Clinical manifestations and complications of scrub typhus: A study from tertiary care centre in Bihar

Anwar Alam; Md Shahid Iqubal; Pallavi Anand; Ritika Singh; Awanish Kumar Singh

ORIGINAL ARTICLE

Year : 2020 | Volume : 6 | Issue : 1 | Page : 62-65

Clinical manifestations and complications of scrub typhus: A study from tertiary care centre in Bihar

Anwar Alam¹, Md Shahid Iqubal², Pallavi Anand³, Ritika Singh⁴, Awanish Kumar Singh⁵
¹ Assistant Professor, Dept. of Neurology, NMCH, Patna, India
² PG Resident, Dept. of Medicine, NMCH, Patna, India
³ 3Senior Resident, Ruban Patliputra Hospital, Patna, India
⁴ Medical Officer, Dept. of Medicine, Ruban Patliputra Hospital, Patna, India
⁵ Consultant, Dept. of Gastroenterology, Ruban Patliputra Hospital, Patna

Date of Submission	08-Dec-2019
Date of Acceptance	20-Feb-2020
Date of Web Publication	16-Nov-2020

Correspondence Address:
Anwar Alam
Assistant professor Dept. of Neurology, NMCH, Patna
India

Source of Support: None, Conflict of Interest: None

Abstract

Background: Scrub typhus is a rickettsial infection that can be life threatening. There are several outbreaks of scrub typhus have been reported from different parts of India, but still clinicians are not much aware of this. We studied the diversity of clinical manifestations, laboratory investigations, complications and outcomes of scrub typhus in a tertiary care hospital.
Materials and Methods: All the cases of acute febrile illness diagnosed as scrub typhus over a period of 10 months (march 2018 to December 2018) were analysed. Diagnosis was based on positive Weil-Felix with titre of ? 1:80.
Results: A total of 13 cases of scrub were diagnosed and analysed during the study period. The most common symptoms among the patients were fever in 100% cases, headache, seizure and altered sensorium in 61.5% cases. Other symptoms were nausea, vomiting, breathlessness and urinary symptoms. The pathognomonic features such as eschar was seen in only one case (7%). On investigations, deranged liver function tests (LFT) were present in 61% of cases and deranged renal function tests (RFT) were present in 38% of patients. Thrombocytopenia (92%), meningoencephalitis (61%), acute respiratory distress syndrome (ARDS) (30%) were common complications of scrub typhus in this study. All patients responded dramatically to doxycycline and there was no mortality in this study.
Conclusion:- Scrub typhus should be considered as an important differential diagnosis of acute febrile illness if it is associated with thrombocytopenia, deranged LFT and deranged RFT. Although eschar is pathognomonic of scrub typhus, even in the absence of eschar and lymphadenopathy a high index of suspicion and empirical addition of doxycycline is crucial for decreasing mortality.

Keywords: Fever, Meningoencephalitis, Orientia tsutsugamushi, Scrub typhus, Weil-Felix test.

How to cite this article:
Alam A, Iqubal MS, Anand P, Singh R, Singh AK. Clinical manifestations and complications of scrub typhus: A study from tertiary care centre in Bihar. J Indira Gandhi Inst Med Sci 2020;6:62-5

How to cite this URL:
Alam A, Iqubal MS, Anand P, Singh R, Singh AK. Clinical manifestations and complications of scrub typhus: A study from tertiary care centre in Bihar. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2021 Oct 21];6:62-5. Available from: http://www.jigims.co.in/text.asp?2020/6/1/62/300743

Introduction

Scrub typhus is a zoonotic disease. It is caused by Orientia tsutsugamushi and transmitted by vector of the trombiculidae family. Small rodents particularly wild rats are the natural hosts for scrub typhus and humans are the accidental host. Scrub typhus is prevalent in south Asia and western pacific regions.^[1] There are several reports of outbreaks of scrub typhus from different parts of India such as Himachal Pradesh, Pondicherry, Sikkim, and Jaipur during 2003, 20062008, 2011 and 2012.^{[2],[3],[4],[5],[6]} The clinical presentation of scrub typhus may varied from acute febrile illness to central nervous system (CNS) manifestations mimicking meningoencephalitis. Malaria, typhoid, dengue, chikungunya, enteric fever, leptospirosis may mimic scrub typhus. Although it is epidemic in India, scrub typhus is underdiagnosed in our state Bihar (eastern part of India) due to low index of suspicion, non specific presentation, lack of access of specific diagnostic facility, lack of awareness between clinicians and prevalent disease like malaria, dengue, enteric fever, kala-azar mimicking scrub typhus. So, we can diagnose scrub typhus by high index of suspicion and proper tests.

