Scrub typhus meningoencephalitis, a diagnostic challenge for clinicians: A hospital based study from North-East India

Abstract

Central nervous system (CNS) involvement is a known complication of scrub typhus which range from mild meningitis to frank meninigoencephalitis.Aims and objectives:To study the clinical feature, laboratory parameters and response to treatment of scrub typhus meningitis/meningoencephalitis.Methods and Materials:This is a hospital based prospective observational study from North Eastern India. Diagnosis was based on clinical features and positive serological test (Weil's Felix test and IgM antibody card test).Results:13 patients of scrub typhus with features of meningitis/meningoencephalitis were included. The mean duration of fever before presentation was 5.61±3.08 days and 4 (30.76 %) patients had eschar. Altered sensorium, headache, seizure and meningeal sign were present in 13 (100%), 13 (100%), 6 (46.15%) and 10 (76.92%) patients respectively. Mean CSF protein, glucose and Adenosine deaminase was 152.16±16.88mg/dl, 55.23±21.7mg/dl, and 16.98±7.37U/L respectively. Mean total count of CSF leukocyte and lymphocyte percentage was 46.07±131 cell/cumm and 98.66±3.09% respectively. Tablet doxycycline with or without injection azithromycin was used and that shows good response 15.38% of patients died and all of them had multi organ dysfunction.Conclusion:Meningoencephalitis is a common manifestation of scrub typhus and diagnosis requires high degree of clinical suspicion which if diagnosed early and specific treatment started, patients usually recover completely with few complications.

Differentiating scrub typhus meningoencephalitis, from tuberculous meningitis: Two case reports and a review

“…Tetracycline 500 mg qid or doxycycline 200 mg once daily for 7 days is the treatment of choice. Azithromycin has been proven to be more effective than doxycycline in doxycycline-susceptible and doxycycline-resistant strains causing scrub typhus and can be used in pregnancy and in renal failure (11). Suggested mechanism for doxycycline resistance include poor CNS penetration with 15 -30% of drug reaching the CNS, resistance, bacteriostatic nature, immune mediated injury etc.…”

“…Central nervous system (CNS) involvement is a well-known complication of scrub typhus ranging from aseptic meningitis to frank meningoencephalitis (10).Patients with scrub typhus with meningitis and/or encephalitis present as confusion, agitation or seizures. Focal neurological signs are rare but are known to occur (11). Cranial nerve deficits are seen in ~25% of patients with the sixth being the most commonly involved (12).…”

“…Cerebrospinal fluid (CSF) profile may show changes similar to viral meningitis such as mild leukocytosis, slightly increased protein content, and normal glucose levels (6). It should be included in differential diagnosis of aseptic meningitis and encephalitis in patients in endemic areas especially when alternative diagnoses are uncertain (5,11,16). In some instances features similar to tuberculous meningoencephalitis (TBM) such as cranial nerve palsies with CSF showing lymphocytic pleocytosis, moderately elevated protein levels, low glucose and elevated CSF adenosine deaminase (ADA) levels have been described (10).…”

Successfully Managed Acute Transverse Myelitis Related to Scrub Typhus and Serial Image Findings

“…1,3 Other neurologic manifestations include cerebral infarction and brain hemorrhage. [4][5][6] Although there are reports of brain lesions and meningitis in patients with scrub typhus, reports of spinal cord involvement, such as acute transverse myelitis (ATM) associated with scrub typhus, are extremely rare. 7,8 ATM is a focal inflammatory disorder of the spinal cord, characterized clinically by acute or subacute motor, sensory, and autonomic dysfunction.…”

Viewing the Unseen: Scrub Encephalopathy as an Important Differential Diagnosis of AES

“…Aseptic meningitis is very commonly seen but other complication like cerebritis, myelitis and cerebral haemorrhage has been reported 4 . Study done by KarAetalfound that among 20 consecutive patients with acute encephalitic syndrome (AES), six (30%) were due to scrub infection 5 .…”