Scrub typhus in children: Clinical profile and complications at a Tertiary Care Teaching Hospital in Uttarakhand

Abstract

Background: Scrub typhus is an acute febrile illness caused by rickettsia Orientia tsutsugamushi. Rickettsial infections are grossly underdiagnosed in India because of their non-specific clinical presentation, low index of suspicion among clinicians, and lack of diagnostic facilities. Objective: Objective of the study is to study the clinical profile, complications, and outcome of pediatric scrub typhus. Materials and Methods: This prospective observational study was conducted in the Department of Pediatrics, SGRR Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India, over a period of 2 years from November 2013 to October 2015. Children up to 18 years of age with signs and symptoms compatible with scrub typhus along with serological confirmation were included in the study. Serological study was conducted using rapid immunochromatographic assay and/or immunoglobulin M enzyme-linked immunosorbent assay technique. Clinical presentation, laboratory findings, complications, and outcome of these children were recorded on a performa. The data were analyzed using SPSS version 20 for windows. Results: About 115 children were diagnosed as scrub typhus during the study period. All children presented with fever. Other common symptoms were myalgia (56%), vomiting (50.5%), abdominal pain (26%), headache (28%), facial puffiness (15%), and seizures (8.7%). Pallor was present in 48% of children. Other common signs were hepatomegaly (29%), splenomegaly (28%), hypotension (24%), edema (21%), oliguria (17%), maculopapular rash (10%), meningeal signs (10.4%), and conjunctivitis (3%). Thrombocytopenia (67%), anemia (51%), pleural effusion (23%), shock (16%), hepatitis (23%), acute kidney injury (17%), meningoencephalitis (10%), myocarditis (7%), and acute respiratory distress syndrome (7%) were the complications observed. Azithromycin, doxycycline or chloramphenicol were used for the treatment. Overall mortality rate was 12.2%. Conclusion: A high degree of suspicion and knowledge of geographicaldistribution of rickettsial diseases is crucial for its early diagnosis and favorable outcome. The presence of an eschar is a valuable clinical clue in the diagnosis of scrub typhus; however, its absence does not rule out the disease.

<p>Scrub Typhus in Children at Tribhuvan University Teaching Hospital in Nepal</p>

“…11 AKI as a complication is observed in various studies with a range between 2% and 20% and in our study it was 14%. 11,17,26,27 In our study, one case of hemophagocytic lymphohistiocytosis (HLH) was found similar to a study done by Khandelwal et al 17 In the study done by Sankhyan et al three cases (20%) of HLH were diagnosed out of which one child died. 28 In our study, the mainstay of antibiotics was oral doxycycline and intravenous chloramphenicol.…”

“…Thrombocytopenia was detected between 20 and 88% in various studies but in our study it was 52%. 17,25,27,30 Leukopenia was uncommon in our study being around 3.6% whereas it was seen in 23% of the patients in another study. 17 Leukocytosis was seen in 39.2% which is almost the same as that seen in other studies ranging from 21-47%.…”

“…26 All children presented with fever which has also been observed in other studies. 10,27,28 Most of them (70%) had fever for 7-13 days. The next most common symptoms were that of respiratory symptoms such as shortness of breath (50%), cough (26%) and chest pain (15.5%) which is similar to studies done in Eastern Nepal 29 and India.…”

“…10 Other studies also showed wide range in detection of splenomegaly which is from 26% to almost 60%. 10,11,17,[25][26][27]31 Presence of an eschar provides a valuable clinical clue in the early diagnosis of scrub typhus. 13 It may develop before the onset of systemic signs.…”

“…In the study by Kumar et al, all three drugs (azithromycin, chloramphenicol and doxycycline) were used. 27 In a Sri Lankan study, rapid response to treatment with intravenous chloramphenicol was observed in comparison to oral chloramphenicol. 31 In the study done by Kumar et al, a dramatic response was seen with doxycycline.…”