Scrub typhus complicated by acute respiratory distress syndrome and acute liver failure: a case report from Northeast India

Acute respiratory distress syndrome (ARDS) is a serious complication of scrub typhus. Only a few cases of scrub typhus complicated by ARDS have been discussed in the literature to date. Herein we report the case of a patient who presented with scrub typhus complicated by ARDS and acute liver failure (ALF) and who was successfully treated in our institute. Due to the non-specificity and diversity of the initial presenting symptoms, a lack of awareness about the disease amongst physicians, and the lack of accessibility to facilities for serodiagnosis in developing countries, there is a chance of misdiagnosis during the early stage. At the same time, early diagnosis and prompt treatment are crucial to prevent life-threatening complications. Our patient was initially misdiagnosed with a common cold and then malaria. By the time a correct diagnosis was made, complications had already developed. To the best of our knowledge, this is the first case of scrub typhus complicated by ARDS and ALF to be reported from the northeastern region of India.

Scrub typhus: surveillance, clinical profile and diagnostic issues in Shandong, China

To elucidate the epidemic status, clinical profile, and current diagnostic issues of scrub typhus in Shandong Province, we analyzed the surveillance data of scrub typhus from 2006 to 2011 and conducted a hospital-based disease survey in 2010. Scrub typhus was clustered in mountainous and coastal areas in Shandong Province, with an epidemic period from September to November. The most common manifestations were fever (100%), eschar or skin ulcer (86.3%), fatigue (71.6%), anorexia (71.6%), and rash (68.6%). Predominant complications included bronchopneumonia, toxic hepatitis, and acute cholecystitis in 21.6%, 3.9%, and 2.9% of the cases, respectively. Severe complications including toxic myocarditis, heart failure, pneumonedema, pleural effusion, and emphysema were first reported in Shandong. Missed and delayed diagnosis of scrub typhus was common in local medical institutions. Alarm should be raised for changes of clinical features and current diagnostic issues of scrub typhus in newly developed endemic areas.

Clinical profile of scrub typhus in children

OBJECTIVE

To study the clinical profile and outcome of scrub typhus cases admitted in an urban referral centre.

METHODS

This descriptive study describes the clinical profile of 67 children with scrub typhus, who were admitted in an urban referral centre(ICH & HC,Chennai) during the period between October 2010 and March 2011.The diagnosis was confirmed by IgM ELISA.

RESULTS

All children presented with fever. Eschar and rash were present in 46% and 35% cases, respectively. Cough, vomiting, altered sensorium and oliguria were present in 73%,59%,58% and 43%, respectively. Hepatosplenomegaly and pallor were the commonest findings encountered in more than 80% children. Other findings were edema, lymphadenopathy and icterus.Thrombocytopenia, elevated liver enzymes and leukocytosis were seen in 77%, 64% and 49% cases, respectively. Pleural effusion, ascites, shock and respiratory failure were seen in 61%, 47%,45%,34% cases, respectively. Acute renal failure, hepatic failure, multiorgan dysfunction syndrome (MODS), meningoencephalitis and acute respiratory distress syndrome(ARDS) were seen in 10%,10%,7%,6% and 4% cases, respectively. Doxycycline and azithromycin were the antibiotics used. The overall mortality rate was 11.94%. Causes of death were shock, ARDS, acute renal failure(ARF), MODS and disseminated intravascular coagulation(DIVC).

CONCLUSIONS

When a child presents with acute febrile illness, maculopapular or erythematous rash, hepatosplenomegaly, lymphadenopathy, thrombocytopenia and features suggestive of capillary leak, diagnosis of Scrub typhus must be considered and the child should be started on empirical therapy with doxycycline or azithromycin which is life saving.

Phylogenetic analysis of the 56-kDa type-specific protein genes of Orientia tsutsugamushi in Central Korea

There are several antigenic variants of Orientia tsutsugamushi. The 56-kDa type-specific antigen (TSA) is responsible for the antigenic variation. Nucleotide sequences of the 56-kDa TSA obtained from 44 eschar samples of Korean scrub typhus patients and from 40 representative strains retrieved from the GenBank database were analyzed phylogenetically. Clinical patient data were assessed based on the genotyping results. Of the 44 nucleotide sequences, 32 (72.7%) clustered with the Boryong genotype, which is the major genotype in Korea. Eleven nucleotide sequences (25%) clustered with the Kawasaki genotype, not identified in Korea until 2010. One nucleotide sequence was consistent with the Karp genotype. The clinical course of the patients infected with each genotype showed no differences. Diagnostic performance of the immunofluorescence assay (IFA) using the 56-kDa TSA from Gilliam, Karp and Boryong as test antigens were not different for the Boryong and Kawasaki genotypes. Although Boryong is still the predominant genotype, the results suggest that Kawasaki genotype is quite prevalent in Chungbuk province of Korea.

A case of scrub typhus with haematuria

Scrub typhus, once endemic in India, has virtually disappeared from our country. Recently, there have been many case reports of scrub typhus. Haematuria in scrub typhus is a rare presentation, but it has been reported earlier. Here one such case of a 55-year-old man is reported who presented with fever and arthralgia. There was an erythematous maculopapular rash on his body. One enlarged lymph node in the right axilla and hepatomegaly were elicited. Weil-Felix reaction Ox-K was positive with 1:360 dilution. Doxycycline was advised for 7 days. Two months after follow-up, he had no symptoms.

Pediatric Scrub typhus in South Sikkim

We present five cases of paediatric Scrub typhus from Community Health Centre, Namchi, South Sikkim emphasize timely diagnosis of scrub typhus for appropriate management. Response to doxycycline was good, with fever subsiding within 48-72 hrs of starting the treatment. Four out of five cases completely recovered once appropriate medication was given.

