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Rickettsia prowazekii infections occur in three situations: louse-transmitted epidemics, reactivation of a long-standing latent infection, and zoonotic infection transmitted from flying squirrels by their ectoparasites. Onset of disease is characterized by fever, chills, headache, and myalgia. Macules of 2-6 mm usually appear first on the trunk on day 5 and later spread to the extremities. Rales, conjunctival injection, and delirium are frequent manifestations. Reactivated typhus is a milder version with the same signs and symptoms. Flying squirrel-associated typhus has also been described as less severe; whether this is due to antimicrobial treatment or less virulent strains of rickettsiae is unclear.