Nationwide Incidence of Chigger Mite Populations and Molecular Detection of Orientia tsutsugamushi in the Republic of Korea, 2020

The Korea Disease Control and Prevention Agency has established regional centers at 16 locations to monitor vectors and pathogens. We investigated the geographical and temporal distribution of chigger mite populations to understand tsutsugamushi disease epidemiology in 2020. To monitor weekly chigger mite populations, 3637 chigger mites were collected from sticky chigger mite traps in autumn. Chigger mites appeared from the first week of October to the third week of December, peaking in the fourth week of October. The predominant species were Leptotrombidium scutellare, Leptotrombidium palpale, Neotrombicula kwangneungensis, Neotrombicula tamiyai, and Leptotrombidium pallidum. To monitor Orientia tsutsugamushi infection in chigger mites, 50,153 chigger mites were collected from 499 trapped wild rodents in spring and autumn, with a chigger index of 100.5. Approximately 50% of chigger mites were pooled into 998 pools, and the minimum infection rate (MIR) of O. tsutsugamushi was 0.1%. Jeongeup had the highest MIR for O. tsutsugamushi (0.7%). The Kato-related genotype was the most common (52.2%), followed by the Karp-related (17.4%), Boryong (13.0%), JG-related (8.7%), Shimokoshi (4.3%), and Kawasaki (4.3%) genotypes. Ecological and geographical studies focusing on the basic ecology and pathology of mites will improve our understanding of tsutsugamushi disease risks in the Republic of Korea.

Endothelial Activation in Orientia tsutsugamushi Infection Is Mediated by Cytokine Secretion From Infected Monocytes

Scrub typhus, caused by Orientia tsutsugamushi, is a common systemic infection in Asia. Delay in diagnosis and treatment can lead to vasculitis in the visceral organs and other complications. The mechanisms that drive endothelial activation and the inflammatory response in O. tsutsugamushi infection remain unknown. In addition, the interaction between monocytes and endothelial cells is still unclear. Here we demonstrate that O. tsutsugamushi-infected human dermal microvascular endothelial cells produced moderate levels of chemokines and low levels of IL-6 and IFN-β, but not TNF or IL-1β. Recombinant TNF and cytokine-rich supernatants from infected monocytes markedly enhanced chemokine production in infected endothelial cells. We also show that TNF and monocyte supernatants, but not O. tsutsugamushi infection of endothelial cells per se, upregulated the endothelial cell surface expression of ICAM-1, E-selectin, and tissue factor. This finding was consistent with the inability of O. tsutsugamushi to induce cytokine secretion from endothelial cells. The upregulation of surface molecules after stimulation with monocyte supernatants was significantly reduced by neutralizing anti-TNF antibodies. These results suggest that endothelial cell activation and response are mainly mediated by inflammatory cytokines secreted from monocytes.

Urinary Exosomal microRNA-21 as a Marker for Scrub Typhus-Associated Acute Kidney Injury

Background: Urinary microRNA (miRNA)-21 is a biomarker for acute kidney injury (AKI). We conducted this study to determine if a urinary exosomal analysis for this biomarker could serve as a novel diagnostic approach for detecting kidney disease. Materials and Methods: We investigated the clinical significance of urinary exosomal miRNA-21 levels for AKI in scrub typhus patients. We collected 138 urine samples from scrub typhus patients at the time of admission. Urinary exosomal miRNA-21 was assessed in 25 age- and sex-matched scrub typhus patients with and without AKI. Results: The total leukocyte count was higher in AKI patients than in non-AKI patients (10.40 × 10³/mL vs. 6.40 × 10³/mL, p < 0.01). Urinary exosomal miRNA-21 levels were higher in the AKI group than in the non-AKI group (20.1 ± 1.2 vs. 17.8 ± 1.8 ΔCt value of miRNA-21, p < 0.01). Additionally, the miRNA-21 levels correlated directly with the total leukocyte counts and inversely with the estimated glomerular filtration rate. A receiver operating characteristic curve analysis demonstrated good discriminative power for the diagnosis of scrub typhus-associated AKI, with an area under the curve value of 0.907. Conclusion: Urinary exosomal miRNA-21 could be a surrogate marker for scrub typhus-associated AKI diagnosis.

