|Year : 2015 | Volume
| Issue : 1 | Page : 47-49
A case report of scrub typhus
Pothukuchi Venkata Krishna, Shaik Ahmed, Katreddy Venkata Narasimha Reddy
Department of General Medicine, Guntur Medical College and Government General Hospital, Guntur, Andhra Pradesh, India
|Date of Web Publication||16-Mar-2015|
Dr. Pothukuchi Venkata Krishna
57-9-15, New Postal Colony, Patamata, Vijayawada - 520 010, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Although scrub typhus is endemic in our country, it is grossly under diagnosed owing to the nonspecific clinical presentation, lack of access to specific diagnostic facilities in most areas, and low index of suspicion by the clinicians. It presents as either a nonspecific febrile illness with constitutional symptoms such as fever, rash, myalgias and headache or with organ dysfunctions involving organs such as kidney (acute renal failure), liver (hepatitis), lungs (acute respiratory distress syndrome), central nervous system (meningitis), or with circulatory collapse with hemorrhagic features. We are reporting a case report of scrub typhus presenting as fever with bilateral bronchopneumonia.
Keywords: Bilateral bronchopneumonia, eschar, fever, scrub typhus
|How to cite this article:|
Krishna PV, Ahmed S, Narasimha Reddy KV. A case report of scrub typhus. J NTR Univ Health Sci 2015;4:47-9
| Introduction|| |
Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi (Rickettsia tsutsugamushi). In India, the presence of scrub typhus and other Rickettsial diseases has been known for several decades. During World War II, scrub typhus produced considerable morbidity and mortality among troops deployed In Southeast Asia. However, there has been a considerable decline in the incidence of scrub typhus in the later decades.  Rickettsiosis is generally believed to have disappeared from many parts of India. 
Recent reports from several parts of India, including South India, indicate that there is a resurgence of scrub typhus.  In India, epidemics of scrub typhus have been reported from North, East and South India. ,,,,,,,, There are no case reports of scrub typhus from the coastal Andhra Pradesh in the literature, though we are encountering the cases sporadically recently. The public health importance of this disease is underestimated because of difficulties with the clinical diagnosis and lack of laboratory methods in many geographical areas.  So we are presenting a case of scrub typhus from coastal Andhra Pradesh.
| Case Report|| |
A 65-year-old male agricultural laborer from Chinnaganjam, Prakasam district, Andhra Pradesh was presented with symptoms of high-grade fever since 10 days followed by pedal edema and decreased urine output since 4 days and shortness of breath after 2 days which were associated with dry cough. There was no history of paroxysmal nocturnal dyspnea and orthopnea. History of epistaxis was present since 1 day. Patient had taken some treatment outside, but treatment particulars were not available. There was no history of travel to another place. On examination, his blood pressure was 130/80 mm Hg, pulse rate was 88/min, patient was afebrile. There were no rashes or jaundice or pedal edema, liver, and spleen was not palpable. Cardiovascular examination revealed no abnormality. Examination of lungs revealed bilateral crepitations, which were heard more on the left side. Blood was sent for investigations and treatment was started with ceftriaxone. Investigations revealed hemoglobin -9.1 mg/dl, platelet count -30,000/mm 3 , blood urea -96 mg/dl, serum creatinine -1.8 mg/dl, blood sugar -71 mg/dl, serum electrolytes: Sodium -142 mm, potassium -3.7 mm, chlorine -106 mm, bicarbonate -17 mm, X-ray chest was suggestive of bilateral bronchopneumonia [Figure 1]. Malaria strip test and blood smear for malarial parasite were negative. Leptospiral IgG and IgM enzyme-linked immunosorbent assay (ELISA) test was negative.
Patient condition was not improved on 3 rd day after admission. His pulse rate was 110/min, blood pressure was 110/60 mmHg and oxygen saturation was 45%. O 2 supplementation was given by mask and thorough examination was done which revealed an eschar [Figure 2] on the left upper arm near the axilla. Then, tablet azithromycin 500 mg/day and tablet doxycycline 200 mg/day were started. Blood sample was sent for Weil Felix reaction and ELISA for scrub typhus. Weil Felix reaction was positive, and IgM ELISA for scrub typhus was also positive. Next day, patient condition was deteriorated further. Patient developed hypotension for which patient was given inotropic support, hydrocortisone injection and ventilator support but final patient was succumbed to death.
| Discussion|| |
Man is accidentally infected when he encroaches the mite-infested areas, known as the mite islands. These areas consist of areas with secondary scrub growth, which grows after the clearance of primary forest, and hence the term scrub typhus. However, the infection can occur in diverse habitats such as seashore, rice fields, and even semi-deserts. ,
Most cases in disease-endemic areas occur through agricultural exposure such as working in rice fields in South Korea, Thailand and Japan and in oil palm and rubber plantations in Malaysia. Living at the edge of the village, living in the houses near grassland, vegetable field or ditch, house yard without cement floor, piling weeds in the house or yard, all of these were risk factors for scrub typhus infection. Working in vegetable fields and hilly areas, and harvesting in autumn posed the highest risks. 
