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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 272-275

A rare case of rickettsial infection presented as febrile delirium in a 4 years old child from a government hospital, Andhra Pradesh, India


Department of Pediatrics, Kurnool Medical College, Kurnool, Andhra Pradesh, India

Date of Submission15-Mar-2019
Date of Decision15-Apr-2019
Date of Acceptance23-Sep-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Dr. Naresh Gadagani
Department of Pediatrics, Kurnool Medical College, Kurnool, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_53_19

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  Abstract 


We report here a documented case of Febrile delirium in a child caused by Rickettsiae. Rickettsial infection is a relatively under-diagnosed entity in children with fever and rash, probably due to low index of suspicion and the lack of definitive diagnostic facilities. Rickettsial infections can be treated effectively with anti-microbials. Developing countries may use Weil Felix test as a diagnostic method, if they remain undiagnosed and untreated, they are associated with significant morbidity and mortality. This differential diagnosis should be considered when a child is seen with fever and rash.

Keywords: Bacterial infections, febrile delirium, reemerging infections, Rickettsial infections, spotted fever, tropical diseases, Weil Felix test


How to cite this article:
Prasad G S, Mekala S, Gadagani N. A rare case of rickettsial infection presented as febrile delirium in a 4 years old child from a government hospital, Andhra Pradesh, India. J NTR Univ Health Sci 2019;8:272-5

How to cite this URL:
Prasad G S, Mekala S, Gadagani N. A rare case of rickettsial infection presented as febrile delirium in a 4 years old child from a government hospital, Andhra Pradesh, India. J NTR Univ Health Sci [serial online] 2019 [cited 2020 Apr 7];8:272-5. Available from: http://www.jdrntruhs.org/text.asp?2019/8/4/272/273131




  Introduction Top


Rickettsiae are small, non-flagellate, Gram-negative pleomorphic, coccobacilli adapted to obligate intracellular parasitism and transmitted by arthropod vectors like fleas, ticks, mites and lice.[1] Vasculitis is the basic pathogenic mechanism and is responsible for skin rash, microvascular leakage, edema, and tissue hypoperfusion and end organ ischemic injury. Severe involvement of the central nervous system (CNS) has been reported in adults with  Rickettsia conorii Scientific Name Search ction,[2],[3] but rarely in children.[4],[5]


  Case Report Top


A 4-year-old, previously healthy male child was admitted to Government Hospital, Kurnool, with history of fever for 10 days, rash for 5 days, loose stools and altered sensorium on the day of admission. There is no history of significant tick/flea bite. The maculopapular type of rash was over the face, both extremities including palms [Figure 1] and soles and over abdomen [Figure 2].
Figure 1: Showing rash over soles

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Figure 2: Showing rash over abdomen

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Edema of both hands and feet present on admission, Conjunctivitis also noted on the day of admission. Liver was 3 cm; spleen was 2 cm below the costal margins. On examination child was in altered sensorium with severe irritability and significant menigismus. And no focal deficits and no cranial nerve palsies on admission. No evidence of Papilloedema on fundoscopy. Rathi, Goodman et al. scoring[6] was noted on Admission [Table 1].
Table 1: Total RGA (Rathi, Good Man et al.) score for this child is 23/35.[22]

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On Investigation Hemoglobin was 5.7 gram %, leukocyte count was 21,600 with 50% polymorphs and 40% of Lymphocytes. Peripheral blood smear for malaria parasite and Dengue Serology were negative. Initial blood sugars were 110 mg/dl and serum electrolytes and renal function tests were normal. Serum bilirubin is normal but Liver enzymes and Coagulation Profile was abnormal with increased enzymes SGPT is 499 U/L, SGOT 105 U/L. CSF sample was obtained by Lumbar Puncture revealed WBC of 3 cells with no polymorphs and 100% lymphocytes glucose level of 35 mg/dl and Protein level of 46 mg/dl appears to be normal. Blood cultures for bacteria, fungi were negative.

The patient was started on intravenous ceftriaxone (100 mg/kg/day) in 2 divided doses and in view of characteristic rash and its distribution, possibility of rickettsial infection was considered and started on Doxycycline 2.2 mg/kg/Dose in 2 doses per day through feeding tube. He responded well to doxycycline after starting therapy. His serum sent for Weil-Felix (WF) test, which was found positive with titers of 1:320 for OX-2, OX 19 and negative for OX- K by Tube agglutination test.