Comparison of Lethal and Nonlethal Mouse Models of Orientia tsutsugamushi Infection Reveals T-Cell Population-Associated Cytokine Signatures Correlated with Lethality and Protection

The antigenic diversity of Orientia tsutsugamushi as well as the interstrain difference(s) associated with virulence in mice impose the necessity to dissect the host immune response. In this study we compared the host response in lethal and non-lethal murine models of O. tsutsugamushi infection using the two strains, Karp (New Guinea) and Woods (Australia). The models included the lethal model: Karp intraperitoneal (IP) challenge; and the nonlethal models: Karp intradermal (ID), Woods IP, and Woods ID challenges. We monitored bacterial trafficking to the liver, lung, spleen, kidney, heart, and blood, and seroconversion during the 21-day challenge. Bacterial trafficking to all organs was observed in both the lethal and nonlethal models of infection, with significant increases in average bacterial loads observed in the livers and hearts of the lethal model. Multicolor flow cytometry was utilized to analyze the CD4+ and CD8+ T cell populations and their intracellular production of the cytokines IFNγ, TNF, and IL2 (single, double, and triple combinations) associated with both the lethal and nonlethal murine models of infection. The lethal model was defined by a cytokine signature of double- (IFNγ-IL2) and triple-producing (IL2-TNF-IFNγ) CD4+ T-cell populations; no multifunctional signature was identified in the CD8+ T-cell populations associated with the lethal model. In the nonlethal model, the cytokine signature was predominated by CD4+ and CD8+ T-cell populations associated with single (IL2) and/or double (IL2-TNF) populations of producers. The cytokine signatures associated with our lethal model will become depletion targets in future experiments; those signatures associated with our nonlethal model are hypothesized to be related to the protective nature of the nonlethal challenges.

Spotted Fever Group Rickettsiae among Children with Acute Febrile Illness, in Gorakhpur, India

Seasonal outbreaks of acute encephalitis syndrome have been occurring in Gorakhpur division in the Indian state of Uttar Pradesh during monsoon and post-monsoon months. Orientia tsutsugamushi was identified as the major aetiology of these outbreaks. Orientia tsutsugamushi was also identified as one of the important aetiology of febrile illness among children attending peripheral health facilities. The present study was undertaken to detect antibodies against spotted fever group rickettsiae (SFGR) and typhus group rickettsiae (TGR) among children with acute febrile illness presenting at peripheral health facilities in Gorakhpur district. Of the 224 blood samples tested, SFGR infection was detected in 13 (6%) patients. None of the samples tested positive for TGR.

Circulating Plasmacytoid and Conventional Dendritic Cells Are Numerically and Functionally Deficient in Patients With Scrub Typhus

Background

Dendritic cells (DCs) are specialized antigen-presenting cells known to bridge innate and adaptive immune reactions. However, the relationship between circulating DCs and Orientia tsutsugamushi infection is unclear. Therefore, this study aimed to examine the level and function of plasmacytoid DCs (pDCs) and conventional DCs (cDCs), two subsets of circulating DCs, in scrub typhus patients.

Methods

The study included 35 scrub typhus patients and 35 healthy controls (HCs). pDC and cDC levels, CD86 and CD274 expression, and cytokine levels were measured using flow cytometry.

Results

Circulating pDC and cDC levels were found to be significantly reduced in scrub typhus patients, which were correlated with disease severity. The patients displayed increased percentages of CD86⁺ pDCs, CD274⁺ pDCs, and CD274⁺ cDCs in the peripheral blood. The alterations in the levels and surface phenotypes of pDCs and cDCs were recovered in the remission state. In addition, the production of interferon (IFN)-α and tumor necrosis factor (TNF)-α by circulating pDCs, and interleukin (IL)-12 and TNF-α by circulating cDCs was reduced in scrub typhus patients. Interestingly, our in vitro experiments showed that the percentages of CD86⁺ pDCs, CD274⁺ pDCs, and CD274⁺ cDCs were increased in cultures treated with cytokines including IFN-γ, IL-12, and TNF-α.

Conclusions

This study demonstrates that circulating pDCs and cDCs are numerically deficient and functionally impaired in scrub typhus patients. In addition, alterations in the expression levels of surface phenotypes of pDCs and cDCs could be affected by pro-inflammatory cytokines.