Fever is most common feature of scrub typhus and in endemic areas it is one of the causes of "fever of unknown origin." The clinical manifestations of this disease range from subclinical disease to organ failure to fatal disease.  After ruling out complicated malaria, leptospirosis and dengue fever, many of these cases remained undiagnosed. 
Scrub typhus is grossly under-diagnosed in India due to its nonspecific clinical presentation limited awareness and low index of suspicion among clinicians, and lack of diagnostic facilities. The infection manifests clinically as a nonspecific febrile illness often accompanied by headache, myalgia, nausea, vomiting, diarrhea, cough or breathlessness. Severity varies from subclinical illness to severe illness with multiple organ system involvements, which can be serious enough to be fatal, unless diagnosed early and treated. 
Serious complications of scrub typhus are not uncommon and may be fatal; they include pneumonia, myocarditis, meningo-encephalitis, acute renal failure and gastrointestinal bleeding. Early diagnosis is important because there is usually an excellent response to treatment, and timely antimicrobial therapy may help prevent complications. In developing countries with limited diagnostic facilities, it is prudent to recommend empiric therapy in patients with undifferentiated febrile illness having evidence of multiple system involvements. 
Doxycycline 200 mg/day is the treatment of choice for scrub typhus. Other antibiotics useful for the treatment of this infection are chloramphenicol, azithromycin and rifampicin. Rapid resolution of fever following doxycycline is so characteristic that it can be used as a therapeutic test. , Azithromycin has been proved more effective than doxycycline in doxycycline-susceptible and doxycycline-resistant strains causing scrub typhus. ,
In this case, the patient presented very late - 10 days after his illness started. Initially, we suspected bilateral pneumonia with sepsis or leptospirosis. In the initial examination, we could not find the eschar. With no improvement in clinical condition, another detailed examination of the patient revealed the eschar. Even though, we started azithromycin and doxycycline we could not able to save the patient.
| References|| |
Vivekanandan M, Mani A, Priya YS, Singh AP, Jayakumar S, Purty S. Outbreak of scrub typhus in Pondicherry. J Assoc Physicians India 2010;58:24-8.
Strickman D, Sheer T, Salata K, Hershey J, Dasch G, Kelly D, et al. In vitro
effectiveness of azithromycin against doxycycline-resistant and -susceptible strains of Rickettsia tsutsugamushi, etiologic agent of scrub typhus. Antimicrob Agents Chemother 1995;39:2406-10.
Mathai E, Lloyd G, Cherian T, Abraham OC, Cherian AM. Serological evidence for the continued presence of human rickettsioses in southern India. Ann Trop Med Parasitol 2001;95:395-8.
Varghese GM, Abraham OC, Mathai D, Thomas K, Aaron R, Kavitha ML, et al.
Scrub typhus among hospitalised patients with febrile illness in South India: Magnitude and clinical predictors. J Infect 2006;52:56-60.
Kamarasu K, Malathi M, Rajagopal V, Subramani K, Jagadeeshramasamy D, Mathai E. Serological evidence for wide distribution of spotted fevers & typhus fever in Tamil Nadu. Indian J Med Res 2007;126:128-30.
Mahajan SK, Rolain JM, Sankhyan N, Kaushal RK, Raoult D. Pediatric scrub typhus in Indian Himalayas. Indian J Pediatr 2008;75:947-9.
Somashekar HR, Moses PD, Pavithran S, Mathew LG, Agarwal I, Rolain JM, et al.
Magnitude and features of scrub typhus and spotted fever in children in India. J Trop Pediatr 2006;52:228-9.
Ittyachen AM. Emerging infections in Kerala: A case of scrub typhus. Natl Med J India 2009;22:333-4.
Sharma A, Mahajan S, Gupta ML, Kanga A, Sharma V. Investigation of an outbreak of scrub typhus in the himalayan region of India. Jpn J Infect Dis 2005;58:208-10.
Narvencar KP, Rodrigues S, Nevrekar RP, Dias L, Dias A, Vaz M, et al.
Scrub typhus in patients reporting with acute febrile illness at a tertiary health care institution in Goa. Indian J Med Res 2012;136:1020-4.
Mahajan SK. Scrub typhus. J Assoc Physicians India 2005;53:954-8.
Lyu Y, Tian L, Zhang L, Dou X, Wang X, Li W, et al.
A case-control study of risk factors associated with scrub typhus infection in Beijing, China. PLoS One 2013;8:e63668.
Chogle AR. Diagnosis and treatment of scrub typhus - The Indian scenario. J Assoc Physicians India 2010;58:11-2.
[Figure 1], [Figure 2]