A Case Study On Scrub typhus with disease information.pptx

It contains a detailed description of the disease and case study

1. A Case Presentat i on on SCRUB TYPHUS P.J. Hemanth Reddy PHARM.D VI th year 19Y01T0018 CESCOP

2. Scrub typhus is an acute, febrile, infectious illness that is caused by Orientia tsutsugamushi , transmitted through the bite of infected chigger mites (larval mites). It is prevalent in rural and tropical areas, particularly in the Asia-Pacific region, including India. It was first recognized in the early 20th century. It was discovered by Japanese researcher Hakuju Hashimoto in 1930, who identified the organism from patients with a febrile illness in Japan. This bacterium is an gram-negative obligate intracellular pathogen, belonging to the family Rickettsiaceae. Antibody levels, particularly IgM and IgG, rise in response to infection, with IgM appearing early and IgG indicating longer-term immunity. Detection of these antibodies forms the basis of serological diagnosis of scrub typhus. The disease presents with a range of symptoms such as fever, headache, rash, and muscle pain, and may also include a characteristic eschar at the site of the bite. INTRODUCTION

3. ETIOLOGY Scrub typhus is endemic to eastern Asia, the southwestern Pacific (from Korea to Australia), and from Japan to India and Pakistan. Primarily affects in rural villages and suburban areas, rarely encountered in cities. An estimated one million cases occurring annually. The disease is particularly prevalent in southern states such as Tamil Nadu, Andhra Pradesh, Karnataka, and Kerala, as well as northern regions like Himachal Pradesh and Jammu & Kashmir. Men and women are affected at equal rates, and no race-related differences in incidence have been reported. EPIDEMIOLOGY Scrub typhus is caused by the bacterium Orientia tsutsugamushi , transmitted to humans through the bite of infected chigger mites (larval mites).

4. PATHOPHYSIOLOGY Chigger Bite Attach to Endothelial cells Bacteria multiply at Inoculation site Replicate in cytoplasm Stimulate Phagocytosis Escapes Phagosomes Disseminate into multiple organs (Through endothelial cells and macrophages) Eschar + Lymphadenopathy Papule Necrosis Ulcer Type 1 immune response Cytokines

5. CLINICAL PRESENTATION Fever with Chills Maculopapular rash myalgia Nausea & Vomiting Headache Eschar A dark, scab-like lesion at the site of the chigger bite Loss of appetite Abdominal pain

6. Clinical Diagnosis : Based on the patient's symptoms (fever, rash, eschar, etc.) and history of exposure to endemic areas or outdoor activities in rural regions. Laboratory Tests : Serology : Immunofluorescence assay (IFA), which is considered the gold standard. ELISA (Enzyme-Linked Immunosorbent Assay) PCR (Polymerase Chain Reaction) Eschar Biopsy DIAGNOSIS

7. First-Line Therapy (Antibiotics) : Doxycycline :100 mg twice daily for 5–7 days. Mechanism : Inhibits protein synthesis in Orientia tsutsugamushi , the causative agent of scrub typhus. Use in pregnancy : Contraindicated due to risks of dental and bone defects in the fetus. Azithromycin : 500 mg once daily for 3–5 days. Alternative : Preferred in pregnancy and for children under 8 years old, where doxycycline is contraindicated. Effectiveness : Comparable to doxycycline, often used in regions with doxycycline resistance or for those intolerant to it. Chloramphenicol : 500 mg four times daily for 7 days. Reserved for : Cases where doxycycline and azithromycin are contraindicated. Note : There is a risk of aplastic anemia, so it is generally not a first choice unless necessary. Supportive Treatment : For Fever : Paracetamol (Acetaminophen) 500–1000 mg every 6–8 hours as needed. For Rash : Generally self-limiting, Antihistamines like cetirizine or diphenhydramine may be used if itching is present. Nausea, and Vomiting : Antiemetics such as ondansetron (4–8 mg) or metoclopramide can help control nausea and vomiting. Proton Pump Inhibitors (PPIs) or H2 blockers can be prescribed for managing gastritis if gastrointestinal symptoms are related to the infection. MANAGEMENT PHARMACOTHERAPY

8. PATIENT CASE DATA

9. A 60 years old Female patient was admitted in Female medical ward with IP No: 45891 under the consultant doctor Dr.K.Vidya Sagar M.D, with chief complaints of Fever ∵ 2 months, a/w chills & rigors , not relieved on medication and also presented c̅ Headache and Altered sensorium since one day . And he also had H/O Rash ⊕ The personal History & Habits shows Mixed diet , Normal Sleep , Normal appetite and with Regular Bowel & Bladder habits with no significant Family history . SOAP NOTES DEMOGRAPHIC DATA SUBJECTIVE EVIDENCE Patient name: xxxxxx Gender: Female Age: 60 years IP.no: 45891 DOA: 27/07/2024 Department: FM-I Consultant Doctor: Dr. Vid ya sagar M.D

10. SOAP NOTES OBJECTIVE EVIDENCE Complete blood picture Results Units WBC 4,300 cells/µL RBC 3.73🔻 cells/µL HB 7.6🔻 gm/d L PLT 1.55 plt / µL Serum Electrolytes Na+ 129 mmol/L K+ 3.1 mmol/L Cl- 96 mmol/L Urine Culture IMP: Negative for bacterial growth Renal function test Results Units Blood Urea 18 mg/dl Sr Creatinine 0.7 mg/dl Liver function test Total.Br 0.5 mg/dl Direct.Br 0.3 mg/dl Indirect.Br 0.2 mg/dl SGPT 11 U/L SGOT 23 U/L ALP 84 IU/Lit T.proteins 4.9 gm/dl Sr.Albumin 3.6 gm/dl

11. SOAP NOTES OBJECTIVE EVIDENCE Leptospira IgM ELISA Scrub Typhus IgM ELISA IMP: Negative IMP: Positive ⊕ CT/MRI-Brain CRP IMP: No significant abnormality found IMP: Positive ⊕ ASSESSMENT: Based on subjective and objective evidence the patient was diagnosed with Scrub Typhus.

