Scrub typhusISP, STANLEY MEDICAL COLLEGE

Dr Renjini (DCH)Dr Ekambaranath.MDDr Sujatha Sridaran.MDDr Karunakaran .MD

CASE SCENARIO 1

4 yr old female child

From Thirupati Andhra Pradesh

FEVER 10 DAYS

ABDOMINAL PAIN 5 DAYS

VOMITING 2 DAYS

FACIAL PUFFINESS 1 DAY

O/e child alert ,febrile

Pallor +

Peripheral pulses +++/+-

CFT >2 sec

Periorbital puffiness+

Eyes congested

VITALS PR : 100 /min RR:32/min

BP :92/ 60 mmof hg

TEMP :102 F

ESCHAR

- Ulcerative lesion with

erythematous rim

- Left inguinal region

No significant lymphadenopathy

SYSTEM EXAMINATIONLiver palpable 5 cm ↓RCM

Soft tender to touch

Spleen palpable 3 cm firm

INVESTIGATIONSHb: 8 gm

TC: 6100

DC: P45 L55

PCV: 24

PL :29000

URE : alb+

PS for MP : NEG

C XRAY : WNL

WIDAL: NEG

SGOT/PT : 121/96

Blood C/S : No growth

MALARIA

DENGUE FEVER

SCRUB TYPHUS

Started on iv fluids after shock correction

Chloroquine started

Azithromycin started on day 2

DISEASE COURSE Fever Continued

2nd Day Devoloped Upgaze Palsy , Tonic

Posturing With Altered Sensorium

Controlled With Inj Phenytoin

QBC Sent Next Day And Started On Artesunate

CT Brain NORMAL

QBC NEGATIVE

Over Next 48 Hrs Child Improved

Platelet Count Increased

DENGUE IgG IgM :NEG

IgM ELISA for SCRUB TYPHUS

POSITIVE

11 Yrs Old Female Child

From Chennai

Fever 10 Days

Vomiting 2 Days

Treated Outside For ENTERIC FEVER

Child Febrile , Alert

Peripheries Cool Below Knee

Pulses +++ /_ _ ; CFT > 2 SEC

HR: 120 ; RR: 32

BP: 60/30 Mm Of Hg

Purpuric Rashes Over Abdomen And Face

ESCHAR Ulcerative Lesion With

Central Necrotic Area

Rt Axilla

Started 4 Days Before

Fever As A Papule

No Significant Lymphadenopathy

System ExaminationLiver Palpable 6cm ↓RCM

Soft ; Tender To Touch

Spleen 2 Cm ↓ LCM Firm

INVESTIGATIONS

Hb : 8

TC :4100

DC : P 50 L 47 E03

ESR : 8/22

PL :72000

URE alb 1+

PS FOR MP : NEG

C XRAY: WNL

SGOT/PT : 68/48

DIFFERENTIAL DIAGNOSIS

DENGUE FEVER

MALARIA

ENTERIC FEVER

SCRUB TYPHUS

Shock Correction With RL And Colloids

Started On Ceftriaxone

Supportive Care

Chloroquine Started

DISEASE COURSE Fever Was Persisting

On 2nd day Platelet decreased to 32000Facial puffiness And Pedal Edema

Increased Tachypnea

Evidence Of Pleural Effusion And Ascites

On 6th Day Fever Still Persisting

C/O Diplopia

O/E : B/L LR Palsy Blurred Disc Margin

Clouding Of Consciousness

Neck Rigidity + + ; Plantar ↑↑

CT Brain NORMAL

LP Done

Started On ARTESUNATE and AZITHROMYCIN

Fever Spikes Decreased In 48 To 72 Hrs

Recovered From LR Palsy

Sensorium Improved.

Other InvestigationsWidal –Neg

Mx – Neg

MSAT- Neg

Dengue IgG IgM-Neg

Blood C&S - No growth

LP Protein:40

Sugar :54

Acellular

No Growth

Rpt Platelet -

1.2Lac

POSITIVE

SCRUB TYPHUS

Reemerging infectious disease

Agent – Orientia tsutsugamushi

Vector – Reservoir – Chiggers

- larva of trombiculid mite ;Leptotrombidium

Gram Neg Obligate Intracellular Bacteria

Lack Cellwall.

CHIGGER

reservoir

Larval stage

vector

Mode of Transmission

Mite

Rats & Mice

Humans

Mite

No direct person to person transmission

(Accidental host)

Man – accidental host

Vector to human transmission

bite while feeding

No person to person transmission

except – blood transfusion

- organ transplantation

EPIDEMIOLOGY

Himalayan regions

South India

Tamil Nadu

Kerala

Andhra Pradesh

Karnataka

PATHOGENESIS

Local multiplication

Invade vascular endothelium

& RE cells

Vasculitis

Skin rash,microvascular leak

Edema, Tissue hypoperfusion

Inflammaton & vascular leakage

Interstitial pneumonitisNon cardiogenic pulmonary edema

Cerebral edemaMeningoencephalitis

Inf. Of endothelial cells - procoagulant activity

DIC

Ip 5 To 12 Days ;Mean 10 – 20 D

Fever ; High Grade With Shaking Chills

Regional Or Generalised Lymphadenopathy---20 % To 90%

Hepatomegaly --- 2/3

Splenomegaly ---- 1/3

Clinical features

Eschar

Axilla , Inguinal Region,genitalia , Neck

7% To 68%

Gastrointestinal Symptoms ----40%

Thrombocytopenia ---1/4 To 1/3

Rashes < 30%

CLINICAL FEATURES

Headache – frontal

less in children

Myalgia – lumbar region,thigh,calf

Rash – 3 to 5 days

- maculopapular,petechial / hemorrhagic

- palpable purpura

- initially near ankles, lower limbs,wrist

- centripetally to whole body

DIFFERENTIAL DIAGNOSIS

Dengue

Malaria

Typhoid

Anthrax

Leptospirosis

Tularemia

COMPLICATIONS

Interstitial pneumonitis --20 TO 35%

Meningoencephalitis syndrome -- 10%

Myocarditis

Aseptic meningitis

Acute renal failure

DIC

INVESTIGATIONS• CBC – Early leucopenia with late lymphocytosis

- Thrombocytopenia- high ESR

• Hyponatremia• Hypoalbuminemia• Elevated transaminases• hyperbilirubinemia• proteinuria

I INVESTIGATON…..

Weil felix test

Complement fixation test

Gold standard IFA

PCR

Ig M ELISA widely used

Case Fatality In Untreated Case --- 30%

TREATMENT

Doxycycline –

5 to 7 days

5mg/kg/day in 2 div doses in < 45kg

200mg/ day in 2 div doses in > 45kg

Azithromycin, Rifampicin in children and in cases resistant to Doxycycline

Supportive care

KEY POINTS Ricketssial infections are prevalent in Various parts of

India

High index of suspicion is needed for early diagnosis Failure of which leads to significant increase in mortality ,morbidity and expensive PUO workup

References

Indian PediatricsVol 47 Feb 17,2010

CDC Ricketssial Disease at http://www.cdc.gov

Batra HV Spotted fever and typhus fever in TamilNaduIndian J Med Res 2007: 126:101-103

Principles and practices of Pediatric Infectious Diseases – Churchill Livingstone

FAQ on Scrub typhus SEARO WHO

THANK YOU