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Psittacosis
Article Last Updated: Jun 27, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Coauthor(s):
Farhad Arjomand, MD, Pulmonary Fellow, Department of Internal Medicine, Division of Pulmonary and Critical Care, Brooklyn Hospital Center, Cornell University School of Medicine
Editors: Kenneth C Earhart, MD, Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard B Brown, MD, FACP, Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine; Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital; Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Author and Editor Disclosure
Synonyms and related keywords:
psittacosis, ornithosis, parrot fever, Chlamydia psittaci, C psittaci, avian-acquired psittacosis
Background
Psittacosis is an infection caused by the obligatory intracellular bacterium Chlamydia psittaci. The term psittacosis is derived from the Greek word for parrot, psittakos, and was first used by Morange in 1892. This bacterium can infect parrots, parakeets, canaries, and other avian species (eg, turkeys, pigeons, ducks). Another term for this infection is ornithosis, which describes the infection caused by nonpsittacine birds. The largest epidemic occurred in 1930 and affected 750-800 individuals. This epidemic led to the isolation of C psittaci in several laboratories in Europe and the United States. Psittacosis is an occupational disease of zoo and pet-shop employees, poultry farmers, and ranchers. Human-to-human transmission is rare, but possible. These cases may cause more severe disease than avian-acquired psittacosis.
Psittacosis is probably underdiagnosed.
Pathophysiology
The primary route for infection is through the respiratory system. Infection develops after organisms from aerosolized dried avian excreta or respiratory secretions from sick birds are inhaled. C psittaci attaches to the respiratory epithelial cells. After the initial inoculation, the organism spreads via the blood stream to the reticuloendothelial system. Subsequently, secondary bacteremia causes lung infection. Humans may acquire disease by handling sick birds. Mouth-to-beak resuscitation has also been implicated in transmission. Transient exposure to infected birds may cause symptomatic infection, even in visitors to pet shops.
Frequency
United States
Reports show up to 200 cases of psittacosis annually. From 1988-97, the US Centers for Disease Control and Prevention (CDC) received 766 reports of psittacosis, which is probably an underestimate of the actual number of cases because psittacosis is difficult to diagnose, is covered by macrolide antimicrobials (which may be used empirically for therapy of community-acquired pneumonia), and often goes reported. From 1988-2003, 935 human cases of psittacosis were reported to the CDC.1
International
Psittacosis is found worldwide. The incidence seems to be increasing in developed countries, which is correlated to the import of exotic birds.
Breed
Certain strains of C psittaci infect sheep, goats, and cows and may cause chronic infection and abortion.
- Wild birds such as falcons have caused disease through nasal or fecal secretions.
- Mowing lawns without a grass catcher has been found to be a risk factor.
- Most diseases resulted from exposure to infected pet birds, usually cockatiels, parakeets, parrots, and macaws.
Mortality/Morbidity
The mortality rate prior to the advent of antimicrobial treatment was approximately 15-20%. The mortality rate is less than 1% with appropriate antibiotic therapy.
Race
No race predilection is observed.
Sex
No sex predilection is observed.
Age
Psittacosis occurs in all age groups, including children. The infection is more common among individuals in the middle decades of life.
History
The incubation period is generally 5-14 days. The longest observed incubation time was 54 days. The predominant presentation is respiratory tract infection with constitutional symptoms. Clinical findings are variable. - Constitutional
- Fever (50-90%)
- Chills
- Malaise
- Respiratory
- Cough (50-90%), usually not productive
- Pleuritic chest pain (rare)
- Dyspnea
- Sore throat and mild pharyngitis (common)
- Epistaxis (common)
- Gastrointestinal
- Nausea and vomiting (uncommon)
- Abdominal pain (uncommon)
- Diarrhea (rare)
- Jaundice (rare)
- Neurological
- Severe headache (common)
- Photophobia (common)
- Agitation and lethargy
- Dermatological - Includes facial rash (Horder spots)
Physical
Disease may range from mild insidious presentations to severe pneumonia that requires mechanical ventilation.
- Respiratory
- Nonspecific auscultatory findings that often underestimate clinical and radiographic findings may develop.
- Patients may develop fatal pulmonary embolism and pulmonary infarction.
- Pleural effusion is rare.
- Cardiac
- Relative bradycardia is common.
- Physicians may observe pericarditis, culture-negative endocarditis, and myocarditis.
- Gastrointestinal
- Splenomegaly occurs in 10-70% of patients, depending on the study.
- When present, this sign suggests psittacosis in patients with pneumonia.
- Neurological
- Patients may develop meningitis, encephalitis, seizures, and Guillain-Barré syndrome, but these are rare.
- Cerebrospinal fluid (CSF) findings are usually normal.
