Scrub Typhus

Case Presentation 3

1. CASE PRESENTATION Gopika Jagota MBBS 2011 A 48 year male, lab assistant by profession presented to the casualty of PGIMS, Rohtak with following complaints: Fever × 10 days Difficulty in breathing × 3 days

2. HISTORY OF PRESENT ILLNESS FEVER High grade fever since 10 days, acute in onset a/w rigors and chills ; no diurnal variation. Relieved by medication with no aggravating factor. No h/o cough/ epectoration , burning micturition, sore throat, cold, abdominal complaints and altered sensorium. SHORTNESS OF BREATH There is history of shortness of breath since 3 days which is gradually increasing. Now present even at rest( MRC grade 4 ) Past history, personal history, family history : Not significant

3. PHYSICAL EXAMINATION GPE : General appearance- Patient was febrile. He was calm, conscious, well oriented to time, place and person. Pallor⁻ , Icterus⁺ ,Clubbing⁻,Cyanosis⁻, Pedal edema⁻, LAP⁻,JVP⁻ B.P-116/80 mmHg, Pulse Rate- 78/min Resp. system :Patient tachypneic : 24/min . Bilateral basal crepts were present. Po₂: 74.6 mmHg No rash was seen. Other systemic examinations were within normal range

4. An eschar is seen on left backside of abdomen. It has a black central lesion with erythematous boundaries. Bilateral lung consolidation and pleural effusion ECG NORMAL

5. WORKING DIAGNOSIS DIFFERENTIALS POSITIVE FINDINGS Rickettsial infection Fever with eschar c/o ALI and jaundice Hepatorenal dysfunction Dengue Fever with decreased platelet count Malaria Fever associated with rigors and chills Leptospiral infection Biphasic illness with hepatorenal involvement Hepatitis Fever with hepatic involvement Sepsis with MODS Fever with hepatorenal involvement and ALI

6. LAB INVESTIGATIONS Hb 12.2 g/dl TLC 5800/ cmm Platelets 1.31 lac/ cmm SGOT 94mg/dl SGPT 127mg/dl S. bilirubin 2.3mg/dl( C=0.5mg/ dl;UC =1.8mg/dl) S. lactate Normal(15mg/dl) Blood urea 108mg/dl USG Mild bilateral pleural effusion HBs Ag Negative Dengue serology Negative Malaria card Ag Negative Leptospira serology Negative Rickettsial serology Positive for scrub typhus

7. MANAGEMENT A : Airways- The airways were patent B : Breathing- P atient was tachypneic ; so was kept on ventilatory support. C : Circulation was normal. Hydration was done with i.v fluids. D : Drugs- Doxycycline ,100mg/day BD; Piperacillin , and Azithromycin (till cause had not been established) With definitive diagnosis of scrub typhus all other antibiotics were stopped and Doxycycline continued for 15 days.

8. DEFINITIVE DIAGNOSIS SCRUB TYPHUS Clinical findings : Fever with eschar with complication of acute lung injury and jaundice. Hepatorenal dysfunction. Response to Doxycycline is seen Serology : Significant titres of >4 were found in serology for Orientia tsutsugamushi ; causative organism of Scrub Typhus.

9. DISCUSSION Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi via bite of larval stage of chigger . I.P.: 6-10 days. Clinical features: Fever, generalized or regional LAP, m aculopapular rash, severe headache or myalgia A painless papule is seen on the bite site which later ulcerates and forms a black eschar in a variable population (50%) Complications: Jaundice, meningoencephalitis, myocarditis, ARDS, renal failure. Chigger

10. DISCUSSION STAGES CLINICAL MANIFETATION LAB DIAGNOSIS STAGE 1 Local infection Bacteremia Bite is seen Fever, high grade Cultural sensitivity(c/s) of specimen from Scrapings from bite Blood STAGE 2 (Immune response) Fever subsides Serology +/- c/s STAGE 3(a. Recovery) Fever subsides Serology positive STAGE 3(b. Bacteremia) High grade fever Vasculitis c/s for fastidious organism Vasculitic lesion- Biopsy is taken- c/s STAGE 4 ( convalescense ) - Serology positive

11. CONCLUSION Rickettsiosis is not uncommon Should always be kept as a differential for “undifferentiated fever” Eschar = pathognomic Early initiation of Antibiotics= affects mortality Antibiotics= empirical Later on the basis of reports- Descalation

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