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CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 298-300

Lesson learnt from a missed case of scrub typhus: An interesting case report


1 Mount Tabor Medical Mission Hospital, Mathur, Pudukkottai, India
2 Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Irungalur, Trichy, Tamil Nadu, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Prabha Thangaraj
Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Irungalur, Trichy, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_78_18

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  Abstract 


The diagnosis of scrub typhus, though endemic in several parts of India, is missed due to various reasons such as nonspecific presentation of symptoms, lack of knowledge among treating physician, and poor access to diagnostic facilities. We present a case of scrub typhus in a 43-year-old woman whose clinical diagnosis was missed by two other physicians whom she approached before visiting us. A detailed history of social environment and general examination was sufficient to arrive at a diagnosis which was confirmed by the presence of IgM antibodies against scrub typhus.

Keywords: Eschar, fever, scrub typhus


How to cite this article:
Bagavathinathan M, Thangaraj P. Lesson learnt from a missed case of scrub typhus: An interesting case report. J NTR Univ Health Sci 2018;7:298-300

How to cite this URL:
Bagavathinathan M, Thangaraj P. Lesson learnt from a missed case of scrub typhus: An interesting case report. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Mar 18];7:298-300. Available from: http://www.jdrntruhs.org/text.asp?2018/7/4/298/249834




  Introduction Top


Scrub typhus is caused by Orientia tsutsugamushi, a bacteria which is transmitted to humans by the bite of the larval form of the adult trombiculid mite. The disease is characterized by acute febrile illness, which can involve multiple organ systems and result in significant morbidity and mortality. Around 1 billion people over the world are at risk of developing the infection.[1] In India, scrub typhus has been known for several years and reported in many states starting from Jammu and Kashmir, and Himachal Pradesh in the north, Kerala and Tamil Nadu in the south, Maharashtra in the east, and to Assam in the west.[2] It appears to be a typical neglected tropical disease not only affecting rural populations but also, recently, urban populations.[3] Apart from neglecting the disease, its diagnosis and prevention are also unknown to many.[4] Resurgence of scrub typhus in recent times has been considered as a public health threat in several states of India along with the neighboring countries.[5],[6]

The presence of an eschar of size 5–20 mm at the site of bite of the vector is diagnostic of the disease, but it is present only among 20%–87% of the patients.[7] We here present a case of scrub with typical symptoms and eschar present on the abdomen. The diagnosis was missed by two other physicians before we suspected and diagnosed the patient.


  Case History Top


A 37-year-old female homemaker belonging to upper middle class from an urban area in Trichy district, Tamil Nadu, presented with sudden onset of high-grade fever (102–104°C) for the past 12 days. Her fever was continuous and associated with chills and rigor. She also complained of generalized body ache and severe headache for the past 5 days. During this period, she visited two other physicians and was started on antibiotics (cefixime and cefpodoxime) along with antipyretics with no improvement. She was tested for routine blood investigation which was within normal limits.

On the first day of her visit at our clinic, she was started empirically on injections gentamycin and cefoperazone and asked to visit after 2 days with blood and urine reports. The observations were as follows: hemoglobin 12.5 g/dL; platelet count 220,000 cells/mm3; erythrocyte sedimentation rate – half-hour, 20 mm and 1 h, 60 mm; malarial parasite – negative, urea 16 mg/dL, creatinine 0.6 mg, Widal negative, and liver function tests were within normal limits. Her urine routine was also normal. She continued to have a high temperature of 102°C on her second visit. During this visit, a detailed history was taken regarding the presence of any scar or rash on any part of her body, following which she replied of a healing lesion on her abdomen that was present around 10 days back. Examination of the scar revealed the presence of eschar of size 7 mm [Figure 1]. On further enquiry about her home surrounding and any insect bite, we found the presence of shrubs and wild plants around her house. Her blood sample was sent for scrub typhus antibody IgM which was found reactive. She was started on tablet azithromycin 500 mg OD for 3 days and capsule doxycycline 100 mg BD for 7 days. Her temperature returned to normal within 2 days and she showed significant improvement.
Figure 1: Presence of Eschar of size 7 mm on the abdomen of the patient

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  Discussion Top


Clinical diagnosis of scrub typhus is often missed because of vague symptoms and signs of the illness which are often nonspecific. The nonspecific presentation and also the lack of characteristic eschar in about 40% of patients result in misdiagnosis and underreporting of the disease which is common. Even diagnostic tests are not widely available. Therefore, the precise incidence of the disease is still unknown. Mortality rates among untreated patients can range from 0% to 30%.[8] It is well known that scrub typhus is widely prevalent in many parts of India, but data supporting it are not available.[9]

During the past decade, southern India has witnessed an increase in scrub typhus with outbreaks in winter months. In Tamil Nadu, the most common presentation of the disease is fever with myalgia.[10] Even our case presented in a similar way. Studies published in recent years have also reported cases in north and north-eastern parts of the country.[11],[12],[13]