  Discussion Top


Rickettsiae derive their name from the American researcher, Howard Ricketts, who discovered them in 1909 in Montana, USA, as the source of a serious disease [Rocky Mountain spotted fever (RMSF)]. He himself died from typhus in an epidemic in Mexico some years later. Rickettsiae multiply intracellularly. They have a Gram-negative cell wall structure but cannot be detected by Gram staining, although they can be by Giemsa staining but with difficulty. The cases of rickettsial infection have been documented mainly from South India.[7],[8],[9],[10] The R. conorii was first described by Conor in 1910. In September 1932, at the First International Congress of Mediterranean Hygiene, the name Mediterranean spotted fever was adopted. Other names given to this illness are Boutonneure fever, Kenya Tick-Bite Fever, African Tick Typhus, Indian Tick Typhus, Israeli Spotted fever and Marseilles fever, depending on the region.[11] Rickettsia conorii is an obligate intracellular parasite of Ticks. In Mediterranean area, the vector is the brown dog tick Rhipinecephalius sanguineus, but other species of mites may act as vectors in other geographic areas.[12]

Rickettsiae are wide spread in ticks and can parasitize many of their organs including ovaries, and hence can be transmitted transovarially. Therefore, ticks are not only vectors but also reservoir of infection. Hence physical contact with dogs is not necessary. The initial bite passes unnoticed and in many cases the primary lesion/inoculation scar is not always present as in our case. The onset of disease is usually abrupt with headache, malaise and fever, lasting for 6-12 days. Generalized myalgia, especially involving leg muscles and joint pain is a prominent feature. The rash usually develops between 3rd and 5th febrile day with initial lesions appearing on extremities and spreading to trunk, neck, face, buttocks and palms in 24-36 h.

The lesions are macular or maculopapular and may be purpuric. Our patient had maculopapular rash with characteristic distribution. Severe involvement of CNS has been reported in adults with R. conorii infection,[2],[3] but rarely in children.[4],[5] Children present with various degree of impaired consciousness, delirium and convulsions. Neurologic sequelae have been observed. Our patient had no cerebrospinal fluid findings of meningoencephalitis. Other complications like pneumonia, myocarditis, acute respiratory distress syndrome, acute renal failure and disseminated intravascular coagulation have been reported.

Rickettsia conorii cannot be isolated from blood culture by routine laboratory procedure. The clinical features, geographic background, and epidemiological considerations help to establish diagnosis. Laboratory diagnosis is an important adjunct and involves serologic identification of serum antibodies.[13] Diagnosis of rickettsial infection is mainly by serologic methods.[14] Indirect immunofluoroscent assay is the reference diagnostic method for rickettsial infection, but cross-reacting antibodies of related isolates confound interpretation of the results and it becomes positive only in late phase of disease.[15]

Western blot test is more sensitive than IFA test. It is frequently positive in acute phase sera when antibodies cannot be detected by IFA.[16]

Our child's serum tested positive for Weil Felix Test (WF) at a dilution of 1:320 for OX 2. WF is inexpensive and can be performed rapidly to substantiate the diagnosis. However, low sensitivity of WF is a problem.[17] Even though the sensitivity of WF has been claimed less, there are several reports suggesting good correlation of WF Test with other standard tests used.[18],[19] In the study conducted in South India,[20] the sensitivity of patient's antibody was 30% at a titer break point of 1:80, but specificity and positive predictive value were 100%. Some authors have suggested that even though WF test is not a very sensitive test, it is quite a specific test when it is positive.[21] Thus WF test may be the only serological test available in developing countries like India. It can be used in confirming a tentative diagnosis of rickettsial fever mainly during acute phase of the disease when specific therapy can be lifesaving.

Doxycycline is the drug of choice. Other drugs are tetracycline, chloramphenicol, ciprofloxacin, azithromycin and clarithromycin.[22] The optimum duration of specific therapy has not been definitely established and different antibiotic regimens ranging from single dose to treatment for up to 15 days have been recommended. As our patient was critically ill, we used doxycycline 2.2 mg/kg/dose 2 doses per day for 10 days with which the child recovered well.


  Conclusion Top


In summary, early diagnosis of rickettsial infections is important as these can be treated with inexpensive antibiotics and can be fatal if untreated. The availability and the cost of standard serological methods for Rickettsia are the major problems in developing countries like India. The diagnosis should be largely based on high index of suspicion and careful clinical, laboratory and epidemiological evaluation supported by cost-effective tests like WF.