Materials and Methods

This study was a prospective observational study done at tertiary care hospital from March 2018 to December 2018. All patients presenting with acute fever in the hospital during the study period were evaluated. All these patients were physically examined and detailed history was taken. We carefully searched for presence of eschar. Routine investigations including complete blood count, peripheral blood smear, blood sugar, renal and liver function tests were done in all patients. Other investigations such as rapid card test for malaria, serology for dengue, serology for leptospira, Elisa for typhoid, RK39 test were done to exclude and to find concurrent other endemic diseases like malaria, dengue, leptospirosis, enteric fever and kala-azar. A Computed tomography (CT) of the brain and cerebrospinal fluid (CSF) analysis were done in clinically suspected meningoencephalitis. Weil-Felix test was done in all these patients. On the basis of positive weil-felix test with titre ×1:80, patients were diagnosed to have scrub typhus and included in this study. Some of the patients were tested for IgM antibodies to Orientia tsutsugamushi by Enzyme linked immunosorbent assay (ELISA) method.

Results:

Total 13 patients were diagnosed to have scrub typhus in the present study. The age ranged from 20 to 67 years. Majority of the patients were belonged to the younger age group. There were 8 females (61%) and 5 males (38%). 5 cases (38%) belong to rural and 8 cases (61%) were from urban areas.

[Table 1] shows the signs and symptoms of these 13 patients. Fever was the most common presentation found in all of the patients (100%) followed by Headache, seizure and altered sensorium (61.5%). Other symptoms were nausea, vomiting,breathlessness, and urinary symptoms. The duration of symptoms varied from 3 to 25 days with median duration of 8 days. Common signs were Hepatomegaly (38%), splenomegaly (38%), pleural effusion (46%), and hypotension (7.7%). There was only one patient (7.7%) having eschar and one patient had rashes (7.7%). The site of eschar was in the right axilla. There was no case having lymphadenopathy.

Table 1

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[Table 2] shows investigation reports of the patients. There was leukocytosis in 9 cases (70%) and all cases had thrombocytopenia (platelets count <1.5 lac/cumm) in which 12 cases had platelet count <1 lac/cumm. Deranged liver function was present in 8 patients (61%) and deranged renal function in 5 patients (38%). All patients have positive weil-felix test with titre ?1:80. Two patients were tested for IgM antibodies to Orientia tsutsugamushi by Enzyme linked immunosorbent assay (ELISA) method and was positive. [Table 3] shows the complications associated with scrub typhus. Thrombocytopenia (platelet count <1 lac/cumm) (92%), meningoencephalitis (61%), acute renal failure (38%), hepatitis (61%) and ARDS (30%) were common complications and shock (7%) were less common. All 8 patients (61%) of meningoencephalitis were analysed for CSF and showed elevated protein and lymphocytic pleocytosis. All patients in our study responded to doxycycline. There was no mortality in our study.

Table 2: Laboratory investigations

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Table 3: Complications of scrub typhus

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Discussion:

Scrub typhus is a mite-borne disease. It is less reported from Bihar though there is increase in incidence of the disease. Recently in a multicentric study, some cases of scrub typhus were reported from Bihar.^[7] Most of the cases in our study were belong to 20-50 years of age in which 38% cases were belong to 20-29 years of age and 30% cases were belong to 4049 years of age group, an observation similar to Sinha et al. and Madi et al.^[6],[8] In this study, patient mostly belonged to East Champaran area of Bihar (23%). Most of the cases in our study were associated with farming background and especially with rice farming. In a study by Ogawa et al. 64% of the cases were associated with agriculture and related activities.^[9]

Cases were reported from March 2018 to December 2018. In the tropical areas transmission of scrub typhus disease occurs throughout the year. In southern and eastern parts of India outbreaks of scrub typhus have been reported during cooler season.^{[4],[10],[11]} In this study more cases were reported in September to November months.

In our study fever was the most common presentation found in all patients (100%) followed by headache, altered sensorium, seizure and urinary symptoms in 46% cases. Vivekanadan et al. and Mahajan et al. reported headache in 52% and 38% respectively.^[4],[12]

Eschar which is considered pathognomonic for scrub typhus, found in only one case (7.7%) in our study. Mathai et al., Vivekanandan et al., and Mahajan et al. reported an incidence of eschar in 4%, 46% and 10% of cases respectively.^{[4],[10],[12]}