12. PLANNING S.No Brand Name Generic Name Indication Dose ROA Frequency Duration 1. Inj. Ceftriaxone Ceftriaxone Antibiotic 1gm IV BD D1 To D4 2. Cap. Doxycycline Doxycycline Antibiotic 100 mg PO BD D1 To D4 3. Inj. Artesunate Artesunate Antimalarial 120 mg IV TID D1 To D3 4. Tab. pantop Pantoprazole Antisecretory 40 mg PO OD D1 To D4 5. Tab. PCT Paracetamol Antipyretic 650 mg PO TID D1 To D4 6. Tab. IFA Iron & folic acid Iron supplement 100+1.5 mg PO OD D1 To D4

13. PROGRESS CHART Prognosis Treatment Day-1 ℅ Fever O/E Patient - C/C Temp- Febrile PR - 85 bpm BP- 90/60 🔻 mmHg FBS - 95 mg/dl 6AM RBS- 103 mg/dl P/A- Soft CVS- S1S2 + RS- B/L BAE + CNS- NFND 🔺 IgM ⊕ SCRUB TYPHUS Rx Inj. Ceftriaxone 1gm IV BD C a p . Doxycycline 100 mg PO BD Tab. PCT 650 mg PO TID IVF-2⊙NS & 2⊙RL @ 80 ml/hr Inj. Artesunate 120 mg IV TID Tab. Pantop 40 mg PO OD ORS Sachets TID Tab. IFA PO OD

14. PROGRESS CHART Prognosis Treatment Day-2 ℅ Fever O/E PT- C/C Temp- Febrile BP- 110 /80 🔻 mmHg PPBS- 121 mg/dl 10AM Remaining vitals are normal Rx. Continue same treatment Day-3 ℅ no fresh complaints ℅ 🔽 Fever O/E PT- C/C ALL vitals are normal Rx. Continue same treatment Day-4 ℅ no fresh complaint O/E PT- C/C BP- 90/80 🔻 mmHg ALL vitals are normal Rx. Continue same treatment Stop: Inj. Artesunate

15. MECHANISM OF ACTION Mechanism of Action ADRs MP Ceftriaxone : It exhibit bactericidal effect by inhibiting the cell wall synthesis of bacteria by inhibiting the enzyme called transpeptidases Nausea Vomiting Abdominal pain CBP and signs of allergic reaction Doxycycline : Doxycycline inhibits bacterial protein synthesis by binding to the 30S & 50s ribosomal subunit. Photosensitivity Diarrhoea nasopharyngitis CBP LFT RFT Paracetamol: Paracetamol works by inhibiting prostaglandin synthesis, primarily in the central nervous system, exerting its analgesic and antipyretic effects. Stomach pain Nausea Vomiting Fever Pain A rtesunate : The endoperoxide of DHA reacts with heme generating free radicals which inhibit protein and nucleic acid synthesis of plasmodium . Jaundice, Hemoglobinuria LFT, CBP Pantoprazole: It binds to H+/K+ ATPase Pump and thereby inhibiting gastric acid and basal acid secretion. Headache Stomach pain Monitor GI symptoms

16. PHARMACIST INTERVENTION PATIENT COUNSELING REGARDING DISEASES Scrub Typhus is an infectious disease caused by the bacterium Orientia tsutsugamushi , transmitted through the bite of infected mites. It is characterized by fever, headache, rash, and eschar formation. RATIONALITY DRUG INTERACTIONS The given treatment was found to be Rational No Drug- drug Interactions found REGARDING DRUGS Cap . Doxycycline 100 mg sh ould be take twice a day to treat infection. Tab. PCT 650 mg should be taken thrice a day to treat fever. Tab. Pantop 40 mg should be taken once a day to prevent gastric irritation. Tab. IFA should be taken once a day as an iron supplement.

17. Ensure adequate rest to allow the body to recover from the infection. Drink plenty of fluids to stay hydrated and help flush out toxins. Follow a balanced diet rich in vitamins and minerals (fruits, vegetables, lean proteins) to boost immunity and aid recovery. Avoid processed and sugary foods, which can weaken the immune system. Complete the full course of antibiotics (typically doxycycline or azithromycin) as prescribed to prevent relapse . Have regular check-ups, especially if you live in or frequently visits scrub typhus endemic areas, to detect early signs of reinfection. Monitor for fever, rash, or unusual symptoms, and seek medical attention promptly if any are observed. Wear long-sleeved clothing, full-length pants, and closed shoes when visiting areas where scrub typhus is common (such as rural, wooded, or grassy areas). Keep the home and surroundings clean to reduce exposure to mites. PATIENT COUNSELING LIFESTYLE MODIFICATIONS

18. https://emedicine.medscape.com/article/971797-overview#a1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8345853/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9641991/ https://www.ncbi.nlm.nih.gov/books/NBK558901/ REFERENCES

19. Thank you P J Hemanth Reddy