- Dermatological
- Hematological
- Renal symptoms include acute glomerulonephritis and tubulointerstitial nephritis.
- Musculoskeletal symptoms include reactive arthritis that is usually polyarticular. Rarely, rhabdomyolysis has been observed.2
- Stages of disease progression
1. Flulike syndromes without radiographic abnormalities 2. Mild-to-moderate pneumonia 3. Severe pneumonia 4. Acute respiratory failure, sepsis, and septic shock
Causes
Psittacosis is an infectious disease caused by the obligatory intracellular bacterium C psittaci. - C psittaci is associated with psittacine birds and poultry.
- Psittacosis is an occupational disease of poultry farmers, pet-shop workers, and veterinarians.
- Relapses may occur.
- Because psittacosis is a bacterial disease, major protective immunity is unlikely to develop after a single episode of disease. The exact risk of recurrence upon reexposure is unknown. It is reasonable to advise avoidance of infected birds.
Brucellosis
Chlamydial Pneumonias
Infective Endocarditis
Legionnaires Disease
Mycoplasma Infections
Pneumonia, Bacterial
Pneumonia, Fungal
Pneumonia, Viral
Q Fever
Tuberculosis
Tularemia
Typhoid Fever
Other Problems to be Considered
Coxiella burnetii infection
Francisella tularensis infection
Atypical pneumonia (all causes)
Lab Studies
- White blood cell counts are normal to mildly decreased.
- Liver function test values are usually mildly increased.
- The erythrocyte sedimentation rate (ESR) may be elevated.
- Urinalysis may show mild proteinuria (<3500 mg/d).
- Culturing of C psittaci is possible, but this practice is avoided because it can be hazardous to laboratory personnel.
- Test acute-phase serum and convalescent-phase serum 2 weeks after onset to confirm a 4-fold or greater rise in the titer. Complement fixation (CF) is not a specific test and may cross-react with other chlamydial species.
- Physicians use microimmunofluorescence (MIF) and polymerase chain reaction (PCR) studies to detect different chlamydial species. PCR may develop into an early and specific detection test.
- Enzyme-linked immunosorbent assay (ELISA) and direct immunofluorescence (DIF) are experimental in this setting, but physicians have used them to help diagnose C psittaci infection.
- Serologic tests are the mainstays of diagnosis; however, because of the delayed appearance of specific antibodies, these tests are not helpful in emergent clinical management.
Imaging Studies
- Chest radiographic findings are abnormal in up to 90% of cases.
- The most common finding is unilateral, lower-lobe dense infiltrate/consolidation. Psittacosis may present in a bilateral, nodular, miliary, or interstitial pattern.
- Rarely, patients develop pleural effusion.
- Chest radiograph abnormalities resolve within an average of 6 weeks (range, 3-20 wk).
Other Tests
- Few patients have CSF abnormalities.
- CDC criteria for C psittaci infection include the following:
- Confirmed cases produce a positive culture result for C psittaci from respiratory secretions, a 4-fold increase in antibody titer in 2 serum samples obtained via CF or MIF 2 weeks apart, or immunoglobulin M (IgM) antibodies against C psittaci, as detected by MIF to a reciprocal titer of 16.
- Possible cases show the presence of antibodies against C psittaci with titers of 1:32 by CF or MIF.
Histologic Findings
Findings may include tracheobronchitis and interstitial pneumonitis with air-space involvement and predominant mononuclear cell infiltration. Findings may also include macrophages that contain cytoplasmic inclusion bodies (ie, Levinthal-Coles-Lillie [LCL] bodies), focal necrosis of hepatocytes along with Kupffer cell hyperplasia in the liver, and hepatic noncaseating granulomata.
Medical Care
Consider the diagnosis of psittacosis in patients with community-acquired pneumonia who have been exposed to birds. The mainstay of medical care is antibiotic therapy.
Consultations
- Notify public health authorities about cases of psittacosis.
- Obtain a consultation with an infectious disease specialist.
Diet
Patients require no specific diet.