Seroprevalence trends of Scrub typhus among the febrile patients of Northern India: A prospective cross-sectional study

BACKGROUND

Rickettsial infections remain one of the most neglected and underdiagnosed tropical diseases in the developing countries. Scrub typhus can prove to an important diagnosis in pyrexia of unknown origin (PUO) patients and is transmitted by a species of trombiculid mites ("chiggers"). The disease leads to a plethora of symptoms like fever, rash, headache, nausea, abdominal pain, thrombocytopenia, etc. The current study was aimed to assess the seroprevalence as well as other demographic parameters of scrub typhus among patients diagnosed with PUO in the northern part of India.

MATERIALS AND METHODS

This study was undertaken for a period of 3 years from September 2017 to September 2020. Serum samples of suspected cases were tested for IgM Scrub typhus along with other common febrile illnesses like Malaria, typhoid, dengue, leptospirosis, chikengunya, etc. Additional testing for COVID-19 was also planned for samples received after February 2020.

RESULTS

The overall seroprevalence of Scrub typhus during the 3 year study period was noted to be 18.6% in the PUO patients. Typhoid was noted in 39.5%, malaria in 9.2%, Dengue in 13.5%, leptospirosis in 4.8%, and chikungunya in 5.3% of the patients. No cause was identified in 9.1% of the PUO cases. 3.9% of the samples were positive by RT-PCR for COVID-19. No mortality was noted in the scrub typhus positive cases.

CONCLUSION

Scrub typhus is an emerging tropical rickettsial disease in the Indian subcontinent. The present study highlights the importance of screening of PUO cases for this important infection as timely institution of simple empirical treatment can prove to be life saving in such positive cases.

An Inducible Expression System for Recombinant Sca Proteins with an Autotransporter Domain from Orientia Tsutsugamushi in Escherichia coli

BACKGROUND

Orientia tsutsugamushi (Ot) is an obligate, intracellular, gram-negative bacterium causing scrub typhus. Some of its encoded proteins play key roles in the adhesion and internalization of the Ot strain into host cells and are suitable resources for vaccine development and tools for scrub typhus diagnosis. Surface cell antigen (Sca) proteins, classified as autotransporter (AT) proteins, are one of the largest protein families involved in bacterial pathogenesis and can be promising candidates for vaccine development. These proteins are typically large and contain inhibitory domains; therefore, recombinant proteins without such domains have been evaluated for this purpose. However, the expression for recombinant Sca proteins containing the AT domain, which might largely affect their protective role against scrub typhus, has not been analyzed and optimized.

OBJECTIVE

In this study, we optimized expression and purification conditions for individual Ot Sca protein fragments [ScaA (27-1461), ScaC (257-526), ScaD (26-998), and ScaE (35-760)] harboring the AT domain.

METHODS

To this end, we subcloned sequences of codon-optimized DNA encoding Sca protein fragments into the Escherichia coli expression vector. In addition, the expression condition for individual Sca fragments was optimized, and the proteins were purified using one-step Ni-NTA column method. The purified fractions were re-folded by serial dilution method, followed by BCA quantification and densitometric analysis to estimate the yield and purity of proteins.

RESULTS

We prepared platforms for expression of recombinant Sca protein fragments [ScaA (27-1461), ScaC (257-526), ScaD (26-998), and ScaE (35-760)] containing an AT domain without the signal peptide and transmembrane (TM) domain. The protein yield per liter of culture with >70% of purity was ScaC (257-576), ScaE (35-760), ScaD (26-998), and ScaA (27-1461) in order.

CONCLUSION

Our results could be used to develop Sca AT-domain based vaccines and tools for scrub typhus diagnosis with rapid and cost-effective ways.

Scrub typhus in pregnancy presenting with permanent hearing loss: A case report

As clinicians, we need to be vigilant about these rare and atypical presentations given the endemic nature of scrub typhus in southern belt of the country. Timely diagnosis and appropriate treatment is the key aspect to prevent further complications.

Graphene Oxide Nanoparticles Modified Paper Electrode as a Biosensing Platform for Detection of the htrA Gene of O. tsutsugamushi

