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

Abstract

Scrub typhus infection is an important cause of acute undifferentiated fever in South East Asia. The clinical picture is characterized by sudden onset fever with chills and non-specific symptoms that include headache, myalgia, sweating and vomiting. The presence of an eschar, in about half the patients with proven scrub typhus infection and usually seen in the axilla, groin or inguinal region, is characteristic of scrub typhus. Common laboratory findings are elevated liver transaminases, thrombocytopenia and leukocytosis. About a third of patients admitted to hospital with scrub typhus infection have evidence of organ dysfunction that may include respiratory failure, circulatory shock, mild renal or hepatic dysfunction, central nervous system involvement or hematological abnormalities. Since the symptoms and signs are non-specific and resemble other tropical infections like malaria, enteric fever, dengue or leptospirosis, appropriate laboratory tests are necessary to confirm diagnosis. Serological assays are the mainstay of diagnosis as they are easy to perform; the reference test is the indirect immunofluorescence assay (IFA) for the detection of IgM antibodies. However in clinical practice, the enzyme-linked immuno-sorbent assay is done due to the ease of performing this test and a good sensitivity and sensitivity when compared with the IFA. Paired samples, obtained at least two weeks apart, demonstrating a ≥ 4 fold rise in titre, is necessary for confirmation of serologic diagnosis. The mainstay of treatment is the tetracycline group of antibiotics or chloramphenicol although macrolides are used alternatively. In mild cases, recovery is complete. In severe cases with multi-organ failure, mortality may be as high as 24%.

Scrub Typhus in Northeastern Thailand: Eschar Distribution, Abnormal Electrocardiographic Findings, and Predictors of Fatal Outcome

“…1 Presence of an eschar is a useful sign for diagnosing scrub typhus infection. Complications usually develop after the second week of illness, particularly in untreated cases, with systemic involvement 3 and disseminated vasculitis, 4 including septic shock, 5 acute respiratory distress syndrome (ARDS), 6,7 pneumonitis, 7 acute renal failure (ARF), 8,9 meningitis or meningoencephalitis, 10 myocarditis, 11 disseminated intravascular coagulation (DIC), 12 upper gastrointestinal bleeding, 13 and multiorgan dysfunctions (MODS). 1,4 Myocarditis is a rare complication, few reports showed abnormal electrocardiographic (ECG) findings in scrub typhus patients.…”

Tick Bite by NymphalAmblyomma testudinarium

“…Symptoms of Lyme disease include erythema migrans, acute viral-like illness, and febrile episodes9. Scrub typhus is a rickettsial illness caused by Orientia tsutsugamushi and it can cause flu-like illness with fever, headache, and mylgia13. So if the patient presents leukocytopenia, thrombocytopenia, and gastrointestinal symptom with fever after tick bite, physicians should consider SFTS as well as scrub typhus and other febrile infectious disease39111213.…”

“…Scrub typhus is a rickettsial illness caused by Orientia tsutsugamushi and it can cause flu-like illness with fever, headache, and mylgia13. So if the patient presents leukocytopenia, thrombocytopenia, and gastrointestinal symptom with fever after tick bite, physicians should consider SFTS as well as scrub typhus and other febrile infectious disease39111213. Doxycycline is a prophylactic agent for Lyme disease and a drug of choice for scrub typhus913.…”

Immune thrombocytopenia with multi-organ dysfunction syndrome as a rare presentation of scrub typhus: a case report

“…The actual clinical manifestations range from non-specific febrile illness to severe organ dysfunction [13] in the form of disseminated intravascular coagulation (DIC), vascular leak, pulmonary edema, shock, hepatic dysfunction and meningoencephalitis. About a third of patients admitted with scrub typhus have evidence of multi-organ dysfunction [14]. …”