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.
IAP Textbook of Pediatrics. 6th ed, vol 6. New Delhi: Jaypee Publishers; 2016. p. 347-9. ISBN: 978-93-5250-196-0.  Back to cited text no. 1
    
2.
Charra B, Berrada J, Hachimi A, Judate I, Nejmi H, Motaouakkil S, et al. A fatal case of Mediterranean spotted Fever. Med Mal Infect 2005;35:374-5.  Back to cited text no. 2
    
3.
Marcos Dolado A, Sanchez Portocarrero J, Jimenez Madridejo R, Pontes Navarro JC, Garcia Urra D, et al. Meningoencephalitis due to Rickettsia conorii. Etiopathological, clinical and diagnostic aspects. Neurologia 1994;9:72-5.  Back to cited text no. 3
    
4.
Thijssen HS, Leroy PL, van't Hek LG, Hurkx GA, An unsuspected imported disease: Meningo-encephalitis contracted in Spain. Ned Tijdschr Geneeskd 2004;148:113-7.  Back to cited text no. 4
    
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Colonne PM, Sahni A, Sahni SK. Rickettsia conorii infection stimulates the expression of ISG15 and ISG15 protease UBP43 in human microvascular endothelial cells. Biochem Biophys Res Commun 2011;416:153-8.  Back to cited text no. 5
    
6.
Rathi N, Kulkarni A, Yewale V; For Indian Academy of Pediatrics Guidelines on Rickettsial Diseases in Children Committee. IAP guidelines on rickettsial diseases in children. Indian Pediatr 2017;54:223-9.   Back to cited text no. 6
    
7.
Pavithran S, Mathai E, Prabhakar D. Moses. Scrub typhus. Indian Pediatr 2004;41:1254-6.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    
9.
Mathai E, Rolain JM, Varghese GM, Abraham OC, Mathai D, Mathai M, et al. Outbreak of scrub typhus in Southern India during the cooler months. Ann N Y Acad Sci 2003;990:359-64.  Back to cited text no. 9
    
10.
Murali N, Pillai S, Cherian T, Raghupathy P, Padmini V, Mathai E. Rickettsial infections in South India-how to spot the spotted fever. Indian Pediatr 2001;38:1393-6.  Back to cited text no. 10
    
11.
Morven S, Feigin RD, et al. Rickettsial Diseases in Textbook of Pediatric Infectious Diseases. 5th ed, v. Philadelphia: Saunders; 2004. 2: p. 2497-515.  Back to cited text no. 11
    
12.
Harris RL, Kaplan SL, Bradshaw MW, Williams TW Jr. Boutonneuse fever in American travelers. J Infect Dis 1986;153:126-8.  Back to cited text no. 12
    
13.
Montenegro MR, Mansueto S, Hegarty BC, Walker DH. The histology of “taches noires” of boutonneuse fever and demonstration of Rickettsia conorii in them by immunofluorescence. Virchows Arch A Pathol Anat Histopathol 1983;400:309-17.  Back to cited text no. 13
    
14.
Kovacova E, Kazar J. Rickettsial diseases and their serological diagnosis. Clin Lab 2000;46:239-45.  Back to cited text no. 14
    
15.
Parola P, Fenollar F, Badiaga S, Brouqui P, Raoult D. First documentation of Rickettsia conorii infection (strain Indian tick typhus) in a Traveler. Emerg Infect Dis 2001;7:909-10.  Back to cited text no. 15
    
16.
Lascola B, Raoult D. Laboratory diagnosis of rickettsioses: Current approaches to diagnosis of old and new rickettsial diseases. J Clin Microbiol 1997;35:2715-27.  Back to cited text no. 16
    
17.
Bhattacharya D, Mittal V, Bhatia R, Sehgal S, Passey MN. Comparison between indirect fluorescent antibody and Weil-Felix tests for detecting antibodies against rickettsia. J Commun Dis 1991;23:144-8.  Back to cited text no. 17
    
18.
Amano K, Suzuki N, Fujita M, Nakamura Y, Suto T. Serological reactivity of sera from scrub typhus patients against WF test antigens. Microbiol Immunol 1993;37:927-33.  Back to cited text no. 18
    
19.
Amano K, Suzuki N, Hatakeyama H, Kasahara Y, Fujii S, Fukushi K, et al. The reactivity between rickettsiae and Weil-Felix test antigens against sera of rickettsial disease patients. Acta Virologica 1992;36:67-72.  Back to cited text no. 19
    
20.
Isaac R, Varghese G, Mathai E, Manjula J, Joseph I, et al. Scrub typhus: Prevalence and diagnostic issues in rural Southern India. Clin Infect Dis 2004;39:1395-6.  Back to cited text no. 20
    
21.
Saah AJ. Orientia tsutsugamushi (scrub typhus). In: Mandell GL, Bennet GE, Doalin R, editors. Principles and Practice of Infectious Diseases. Vol. 8. Philadelphia: Churchill Livingstone; 2000. p. 2056-7.  Back to cited text no. 21
    
22.
Otero R, Fenoll A, Casal J, Gross E, Yagupsky P, Torok V, et al. Resurgence of mediterranean spotted fever. Lancet 1982;320:1107.  Back to cited text no. 22
    


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