The unique structural and electrochemical properties of graphene oxide (GO) make it an ideal material for the fabrication of biosensing devices. Therefore, in the present study, graphene oxide nanoparticles modified paper electrodes were used as a low-cost matrix for the development of an amperometric DNA sensor. The graphene oxide was synthesized using the modified hummers method and drop cast on a screen-printed paper electrode (SPPE) to enhance its electrochemical properties. Further, the GO/SPPE electrode was modified with a 5′NH2 labeled ssDNA probe specific to the htrA gene of Orientia tsutsugamushi using carbodiimide cross-linking chemistry. The synthesized GO was characterized using UV-Vis, FTIR, and XRD. The layer-by-layer modification of the paper electrode was monitored via FE-SEM, cyclic voltammetry, and electrochemical impedance spectroscopy (EIS). The sensor response after hybridization with single-stranded genomic DNA (ssGDNA) of O. tsutsugamushi was recorded using differential pulse voltammetry (DPV). Methylene blue (1 mM in PBS buffer, pH 7.2) was used as a hybridization indicator and [Fe(CN)₆]^−3/−4 (2.5 mM in PBS buffer, pH 7.2) as a redox probe during electrochemical measurements. The developed DNA sensor shows excellent sensitivity (1228.4 µA/cm²/ng) and LOD (20 pg/µL) for detection of O. tsutsugamushi GDNA using differential pulse voltammetry (DPV).

Scrub typhus and antibiotic-resistant Orientia tsutsugamushi

Introduction: Scrub typhus is one of the most underdiagnosed and under-reported febrile illnesses requiring hospitalization, mainly occurring in Southeast and East Asia and the Pacific Islands, in an area referred to as the 'Tsutsugamushi Triangle.' Scrub typhus is a zoonotic rickettsial disease that is transmitted to humans by trombiculid mites.Areas covered: A MEDLINE/PubMed search of the available literature was performed to describe the role of antibiotic-resistant scrub typhus in therapy failure.Expert opinion: Scrub typhus is characterized by an eschar that may appear 2-3 days before sudden-onset fever with chills, headache, backache, myalgia, profuse sweating, vomiting, and enlarged lymph nodes. A macular or maculopapular skin rash can develop within 3-8 days after the onset of fever. Various antibiotics, such as chloramphenicol, tetracycline, doxycycline, macrolides, quinolones, and rifampicin, have been used to treat scrub typhus. Resistance to tetracycline has been proposed to underlie delayed clinical improvement since 1996, but recent reports have questioned the existence of doxycycline resistance. Nevertheless, the existence and importance of antibiotic-resistant scrub typhus remain uncertain and require further study.

Molecular Description of a Novel Orientia Species Causing Scrub Typhus in Chile

Scrub typhus is a potentially fatal rickettsiosis caused by Orientia species intracellular bacteria of the genus Orientia. Although considered to be restricted to the Asia Pacific region, scrub typhus has recently been discovered in southern Chile. We analyzed Orientia gene sequences of 16S rRNA (rrs) and 47-kDa (htrA) from 18 scrub typhus patients from Chile. Sequences were ≥99.7% identical among the samples for both amplified genes. Their diversity was 3.1%–3.5% for rrs and 11.2%–11.8% for htrA compared with O. tsusugamushi and 3.0% for rrs and 14.8% for htrA compared with Candidatus Orientia chuto. Phylogenetic analyses of both genes grouped the specimens from Chile in a different clade from other Orientia species. Our results indicate that Orientia isolates from Chile constitute a novel species, which, until they are cultivated and fully characterized, we propose to designate as Candidatus Orientia chiloensis, after the Chiloé Archipelago where the pathogen was identified.

Genotypic Heterogeneity of Orientia tsutsugamushi in Scrub Typhus Patients and Thrombocytopenia Syndrome Co-infection, Myanmar

Serologic and molecular surveillance of serum collected from 152 suspected scrub typhus patients in Myanmar revealed Orientia tsutsugamushi of genotypic heterogeneity. In addition, potential co-infection with severe fever with thrombocytopenia syndrome virus was observed in 5 (3.3%) patients. Both scrub typhus and severe fever with thrombocytopenia syndrome are endemic in Myanmar.

Epidemiologic Changes of Scrub Typhus in China, 1952-2016

Scrub typhus, a miteborne rickettsiosis, has emerged in many areas globally. We analyzed the incidence and spatial–temporal distribution of scrub typhus in China during 1952–1989 and 2006–2016 using national disease surveillance data. A total of 133,623 cases and 174 deaths were recorded. The average annual incidence was 0.13 cases/100,000 population during 1952–1989; incidence increased sharply from 0.09/100,000 population in 2006 to 1.60/100,000 population in 2016. The disease, historically endemic to southern China, has expanded to all the provinces across both rural and urban areas. We identified 3 distinct seasonal patterns nationwide; infections peaked in summer in the southwest, summer-autumn in the southeast, and autumn in the middle-east. Persons >40 years of age and in nonfarming occupations had a higher risk for death. The changing epidemiology of scrub typhus in China warrants an enhanced disease control and prevention program.

