Rickettsial infections and Q fever amongst febrile patients in Bhutan

There is limited evidence of rickettsial diseases in Bhutan. We explored the contribution of rickettsioses as a cause of undifferentiated febrile illness in patients presenting to 14 Bhutanese hospitals from October 2014 to June 2015. Obvious causes of fever were excluded clinically. Clinico-demographic information and acute blood samples were collected. Samples were tested by immunofluorescence assay (IFA) and qPCR against scrub typhus group (STG), spotted fever group (SFG) and typhus group (TG) rickettsiae, and Q fever (QF). Of the 1044 patients, 539 (51.6%) were female and the mean age was 31.5 years. At least 159 (15.2%) of the patients had evidence of a concurrent rickettsial infection. Of these, 70 (6.7%), 46 (4.4%), 4 (0.4%), and 29 (2.8%) were diagnosed as acute infections with STG, SFG, TG, and QF respectively. Ten (1.0%) patients were seropositive for both SFG and TG. Seven of the 70 STG patients were positive by qPCR. Eschar (p < 0.001), myalgia (p = 0.003), and lymphadenopathy (p = 0.049) were significantly associated with STG, but no specific symptoms were associated with the other infections. Disease incidences were not different between age groups, genders, occupations, and districts, except for students with significantly lower odds of infection with STG (OR = 0.43; 95% CI = 0.20, 0.93; p = 0.031). Rickettsioses were responsible for at least 15% of undifferentiated febrile illnesses in Bhutan, scrub typhus being the commonest. Health authorities should ensure that health services are equipped to manage these infections.