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Flea-borne R. typhi infections cause extreme discomfort but are seldom fatal healthy young individuals. The difficulty in detecting a rash in darkly pigmented skin was evident in a study finding only 20% of experimentally infected African-American volunteers had rashes, compared to 80% of Caucasian volunteers. The infection can follow a mild course in children with as many as half suffering only fever at night, but necessitates intensive care unit support in 10% of hospitalized adult patients. Pneumonitis or meningoencephalitis can be the major manifestation in some patients.