Association of Dengue Virus and Leptospira Co-Infections with Malaria Severity

Plasmodium infections are co-endemic with infections caused by other agents of acute febrile illnesses, such as dengue virus (DENV), chikungunya virus, Leptospira spp., and Orientia tsutsugamushi. However, co-infections may influence disease severity, treatment outcomes, and development of drug resistance. When we analyzed cases of acute febrile illness at the All India Institute of Medical Sciences, New Delhi, India, from July 2017 through September 2018, we found that most patients with malaria harbored co-infections (Plasmodium mixed species and other pathogens). DENV was the most common malaria co-infection (44% of total infections). DENV serotype 4 was associated with mild malaria, and Leptospira was associated with severe malaria. We also found the presence of P. knowlesi in our study population. Therefore, in areas with a large number of severe malaria cases, diagnostic screening for all 4 DENV serotypes, Leptospira, and all Plasmodium species should be performed.

Evaluation of the Diagnostic Accuracy of Antibody Assays for Patients with Scrub Typhus

This study was carried out to evaluate the accuracy of various antibody tests for scrub typhus, namely, the indirect immunofluorescence assay (IFA) from the Korea Centers for Disease Control and Prevention (KCDC) and four commercial kits (companies A to D). The test accuracy was based on the diagnosis of scrub typhus, as defined by a positive PCR or culture. In total, serum samples from 97 patients with scrub typhus and 200 non-scrub typhus patients were tested. The respective sensitivity and specificity of each test were as follows. For the KCDC IFA, sensitivity and specificity were 55.7% (95% confidence interval [CI], 45.2 to 65.8%) and 94.8% (95% CI, 90.4 to 97.3%) for IgM and 42.3% (95% CI, 32.3 to 52.7%) and 96.3% (95% CI, 92.6 to 98.5%) for IgG, with diagnostic cutoffs of ≥1:16 for IgM and ≥1:256 for IgG. For kit A, the sensitivity and specificity were 70.1% (95% CI, 59.8 to 78.8%) and 74.6% (95% CI, 67.6 to 80.6%) for total immunoglobulins, with a cutoff of ≥1:40. For kit B, the sensitivity and specificity were 64.3% (95% CI, 51.9 to 75.1%) and 94.9% (95% CI, 81.4 to 99.1%) for IgM and 67.1% (95% CI, 54.8 to 77.6%) and 74.4% (95% CI, 57.6 to 86.4%) for IgG. For kit C, the sensitivity and specificity were 53.6% (95% CI, 43.2 to 63.7%) and 99.5% (95% CI, 96.8 to 100%) for IgM and 36.1% (95% CI, 26.8 to 46.5%) and 100% (95% CI, 97.6 to 100%) for IgG. For kit D, the sensitivity and specificity were 73.2% (95% CI, 63.1 to 81.4%) and 89.5% (95% CI, 84.2 to 93.2%) for total immunoglobulins. These results are all unsatisfactory, highlighting an urgent need for the development of more highly sensitive and specific tests.

Outbreak prone communicable diseases of public health importance in the northern districts of West Bengal - Current status & the way forward

India is perilously poised on the threshold of an explosion of infectious diseases, some of which have witnessed re-emergence while others await apposite opportunity to do so. The State of West Bengal is uniquely positioned with its innate geographical vulnerabilities that favour outbreaks of a host of infectious diseases. The northern districts of this State are well known endemic areas for many outbreak prone communicable diseases like malaria, Japanese encephalitis, scrub typhus, dengue and kala-azar. An outbreak of Nipah virus in the recent past is a pointer towards the emerging and re-emerging threat in these regions and warrants urgent prioritization for surveillance and monitoring of these diseases. Identification of risk factors, challenges in delivery of primary healthcare, implementation of intervention strategies along with strengthening of healthcare setup are also the need of the hour. Multisectoral initiatives with emphasis on understanding the complex and rapidly evolving human-animal-vector dynamics as envisaged under the ‘One Health’ concept are indubitably important pillars in the effective management of these emerging public health challenges.

Acute kidney injury and electrolyte abnormalities in patients with scrub typhus admitted to a tertiary care hospital in southern India

Introduction:

Scrub typhus is an acute febrile illness that is seen in many parts of India. Acute kidney injury (AKI) can occur in patients with scrub typhus who are not diagnosed and treated in the early stage of the disease. Such patients can have associated electrolyte abnormalities also.

