organism, and
• serology
• Demonstration of organism or antigen
• Biopsy specimens from the rash, chronic hepatitis,
impression smears from the organs of infected animals
and endolymph from ticks may be stained with Giemsa,
Macchiavello, Giminez stains and with direct or indirect
immunofluorescence
• In tissue smears Rickettsiae are usually seen as bipolar
rods in the cytoplasm of infected cells
• R.rickettsii may be seen in the nuclei of infected cells
In tissue smears Rickettsiae are usually
seen in the cytoplasm of infected cells
• Isolation of rickettsiae
• Rickettsiae are highly infectious and their isolation
should be attempted with utmost care
• Blood clot ground in skimmed milk or BHI broth is
inoculated intraperitoneally in male guinea pigs or mice
• Smears from the peritoneum, tunica and spleen of
infected animals may be stained by Giemsa or Giminez
methods to demonstrate Rickettsiae
• Rickettsiae can also be grown in the yolk sac of
embryonated egg and cell cultures
• Neill-Mooser Reaction / Tunica Reaction
• When male guinea pigs are inoculated intraperitoneally
with blood from a case of endemic typhus or with a
culture of R.mooseri, they develop fever and a
characteristic scrotal inflammation
• The scortum becomes enlarged and the testes cannot be
pushed back into the abdomen because of inflammatory
adhesions between the layers of tunica vaginalis
• This is known as Neill-Mooser reaction or tunica reaction
• Positive with blood from endemic typhus or R.mooseri
(R. typhi) culture
• Negative with blood from epidemic typhus or
R.prowazekii culture
• Serology
• serodiagnosis may be done by weil-felix reaction, CFT,
IF, latex agglutination test, ELISA
• Weil-Felix Reaction (heterophile tube agglutination
test) used in serodiagnosis of typhus fever caused by
rickettsial species
• The test is negative in rickettsial pox, trench fever and
Q fever
• Patients with rickettsial infection develop antibodies in
their blood, which react with Proteus vulgaris OX 19
and OX 2 and Proteus mirabilis OX K due to sharing of
an alkaline stable carbohydrate antigen
• The antibody appears rapidly and reaches a peak titre
up to 1:1000 or 1:5000 by the second week and declines
rapidly in convalescence
• Sera from epidemic and endemic typhus and tick borne
spotted fever agglutinate Proteus vulgaris OX 19 & OX 2
• Sera from scrub typhus agglutinates Proteus mirabilis
OX K
Genus: Coxiella

Q fever
• Q Fever is a disease of cattle, sheep and poultry
caused by Coxiella burnetii
• Infection is transmitted among them by ticks
• Bacilli are shed in milk and conception products
• zoonotic disease; Man acquires infection due to
consumption of infected milk, handling of infected
wool, hides etc.
• The bacilli enter through skin, mucus membranes, lungs
and GI tract
• Coxiella burnetii is pleomorphic, filterable, Gram
negative, but appears Gram positive when alcoholic
iodine is used as mordant
• It is relatively resistant to physical and chemical agents
and survives the Holder method in pasteurization
• It grows well in yolk sac of chick embryos and in cell
cultures
• It exhibits phase variation
• Fresh isolates are phase I; on repeated passage into yolk
sac, become phase II
• The sera from Q fever patients does not react with
rickettsial antigens or Proteus antigens
Replication of C. burnetii
Bartonella (Rochalimaea) quintana

Trench fever
• Trench Fever is a five day fever transmitted by louse
• The causative agent is Bartonella (Rochalimaea)
quintana and it differs from Rickettsia in the following
respects:
• a) Occurs extracellularly in vector
• b) Grows poorly in yolk sac of chick embryos
• c) It does not cause experimental infections in any
animal except monkeys
• d) Can grow on bacteriological media like blood agar
• e) Sera from patients cannot react with rickettsial or
Proteus antigens
 TREATMENT

• Rickettsial diseases may be treated with tetracycline or

chloramphenicol
The End