Activity
Patients do not require activity restrictions.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. Tetracycline and doxycycline are the antibiotics of choice. Treating patients for 2-3 weeks usually prevents relapse. Clinical response occurs within 24-72 hours. Use erythromycin in children younger than 9 years and in pregnant women. Chloramphenicol is a third alternative antibiotic. Doxycycline remains the drug of choice. Macrolide and quinolone failures have been observed.
| Drug Name | Azithromycin (Zithromax) |
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| Description | Anecdotal reports suggest that it is effective. Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
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| Adult Dose | Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Community-acquired pneumonia: 500 mg PO/IV qd for 7-10 d |
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| Pediatric Dose | <6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
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| Contraindications | Documented hypersensitivity; hepatic impairment; do not administer with pimozide |
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| Interactions | May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals |
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| Drug Name | Doxycycline (Vibramycin) |
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| Description | DOC; inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Continue treatment for at least 2 wk to prevent relapse. |
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| Adult Dose | 100 mg PO bid
Severe cases: 4.4 mg/kg IV q12h |
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| Pediatric Dose | <8 years: not recommended
>8 years and <100 lb: 2 mg/kg/d in PO/IV in 1-2 divided doses on day 1; then 1-2 mg/kg/d in 1-2 divided doses; not to exceed 200 mg/d
>8 years and >100 lb: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Bioavailability decreases slightly with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Photosensitivity is very rare with prolonged exposure to sunlight; avoid during last half of pregnancy through 8 y |
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| Drug Name | Erythromycin (E-Mycin, Ery-Tab, E.E.S.) |
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| Description | Macrolide antibiotic; second DOC. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, administer half total daily dose q12h. For more severe infections, double the dose. |
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| Adult Dose | 500 mg erythromycin stearate/base (or 800 mg ethylsuccinate) PO qid 1 h ac for 2-3 wk
Alternatively, use 333 mg q8h; increase up to 4 g/d, depending on severity of infection |
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| Pediatric Dose | 30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection |
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| Contraindications | Documented hypersensitivity; hepatic impairment |
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| Interactions | Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur |
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| Drug Name | Chloramphenicol (Chloromycetin) |
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| Description | Third DOC but rarely used in the US. Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. |
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| Adult Dose | 500 mg IV qid for 2-3 wk |
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| Pediatric Dose | 50-100 mg/kg/d IV divided q6h for 2-3 wk |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase and cause toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (ie, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (ie, gray syndrome) |
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| Drug Name | Moxifloxacin (Avelox) |
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| Description | Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription. Anecdotal reports suggest that this drug is effective. |
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| Adult Dose | 400 mg PO/IV qd |
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| Pediatric Dose | <18 years: Not recommended
>18 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; known QT prolongation, concurrent administration of drugs that cause QT prolongation |
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| Interactions | Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in CNS disorders and caused tendinitis or tendon rupture |
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Further Inpatient Care
- Severe infection requires intravenous antibiotics and hospital admission.
- Isolation is not indicated during hospital stay.
Further Outpatient Care
- Instruct patients to see a physician if symptoms recur (ie, relapse).
- Patients with relapses may need prolonged retreatment (eg, 3-4 wk).
In/Out Patient Meds
- Patients may require doxycycline, usually 100 mg IV; alternatively, consider PO administration with the same dose twice a day.
- Chloramphenicol is the third drug of choice but is rarely used in the United States.
- Consider changing erythromycin from intravenous to oral administration (eg, 500 mg qid).
- Chloramphenicol is rarely used in the United States because it may cause agranulocytosis.
- Consider changing quinolones from intravenous to oral administration.
Transfer
- Transfer patients with acute respiratory failure to an intensive care unit.
Deterrence/Prevention
- Instruct high-risk individuals to avoid handling newly imported or sick birds.
Complications
- Acute respiratory failure
- Pericarditis
- Myocarditis
- Culture-negative endocarditis
- Renal failure (rare, only a few case reports)
- Disseminated intravascular coagulation (rare)
- Arterial embolism (rare, 2 case reports)
- Pancreatitis
- Reactive arthritis
- Transverse myelitis
- Meningitis or encephalitis
Prognosis
- With appropriate antibiotic therapy, the mortality rate is less than 1%.
- Hypoxemia and renal failure portend a poor prognosis.
Patient Education
- Warn pet owners and pet-shop and poultry workers to be aware of possible respiratory symptoms and fever.
- For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education article Chlamydia.
Medical/Legal Pitfalls
- Failure to make the proper diagnosis (Psittacosis may be easily overlooked, but adherence to published guidelines for the management of community-acquired pneumonia covers this pathogen.)
- Failure to realize that the natural history of the disease carries an approximately 15% mortality rate and the concomitant need for appropriate empiric therapy
- Failure to maintain a high index of suspicion
- Failure to inquire about bird exposure and occupational considerations
- Failure to realize that doxycycline is not recommended in children because it may cause tooth discoloration
Special Concerns
- Educate high-risk individuals about the symptoms of psittacosis. These individuals include zoo workers and pet-shop owners, among others. Individuals must keep accurate records of all bird transactions.
- Avoid purchasing or selling birds that have ocular or nasal discharge, diarrhea, or low body weight.
- Isolate imported and exotic birds for 30-45 days. Test these birds or treat them with prophylaxis.
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Psittacosis excerpt Article Last Updated: Jun 27, 2008
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