Objectives:

This study was done to find out the incidence of occurrence of AKI and electrolyte abnormalities among patients with scrub typhus and correlate the latter with the severity of AKI.

Methods:

This prospective, observational study included 38 patients with scrub typhus admitted to a tertiary care hospital in south India. Serum sodium and serum potassium levels of all the patients were measured at hospital admission. Also, serum creatinine levels of patients on all days of the hospital stay was measured along with other parameters like hemoglobin, leucocyte count, and platelet count.

Results:

The incidence of AKI among patients with scrub typhus was 13.16%. However, electrolyte abnormalities though seen in the patients did not correlate with AKI.

Conclusion:

AKI is not an uncommon phenomenon in patients with scrub typhus. Electrolyte abnormalities in these patients did not correlate with the severity of AKI.

Seroprevalence and Clinical Features of Scrub Typhus among Febrile Patients Attending a Referral Hospital in Kathmandu, Nepal

(1) Background: Scrub typhus (ST) is endemic to Nepal. It is often underdiagnosed and misdiagnosed due to non-specific clinical presentation coupled with limited microbiological facilities, leading to adverse clinical outcomes. This study aimed to assess the seroprevalence of scrub typhus in febrile patients attending Sukraraj Tropical and Infectious Disease Hospital (STIDH), Nepal, from August 2018 to April 2019. (2) Materials and Method: Blood/serum samples and clinical and demographic data of adult febrile patients (≥19 years) who attended or were referred to the hospital were collected after obtaining written informed consent from the participants excluding immunocompromised individuals. Collected blood/serum samples were subjected to hematological, biochemical, and serological tests. A serological test for scrub typhus was performed using the ImmuneMed scrub typhus rapid diagnostic test kit. Data generated were analyzed using SPSS software version 24.0. (3) Results: Amongst the 2070 febrile patients, 462 (22.3%) were seropositive to at least one etiological agent of febrile illnesses (scrub typhus: 253 cases, dengue: 101 cases, leptospirosis: 9, brucellosis: 52, malaria: 9 and kala-azar: 20 cases). Scrub typhus accounted for 12.2% (n = 253) of total febrile illnesses followed by dengue (4.9%, n = 101). Mixed seropositivity of scrub typhus with dengue, brucellosis, and typhoid was found in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. Among 253 scrub typhus patients, 53.4% were female. Among the 154 patients, the most common symptoms were fever (100%), headache (79.2%), sweating (70.1%), breathing difficulty (51.3%), redness of the eye (43.5%), and pathognomonic eschar was observed in 9.1% patients. Fifty percent of scrub typhus patients had low platelet count and >30% of patients had an elevated level of liver enzymes (such as serum glutamic oxaloacetic transaminase (SGPT) and serum glutamic pyruvic transaminase (SGOT). (4) Conclusion: Scrub typhus is a considerable cause of febrile illness in Nepal. Females apparently have a higher chance of acquiring scrub typhus. ST presents nonspecific clinical presentation. The diagnostic dilemma of typhus patients can be minimized by the early monitoring of ST-associated symptoms. The country's health system needs to be strengthened for early outbreak detection, and immediate response actions against scrub typhus to control the future outbreak of ST.

Spatiotemporal Dynamics of Scrub Typhus in Jiangxi Province, China, from 2006 to 2018

Background: Scrub typhus (ST) has become a significant potential threat to public health in Jiangxi. Further investigation is essential for the control and management of the spatiotemporal patterns of the disease. Methods: Time-series analyses, spatial distribution analyses, spatial autocorrelation analysis, and space-time scan statistics were performed to detect spatiotemporal dynamics distribution of the incidence of ST. Results: From 2006 to 2018, a total of 5508 ST cases occurred in Jiangxi, covering 79 counties. The number of ST cases increased continuously from 2006 to 2018, and there was obvious seasonality during the variation process in each year, with a primary peak in autumn (September to October) and a smaller peak in summer (June to August). From 2007 to 2018, the spatial distribution of the ST epidemic was significant heterogeneity, and Nanfeng, Huichang, Xunwu, Anyuan, Longnan, and Xinfeng were hotspots. Seven spatiotemporal clusters were observed using Kulldorff's space-time scan statistic, and the most likely cluster only included one county, Nanfeng county. The high-risk areas of the disease were in the mountainous, hilly region of Wuyi and the southern mountainous region of Jiangxi. Conclusions: Targeted interventions should be executed in high-risk regions for the precise prevention and control of ST.

