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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 65-67

A case report of rare constellation of complications of scrub typhus


Department of General Medicine, Government Medical College, Nagpur, Maharashtra, India

Date of Submission22-Mar-2022
Date of Acceptance26-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
K S Tony
Department of General Medicine, Government Medical College, Kizhakkemuriyil House, Chamampathal PO, Vazhoor, Kottayam, Kerala 686517
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_17_22

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  Abstract 

Scrub typhus is an acute febrile illness widely prevalent in the “Tsutsugamushi Triangle” region of the world. We present a case of a 52-year-old female patient with an atypical presentation of scrub typhus. This is an atypical presentation of scrub typhus because of unusual location of eschar, associated myocarditis, pancytopenia, and cerebellar involvement.

Keywords: Cerebellitis, oxycycline, pancytopenia, scrub typhus


How to cite this article:
Ghuge P, Tony K S, Narwadev A, Shingade PU. A case report of rare constellation of complications of scrub typhus. Amrita J Med 2022;18:65-7

How to cite this URL:
Ghuge P, Tony K S, Narwadev A, Shingade PU. A case report of rare constellation of complications of scrub typhus. Amrita J Med [serial online] 2022 [cited 2022 Aug 11];18:65-7. Available from: https://ajmonline.org.in/text.asp?2022/18/2/65/349261




  Introduction Top


Scrub typhus (tsutsugamushi disease) is a zoonotic rickettsial disease caused by Orientia tsutsugamushi, a gram-negative intracellular coccobacillus.[1] It is endemic in the geographically distinct region called Tsutsugamushi Triangle, which includes Japan, Taiwan, China, and South Korea, and also occurs in Nepal, northern Pakistan, Papua New Guinea, the Australian state of Queensland, and northern New South Wales.[2] Humans are accidental hosts, and scrub typhus is caused by the bite of trombiculid mites or chiggers of the larval stage. Scrub typhus is being increasingly reported from various regions of India, especially the hilly regions of the Himalayas, Assam, West Bengal, and Tamil Nadu. Outbreaks are common in October to December.

The infection is acquired through agricultural activities in the rice fields, oil palm, and rubber plantation, and during recreational activities in the woods or mountainous areas.[3] Scrub typhus has diverse clinical manifestations, often presenting either as a simple febrile illness or as a complicated multi-organ dysfunction. It is one of the main causes of fever of unknown origin in endemic areas.

Pancytopenia is a rare complication of scrub typhus and only few are described in literature. Cerebellitis and myocarditis are also rare complications of scrub typhus. We describe a patient infected with scrub typhus, a constellation of these rare complications.


  Case Report Top


A 52-year-old female patient presented with high-grade intermittent fever, gradual onset progressive breathlessness, and generalized weakness for 5 days, and altered sensorium since 3 days. The patient was admitted to a private hospital for the above complaints. The patient’s general condition got worsened after 3 days of stay in that hospital and was referred to our medicine department.

On general examination, the patients’ general condition was not satisfactory. She was febrile, pale, and icteric. She was also tachycardic and tachypneic. She had a low-volume pulse. Her blood pressure was 80/60 mmHg. On eliciting plantar reflex, the eschar was noticed at the sole of foot as shown in [Figure 1] which made us to think in terms of scrub typhus.
Figure 1: Eschar in the sole of foot

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Central nervous system examination was done after stabilization of the patient and showed nuchal rigidity, hyperreflexia, and extensor plantar, and Wartenberg’s sign and positive Hoffman sign in hands. She also showed truncal ataxia and dissymmetria on the right side, dysdiadochokinesia, and dyssynergia.

Complete blood count and peripheral smear showed pancytopenia (total leucocyte count of 2000 cells/mm3, hemoglobin 6.4 g/dl, and platelet 71,000/mm3).

Liver function test showed mildly raised transaminases (aspartate transaminase = 112 IU/L and alanine transaminase = 77 IU/L), alkaline phosphatase 396 IU/L, total protein 5.6 mg/dL, and albumin 2.4 mg/dL, total bilirubin 1.6 mg%, and direct bilirubin 0.9 mg%. International normalized ratio was estimated to be 1.14.

Kidney function test showed creatinine 1.71 mg/dL and blood urea 104 mg/dL. Serum electrolytes was within normal limits. Chest X ray was within normal limits. Immunoglobulin M scrub typhus was positive.

Arterial blood gas (ABG) analysis showed metabolic acidosis (pH = 7.34. PaO2 = 92,

= 12.8, and PaCO2 = 23.7). Serum procalcitonin was normal.

Magnetic resonance imaging brain and whole spine screening were normal. Cerebrospinal fluid (CSF) analysis showed total leukocytosis (120 cells/mm3) with lymphocytosis (85%), raised protein level (52.4 mg/dL), low glucose level (65 mg/dL), and raised adenosine deaminase (ADA) 17 U/L. Hence, diagnosis of scrub typhus with meningoencephalomyelitis and cerebellitis was made.