The presence of eschar is the key to clinical diagnosis which is often missed as the vector bite is painless and the patients do not notice it. A study done on the distribution of eschars among patients in Vellore found that the most common site for its presence was chest and abdomen in females (42.3%) and axilla, groin, and genitalia in males (55.8%).[14] This correlates with our study. Moreover, women are shy to expose their body to the treating physician, and therefore during history-taking, more emphasis on the presence of any abnormal lesion on any body parts should be asked for. Several studies published in the recent years have emphasized the re-emergence of scrub typhus infection and the need for awareness among the treating physician to diagnosis it and give timely treatment.[15],[16],[17] Hence, this study highlights the importance of proper history-taking and clinical examination before asking for blood report. We also stress on the need for social environment history that can also contribute significantly toward the diagnosis of the disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kelly DJ, Fuerst PA, Ching WM, Richards AL. Scrub typhus: The geographic distribution of phenotypic and genotypic variants of Orientia tsutsugamushi. Clin Infect Dis 2009;48(Suppl. 3):S203-30.  Back to cited text no. 1
    
2.
Mahajan SK, Kashyap R, Kanga A, Sharma V, Prasher BS, Pal LS. Relevance of Weil-Felix test in diagnosis of scrub typhus in India. J Asssoc Physicians India 2006;54:619-21.  Back to cited text no. 2
    
3.
Bonell A, Lubell Y, Newton PN, Crump JA, Paris DH. Estimating the burden of scrub typhus: A systematic review. PLoS Negl Trop Dis 2017;11:e0005838.  Back to cited text no. 3
    
4.
Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM. A review of the global epidemiology of scrub typhus. PLoS Negl Trop Dis 2017;11:e0006062.  Back to cited text no. 4
    
5.
Varghese GM, Janardhanan J, Trowbridge P, Peter JV, Prakash JA, Sathyendra S, et al. Scrub typhus in South India: Clinical and laboratory manifestations, genetic variability, and outcome. Int J Infect Dis 2013;17:e981-7.  Back to cited text no. 5
    
6.
Mangaraj J, Sharma A, Alam ST. Report of sporadic cases of scrub typhus – A threat to re-emergence in Assam, India. Int J Curr Microbiol Appl Sci 2017;6:1037-41.  Back to cited text no. 6
    
7.
Ogawa M, Hagiwara T, Kishimoto T, Shiga S, Yoshida Y, Furuya Y, et al. Scrub typhus in Japan: Epidemiology and clinical features of cases reported in 1998. Am J Trop Med Hyg 2002;67:162-5.  Back to cited text no. 7
    
8.
World Health Organization. Frequently asked question Scrub Typhus. Available on: http://www.searo.who.int/entity/emerging_diseases/CDS_faq_Scrub_Typhus.pdf. [Last accessed on 2018 Jul 23].  Back to cited text no. 8
    
9.
Traub R, Wisseman Jr CL. Ecological considerations in scrub typhus: 2. Vector species. Bull World Health Organ 1968;39:219.  Back to cited text no. 9
    
10.
Stephen S, Sangeetha B, Ambroise S, Sarangapani K, Gunasekaran D, Hanifah M, et al. Outbreak of scrub typhus in Puducherry and Tamil Nadu during cooler months. Indian J Med Res 2015;142:591.  Back to cited text no. 10
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11.
Singh SI, Devi KP, Tilotama R, Ningombam S, Gopalkrishna Y, Singh TB, et al. An outbreak of scrub typhus in Bishnupur district of Manipur, India, 2007. Trop Doct 2010;40:169-70.  Back to cited text no. 11
    
12.
Ahmad S, Srivastava S, Verma SK, Puri P, Shirazi N. Scrub typhus in Uttarakhand, India: A common rickettsial disease in an uncommon geographical region. Trop Doct 2010;40:188-90.  Back to cited text no. 12
    
13.
Chaudhry D, Garg A, Singh I, Tandon C, Saini R. Rickettsial diseases in Haryana: Not an uncommon entity. J Assoc Physicians India 2009;57:334-7.  Back to cited text no. 13
    
14.
Kundavaram AP, Jonathan AJ, Nathaniel SD, Varghese GM. Eschar in scrub typhus: A valuable clue to the diagnosis. J Postgrad Med 2013;59:177.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Isaac R, Varghese GM, Mathai E, Manjula J, Joseph I. Scrub typhus: Prevalence and diagnostic issues in rural Southern India. Clin Infect Dis 2004;39:1395-6.  Back to cited text no. 15
    
16.
Ittyachen AM. Emerging infections in Kerala: A case of scrub typhus. Natl Med J India 2009;22:333-4.  Back to cited text no. 16
    
17.
Krishna PV, Ahmed S, Reddy KV. A case report of scrub typhus. J NTR Univ Health Sci 2015;4:47.  Back to cited text no. 17
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