Association of leptospirosis and scrub typhus in acute encephalitis syndrome in a tertiary care hospital in Odisha, India

BACKGROUND

Acute encephalitis syndrome (AES) is a major public health concern in India, causing febrile illness principally associated with viral infection. Bacteria-like scrub typhus and leptospirosis also cause acute febrile illness. Therefore, this study was conceived to address the possible etiological agents contributing to sporadic AES in a tertiary care center in Odisha, India.

METHOD

This was a prospective hospital-based study that enrolled 92 consecutive patients with clinically diagnosed AES whose blood/cerebrospinal fluid samples were tested for IgM antibodies to dengue, Japanese encephalitis (JE), herpes simplex virus (HSV), Epstein-Barr virus (EBV), leptospirosis and scrub typhus.

RESULTS

Viral antibodies to dengue were detected in three (3.26%) cases, HSV1 in four (4.34%) and HSV2 in three (3.26%) cases. Significantly, antibodies to EBV in 22 (23.591%) and to JE in 27 (29.34%) cases were detected. Notably, 30 (32.60%) and 11(12.0%) of patients had IgM antibodies to leptospirosis and scrub typhus, respectively.

CONCLUSION

This observation indicates an association of leptospirosis and scrub typhus infection in sporadic cases of AES, besides other viruses.

Clinical and biochemical profile of scrub typhus patients at a tertiary care hospital in Northern India

Background

Scrub typhus is a neglected rickettsial disease in India. Every year, we are facing outbreaks of Scrub typhus after Monsoon season. Patients present with a wide clinical spectrum ranging from pyrexia of unknown origin to multiple organ dysfunction. Some of these clinical features overlap with presentation of other tropical infections prevalent in Indian subcontinent, which leads to diagnostic dilemma and delay in diagnosis. Hence, we planned this study to know the demographic, clinical and biochemical profile of scrub typhus patients.

Methods

This was an observational study conducted in department of Medicine, King George's Medical University Lucknow, India a leading tertiary care hospital of Northern India. All scrub typhus patients were evaluated by detailed history, examination and laboratory tests.

Results

We enrolled 52 patients in our study. The mean age of the patients was 35.17 ± 16.90 years with majority (82.7%) of patients from rural background. All the patients had fever with an average duration of 9.6 ± 2 days. Most of the patients developed hepatitis (69.2%) followed by acute encephalitis syndrome (47%), acute kidney injury (23.1%) and acute respiratory failure (19.2%). Eschar was found in 11 patients (21.2%).

Conclusion

Scrub typhus is often misdiagnosed or diagnosed late due to its wide clinical spectrum overlapping with clinical presentation of other commonly prevalent tropical diseases. One should always consider the differential diagnosis of scrub typhus while evaluating a young febrile patient of rural background, with features of single or multiple organ dysfunction and laboratory findings of leucocytosis, thrombocytopenia and elevation of transaminases.

A Clinical Case of Scrub Typhus in the United States Forces Korea Patient with Eschar and Genetic Identification of Orientia tsutsugamushi Using Multiplex PCR-Based Next-Generation Sequencing

An epidemiological investigation was conducted for a scrub typhus case reported in a U.S. Forces Korea military patient in the Republic of Korea in November 2018. The patient had a fever, maculopapular rash, and an eschar. The full-length sequence of Orientia tsutsugamushi 56-kDa type-specific antigen (TSA) gene was obtained from eschar tissue by multiplex PCR-based Next Generation Sequencing for genetic identification. Based on the 56-kDa TSA gene, the O. tsutsugamushi aligned most closely with the Boryong strain.

Scrub typhus with secondary hemophagocytic lymphohistiocytosis in a 3-month-old child from a tertiary care hospital of Odisha

Scrub typhus is one of the re-emerging infectious diseases in India, whereas hemophagocytic lymphohistiocytosis (HLH) results from an uncontrolled and ineffective hyperinflammatory response to a variety of triggers. HLH is categorized into primary and secondary type with infection being one of the leading causes of secondary HLH. Here, we report a case of 3-month-old girl diagnosed with scrub typhus associated with secondary HLH as both the age of presentation and the association are rarely reported in literature.