Neuropsychiatric Manifestations of Scrub Typhus

Abstract

Scrub typhus is caused by Orientia tsutsugamushi characterized by focal or disseminated vasculitis and perivasculitis which may involve the lungs, heart, liver, spleen and central nervous system. It was thought to have been eradicated from India. Recently it is being reported from many areas of India. The clinical picture and severity of the symptoms varies widely. The neurological manifestations of scrub typhus are not uncommon but are diverse. Meningoencephalitis is classical manifestation of scrub typhus but cerebellitis, cranial nerve palsies, plexopathy, transverse myelitis, neuroleptic malignant syndrome and Guillan-Barré syndrome are other manifestations reported in literature. The availability of literature on the neurological manifestations of scrub typhus is limited to case reports mainly. This article reviews various neurological manifestations of scrub typhus reported in literature.

Acute Parkinsonism and Cerebral Salt-wasting-related Hyponatremia in Scrub Typhus

“…Meningitis is the most common neurological manifestation. Others include cranial neuropathies, plexopathies, peripheral neuropathies, Guillain-Barre syndrome, transverse myelitis, acute disseminated encephalomyelitis, cerebral infarction, subdural hematoma, subarachnoid hemorrhage (SAH), cerebral venous thrombosis, seizures, coma, cerebellitis, neuroleptic malignant syndrome, and psychiatric manifestations [1,2] Parkinsonism has been described in three cases, who were all from rural areas [3][4][5]. Two were elderly males, while the third patient was a middle-aged man like ours.…”

“…The involvement of the central nervous system occurs hematogenously from the peripheral cells of the monocyte-phagocyte system that the rickettsiae parasitize [1]. Leptomeningeal infiltration, CSF invasion, perivasculitis, parenchymal inflammation and infarction, typhus nodules, and demyelination lead to clinical features in scrub typhus [2].…”

“…Scrub typhus is a zoonotic infection that causes a nonspecific febrile illness with multisystem manifestations, most commonly involving the respiratory system. Various neurological manifestations of scrub typhus have been reported in case reports and case series [1,2]. Parkinsonism has been reported in three instances previously, none of whom underwent a lumbar puncture [3][4][5].…”

Facial diplegia as a delayed complication of scrub typhus

“…4 Facial diplegia caused by scrub typhus is rare, and in most cases, occurs concomitantly with GBs, which may present various other forms of nerve palsy besides facial palsy. 3,8,9 This could be explained by the possibility that, in scrub typhus, Orientia tsutsugamushi infiltrates the vascular endothelium of cap-illaries or small arteries, causing intrusion of inflammatory cells, which leads to vasculitis; another possibility is that it is caused by demyelination of the nerves due to a secondary immune response against an infection. [4][5][6] In the present case, the onset of facial diplegia occurred after a certain amount of time had passed since the appearance of symptoms caused by scrub typhus as well as contrast-enhanced magnetic resonance imaging findings in the facial nerves on both sides.…”

Neurologic Infections in Travelers

“…25 Neurologic manifestations are highly variable, with reports of meningitis, encephalitis, cranial nerve palsies, cerebellitis, stroke due to vasculitis, central venous thrombosis, parkinsonism, transverse myelitis, acute inflammatory demyelinating polyradiculoneuropathy, peripheral neuropathy, and psychiatric manifestations with visual hallucinations. 28 The risk of developing neurologic manifestations is unknown. A small series of 25 infected patients without clinical CNS findings had CSF findings of mononuclear pleocytosis in 48% and PCR identification of the bacteria in 24% indicates that CNS invasion can occur without clinical manifestations.…”