Polyneuropathy and Cerebral Infarction Complicating Scrub Typhus

Abstract

We describe a 64-year-old man with scrub typhus who presented with both polyneuropathy and cerebral infarction. A neurological examination revealed a confused mental state, stiff neck, hearing impairment, symmetric weakness, sensory loss, and ataxia. Electrophysiologic studies showed demyelinating sensorimotor polyneuropathy and sensorineural hearing loss. Brain magnetic resonance imaging showed multiple infarctions. Brain involvement or polyneuropathy associated with scrub typhus has been rarely reported, and the pathogenic mechanism underlying the multiple neurological complications remains to be elucidated. Scrub typhus is a febrile illness caused by Orientia tsutsugamushi, and is characterized by fever, rash, eschar, myocarditis, and pneumonitis. Neurological involvement usually includes meningitis and hearing loss, possibly due to involvement of the eighth cranial nerve.1,2 However, involvement of the brain parenchyma and peripheral nerve is rarely reported. 3-5 Here we report a case of scrub typhus with cerebral infarction and polyneuropathy. CASE REPORTA 64-year-old man was admitted due to fever, myalgia, dysarthria, dizziness, and headache that had first appeared several days previously. He had worked at a sewage disposal plant in the northern rural area of Seoul. He had suffered from mild conductive hearing impairment of undetermined cause in the left ear for several years. On admission, his body temperature was 39℃ and his blood pressure was normal (110/70 mmHg). Eschar was not evident. A neurological examination revealed a confused mental state and neck stiffness. Limb weakness was absent, but he exhibited multidirectional sway on tandem gait.Laboratory tests showed leukocytosis (14.9×10 3 cells/μl) and thrombocytopenia (33×10 3 platelets/μl).Liver enzymes were elevated (aspartate aminotransferase = 214 IU/l, alanine aminotransferase = 151 IU/l) and renal function was impaired (blood urea nitrogen = 31creatinine = 1.6 mg/dl). Initial computed tomography (CT) of the brain was normal. (Fig. A), a chest radiograph indicated pulmonary edema, electrocardiography showed sinus tachycardia, and an echocardiogram was normal. Cerebrospinal fluid (CSF) was not examined due to the presence of thrombocytopenia. The patient was initially positive for serum indirect immunofluorescent antibody against O. tsutsugamushi (1:800),

Scrub Typhus Meningitis in South India — A Retrospective Study

“…Tsutsugamushi is the rickettsia with the most meningeal involvement [27] but central nervous system(CNS) involvement is higher in epidemic typhus than that of scrub typhus [8]. CNS complications include infarction [28], cerebellitis [17], hemorrhages [29], encephalitis, demyelination [30], subdural hematoma [31], typhus nodules [32] and meningitis causing altered sensorium, agitation, motor weakness, seizures, neck stiffness, cranial nerve deficits(CND) [33]. Low platelets and DIC contribute towards haemorrhage [29].…”

“…The involved cranial nerves are the optic [17], abducens, facial and cochlear [35] nerves. Peripheral nervous system involvement reported are mononeuritis multiplex [36], brachial plexus neuropathy [37], polyneuropathy [28], myelitis [30], [38] and Guillain-Barre syndrome (GBS) [25].…”

Severe scrub typhus infection: Clinical features, diagnostic challenges and management

“…The most common neurological presentation in scrub typhus is as meningitis, meningoencephalitis or encephalitis [46] . Others include cerebral venous thrombosis [47] , GuillainBarre Syndrome [48] , transient Parkinsonism and myoclonus [49] , opsoclonus [50] , cerebellitis [51] , transverse myelitis [52] , polyneuropathy [53] , facial palsy [54] , abducens nerve palsy [55] and bilateral optic neuritis [56] . Multi-organ dysfunction is not uncommon in severe scrub typhus infection.…”

Evoked response audiometry in scrub typhus: prospective, randomised, case–control study

“…Certain areas provide optimal conditions for the infected mites to thrive, such as forest clearings, riverbanks and grassy regions. 1,2,[4][5][6][7] Unilateral or bilateral deafness can occur in many rickettsial diseases. 1 The geographical location of scrub typhus, the initial sore caused by the chigger bite, and the occurrence of blood-borne antibodies against the infectious organism are useful in establishing the diagnosis.…”