Brill Zinsser Disease

Brill-Zinsser Disease

Brill-Zinsser disease or recrudescent typhus is a delayed complication of epidemic typhus in which mild symptoms of epidemic louse-borne typhus reappear after a latent period, usually after several years, in individuals who had contracted epidemic typhus before.^[1]      

Epidemiology

Brill-Zinsser disease occurs in remote areas of countries in north, central and southern Africa, Mexico, central and southern America, middle and western areas of Asia.^[2]

Causes

The causative agent of epidemic typhus, Rickettsia prowazekii  is usually present in the spinal marrow of patients recovering after endemic fever or murine typhus.  The microorganism remains viable in the body of the host and recrudescence can occur several years, in average 10-20 years,  after the initial illness.^[2] On the time that the host's defense is down, it is reactivated causing recurrent typhus. ^[3] The disease is commonly associated with poor personal hygiene.^[2] Brill-Zinsser disease is more common in the elderly. Lice and fleas of flying squirrels spread the bacteria.^[4] The incubation period is 10 - 14 days.^[2]

Symptoms

The symptoms are almost always mild and resemble those of epidemic typhus, with similar circulatory disturbances and hepatic, renal, and CNS changes. The remittent fever lasts about 7 to 10 days. The rash is often evanescent or absent.^[5] The following may also be noted:  severe headache , rash,  chills , muscle pain, kidney dysfunction , altered mental status, cough, delirium, photophobia and joint pain.^[6]

Diagnosis

Physical examination and medical history particularly taking note of a previous infection of epidemic typhus are important in diagnosis. Laboratory studies are the same as that of primary louse-borne epidemic typhus. But in Brill-Zinsser disease, patients develop an anamnestic immune response whereby only IgG is produced.^[7]

Treatment

Treatment is analogous to that of epidemic typhus. Primary treatment for epidemic typhus is doxycycline 200 mg per orem once followed by 100 mg twice a day until the patient improves, has been afebrile for 24 to 48 h, and has received treatment for at least 7 days.  Second line treatment is chloramphenicol  500 mg per orem or IV qid for 7 days.^[5]

References:

1. http://www.britannica.com/EBchecked/topic/79610/Brill-Zinsser-disease
2. http://www.whonamedit.com/synd.cfm/473.html
3. http://www.encyclo.co.uk/define/brill-zinsser%20disease
4. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002339/
5. http://www.merckmanuals.com/professional/infectious_diseases/rickettsiae_and_related_organisms/epidemic_typhus.html
6. http://www.rightdiagnosis.com/b/brill_zinsser_disease/symptoms.htm
7. http://emedicine.medscape.com/article/968385-workup
   

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