An abdominal ultrasound revealed mild hepatosplenomegaly.

The patient was treated with injectable doxycycline 100 mg IV bd for 14 days, inotropic support, blood transfusion, and other supportive care. The patient’s general condition, neurological signs, and pancytopenia recovered during the course of hospital stay. The patient recovered without using steroids.


  Discussion Top


Scrub typhus manifests with features of fever, rash, and eschar. The mortality of typhus varies from 1% to 60% depending on the pathogenic strain and the geographic area.

An eschar, the pathognomonic sign in scrub, occurs only in 40%–50% cases at the site of inoculation of the chigger mite, which may go unnoticed because of dark skin and also because it is non-painful and non-itchy.[4],[5] Lower limb is comparatively a rare location of eschar, which is reported only in 8% of people according to Jamil et al.[6] Our patient had eschar at the unusual site.

CNS involvement is a well-known complication of scrub typhus ranging from aseptic meningitis to frank meningoencephalitis. Other CNS manifestation includes delirium, myelitis, cerebral hemorrhage, hearing loss, isolated sixth nerve palsy, bilateral sixth and seventh nerve palsy, trigeminal neuralgia, opsoclonus, transient parkinsonism, myoclonus, brachial plexopathy, polyneuropathy, acute disseminated encephalomyelitis, and Guillain–Barré syndrome.[7]

In some instances, it may mimic tuberculous meningoencephalitis such as cranial nerve palsies with CSF showing lymphocytic pleocytosis, moderately elevated protein levels, low glucose, and elevated CSF ADA levels.[3] In our patient, the CSF picture showed similar features as mentioned above.

Scrub typhus is often associated with many hematological abnormalities such as leukocytosis, anemia, and thrombocytopenia. Pancytopenia is a rare occurrence in scrub typhus and is often due to hemophagocytosis,[8],[9] which is caused by excessive immune activation.[10] Early chemotherapy for scrub typhus associated with pancytopenia usually leads to uneventful recovery, but prognosis is very poor if not treated.


  Conclusion Top


Early diagnosis of scrub typhus in the endemic region and prompt antibiotic administration and other supportive measures are necessary for preventing grave complications of this disease. This case report is a gentle reminder regarding the rare location of eschar and neurological and hematological complications that can be associated with the disease, which can be reversed easily with doxycycline.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her image and other clinical information to be reported in the journal. The patient understands that her name and initial(s) will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta S, Grover S, Gupta M, Kaur D Cerebellitis as a rare manifestation of scrub typhus fever. BMJ Case Rep 2020;13:1-3.  Back to cited text no. 1
    
2.
Jatiya BL, Meena CP, Kumar S, Singh R, Meena R Reversible pancytopenia – Rare manifestation of scrub typhus 2019;8:108-9.  Back to cited text no. 2
    
3.
De Silva CM, Fonseka CL, Nanayakkara SD, Singhapura SDAL, Palangasinghe DR, Hewawithana JS, et al. Differentiating scrub typhus meningoencephalitis, from tuberculous meningitis: Two case reports and a review. Gall Med J 2018;23:37.  Back to cited text no. 3
    
4.
Mahajan SK, Sharma S, Kaushik M, Raina R, Thakur P, Taneja GP, et al. Scrub typhus presenting as acute cerebellitis. J Assoc Physicians India 2016;64:69-70.  Back to cited text no. 4
    
5.
Aggrawal P, Mahesh DM Ravi Kumar V, Himral P, Kaushal SS, Verma BS Atypical eschar sites in scrub typhus in sub-Himalayas. JAPI 2009. Available from: https://www.japi.org/s264a494/atypical-eschar-sites-in-scrub-typhus-in-sub-himalayas#:~:text=1 The site bitten by,rash%2C myalgia%2C and lymphadenopathy.  Back to cited text no. 5
    
6.
Jamil M, Bhattacharya P, Mishra J, Akhtar H, Roy A Eschar in scrub typhus: A study from North East India. J Assoc Physicians India 2019;67:38-40.  Back to cited text no. 6
    
7.
Jamil MD, Hussain M, Lyngdoh M, Sharma S, Barman B, Bhattacharya PK Scrub typhus meningoencephalitis, a diagnostic challenge for clinicians: A hospital based study from North-East India. J Neurosci Rural Pract 2015;6:488-93.  Back to cited text no. 7
    
8.
Jarial KDS Pancytopenia in scrub typhus. Pediatr Oncall 2013;10:411060. Available from: https://www.pediatriconcall.com/pediatric-journal/view/fulltext-articles/560/J/0/0/17/0  Back to cited text no. 8
    
9.
Gopal GK, Anugrah C, Boorugu H Scrub typhus associated macrophage activation syndrome. Trop Doct 2010;40:249-50.  Back to cited text no. 9
    
10.
Suganthan N, Mahakumara M, Sooriyakumar T Hemophagocytic lymphohistiocytosis: An unusual presentation of scrub typhus. Cureus 2020;12:e9390.  Back to cited text no. 10
    


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