In a study of Sinha et al. from India, there was not a single case had eschar out of 42 cases.^[2] Detection of low eschar rate in our study may be low due to dark skinned colour patients, in which it is difficult to detect. There is high incidence of eschar were found in Vietnam, Taiwan and Korea, probably due to fair skin colour of the population and or may be due to variation in serotypes.^{[13],[14],[15]} In this study there was no patient having lymphadenopathy. In other studies, the incidence of lymphadenopathy varied from 18% to 53%.^{[4],[6],[11],[12],[16]}

Scrub typhus may also presents with CNS manifestations. In our study 8 (61%) patients presented with meningoencephalitis, in which 5 (60%) were female and 3 (40%) were male. These 8 patients (61.5%) had headache, altered sensorium and seizures. One patient (7.7%) had neck rigidity. Seizure was present in 4 patients (50%) out of 8 patients of meningoencephalitis. In study of 13 cases of scrub typhus meningoencephalitis by Jamil et al. 46.51% cases had seizure and 76.92% cases had meningeal sign.^[17] CSF were analysed of these patients. The results of CSF showed lymphocytic pleocytosis, and elevated protein. There are studies from India in which meningoencephalitis were reported in 9.5% to 23.3% of patients.^[2],[4],[18] In a study authors suggested that scrub typhus should be considered as a differential diagnosis of acute and subacute meningitis, especially when associated with deranged renal and liver function.^[19] Recently scrub typhus emerged as a cause of acute encephalitis syndrome in children in India^[20],[21].

Among laboratory investigations, serum glutamic pyruvic transaminase (SGPT) and serum glutamic oxaloacetic transaminase (SGOT) were elevated in 76.9% of cases. In other studies by Vivekanadan et al. transaminase levels were elevated in 95.9% and in study by Peesapati et al. SGPT and SGOT were elevated only in 8.33% patients.^[4],[22] Raised bilirubin ( >1.2 mg/dl) was present in 61.5% cases and increased serum creatinine was present in 38.4% cases in this study. Thrombocytopenia ( platelets count <1.5 lac/cumm) was present in all cases. There were 69.23 % cases having leukocytosis.

Scrub typhus can cause serious complications like multiple organ dysfunction syndrome (MODS), ARDS, Shock and meningoencephalitis. These complications are the leading cause of death. In our study 11 cases developed MODS having three or more organ system involvement in which 10 cases had involvement of 5 or more organ systems.

30.7% patients developed ARDS in our study, in which one patient required BIPAP ventilation. All patients recovered well. 1 patient (7.7%) developed circulatory collapse in our study, required inotropic support. Other complications caused by scrub typhus which are uncommon such as myocarditis, disseminated intravascular coagulation (DIC), Pancreatitis have been reported^{[14],[23],[24],[25]}.

However in the present study there was no case having these rare complications. Premaratna et al. reported 6 cases of acute hearing loss due to scrub typhus.^[26] In this study no patient had hearing loss. The Mortality rate of scrub typhus has been reported around a median mortality of 6.0% for untreated with a wide range of 0-70% and 1.4% for treated scrub typhus.^[27],[28] High mortality rate was reported in scrub typhus complicated with CNS involvement (13.6% mortality), multi-organ dysfunction (24.1%) and high pregnancy miscarriage rates with poor neonatal outcomes.^[27] There was no mortality occurred in our study, however in other indian studies by Mahajan et al. the mortality rate was 14.2 %, in study of Vivekanandan et al. this was 2% (1 out of 50), Peesapati et al. reported case fatality rate of 8 % and Takhar et al. reported 21.2% mortality.^{[4],[11],[12],[22]}

In the present study weil-felix test was used for the diagnosis of scrub typhus. Weil-Felix test was positive in titres of 1:80, 1:60 and 1;320 or more in 1, 5 and 7 patients respectively. This test is found to be less sensitive but highly specific. In study of Isaac et al. from CMC vellore, the specificity of weil-felix test was found to be high even at a titre as low as 1/20.^[29]

Other immunological tests like ind irect immunofluorescence antibody (IFA), immunoperoxidase (IIP) test etc, have high sensitivity and specificity but these are costly and not easily available. Doxycycline is the drug of choice for the scrub typhus. Nearly all patients in this study responded to doxycycline. Maximum duration of hospital stay of the patient was 10 days with average of 7 days.

Conclusion

The study shows a wide variety of clinical manifestations and complications of scrub typhus in Bihar. Due to the varied presentation and high mortality due to complications, a high index of suspicion is required. The study highlights the clustering of cases during September to November. Scrub typhus deserves as an important differential diagnosis in the endemic areas associated with farming or related activities. Although eschar is pathognomonic of scrub typhus, even in the absence of eschar and lymphadenopathy a high index of suspicion and empirical addition of doxycycline is crucial for decreasing mortality.

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