Performance of SD Bioline Tsutsugamushi assays for the diagnosis of scrub typhus in Thailand

OBJECTIVE

To assess the diagnostic capacity of a commercially available test (SD Bioline Tsutsugamushi assay) to aid with the diagnosis of scrub typhus in febrile patients in Thailand.

MATERIAL AND METHOD

A commercially available lateral-flow-format immunochromatographic test (ICT) for the detection of O. tsutsugamushi IgM, IgG and IgA antibodies was evaluated, using archived serum samples from 102 laboratory confirmed scrub typhus patients and from 63 patients with other causes of fever as the negative control.

RESULTS

The sensitivity, specificity of this rapid immunochromatographic test were 66.7% (95% CI, 57.1 to 75.1%) and 98.4% (95% CI 91.5 to 99.7%) respectively. False positive ICT result occurred in one patient with influenza A infection. Among patients with scrub typhus, 17 out of 38 patients (44.7%, 95% CI 30.2 to 60.3%) with negative IgM antibody test by IFA (titer < 1:50) had positive ICT test. Compared to IFA IgG, 33 out of 54 patients (66.1%, 95% CI 47.8 to 72.9%) with negative IgG antibody test by IFA (titer < 1:50) had positive ICT test.

CONCLUSION

This rapid ICT test for the diagnosis of scrub typhus was more sensitive than the standard IFA in acute phase specimens.

Comparison of a rapid diagnostic test and microimmunofluorescence assay for detecting antibody to Orientia tsutsugamushi in scrub typhus patients in China

OBJECTIVE

To evaluate the detection of IgM and IgG antibodies to Orientia tsutsugamushi (O. tsutsugamushi) by rapid diagnostic test (RDT) and microimmunofluorescence assay (mIFA).

METHODS

RDT using a mixture of recombinant 56-kDa proteins of O. tsutsugamushi and mIFA assay were performed on 20 patients from Fujian and 13 patients from Yunnan Province, and 82 sera samples from healthy farmers in Anhui Province and Beijing City in 2009. Comparison of the RDT and mIFA assay was performed by using X(2) test and the P level of <0.05 was considered to be significance.

RESULTS

Among these 82 normal sera samples, the specificity of RDT was 100% for both IgM and IgG tests. In 33 samples from patients with scrub typhus, 5 cases were positively detected earlier by RDT than by mIFA in IgM test, and 2 cases were positive in IgG test. Sensitivities of RDT were 93.9% and 90.9% for IgM and IgG, respectively. The sensitivity of combination test of IgM and IgG was 100%. Geometric mean titer diluted sera from confirmed cases by IFA and RDT assay were 1:37 vs. 1:113 (P<0.001) in IgM test and 1:99 vs. 1:279 (P<0.05) in IgG test.

CONCLUSIONS

RDT is more sensitivite than mIFA in the early diagnosis of scrub typhus and it is particularly applicable in rural areas.

Diagnostic accuracy of a loop-mediated isothermal PCR assay for detection of Orientia tsutsugamushi during acute Scrub Typhus infection

Background

There is an urgent need to develop rapid and accurate point-of-care (POC) technologies for acute scrub typhus diagnosis in low-resource, primary health care settings to guide clinical therapy.

Methodology/Principal Findings

In this study we present the clinical evaluation of loop-mediated isothermal PCR assay (LAMP) in the context of a prospective fever study, including 161 patients from scrub typhus-endemic Chiang Rai, northern Thailand.

A robust reference comparator set comprising following ‘scrub typhus infection criteria’ (STIC) was used: a) positive cell culture isolate and/or b) an admission IgM titer ≥1∶12,800 using the ‘gold standard’ indirect immunofluorescence assay (IFA) and/or c) a 4-fold rising IFA IgM titer and/or d) a positive result in at least two out of three PCR assays.

Compared to the STIC criteria, all PCR assays (including LAMP) demonstrated high specificity ranging from 96–99%, with sensitivities varying from 40% to 56%, similar to the antibody based rapid test, which had a sensitivity of 47% and a specificity of 95%.

Conclusions/Significance

The diagnostic accuracy of the LAMP assay was similar to realtime and nested conventional PCR assays, but superior to the antibody-based rapid test in the early disease course. The combination of DNA- and antibody-based detection methods increased sensitivity with minimal reduction of specificity, and expanded the timeframe of adequate diagnostic coverage throughout the acute phase of scrub typhus.

There is an urgent need for alternative diagnostic methods for scrub typhus, but evaluation of these is hampered because the current serological gold standard (IFA) is imperfect. In a study from Thailand, 3 of 20 (15%) patients with fever had a positive Orientia tsutsugamushi PCR result despite negative serology. These findings could reflect potential benefits of the PCR assay in detecting rickettsaemia before antibody responses set in and/or a diagnostic advantage in endemic areas with high background levels of antibody in the population. Serology is complicated by the heterogeneity of strains present in Southeast Asia, but high resource costs and training make realtime PCR assays impractical for many areas where scrub typhus is endemic. This is where the new LAMP methodology has potential: it is inexpensive, simple to perform and requires only a waterbath or simple heating block instead of a thermocycler. In the context of a prospective fever study in a scrub typhus-endemic area in Thailand, the results support the validity of LAMP methodology for the diagnosis of scrub typhus, highlight the difficulties in comparing antibody- with DNA-based methods and also contribute towards understanding the dynamics of bacteraemia in this under recognised and under studied disease.

Differences in clinical features according to Boryoung and Karp genotypes of Orientia tsutsugamushi

Background

Scrub typhus is an infectious disease caused by Orientia tsutsugamushi. The differences in virulence of O. tsutsugamushi prototypes in humans are still unknown. We investigated whether there are any differences in the clinical features of the Boryoung and Karp genotypes.

Methodology/Principal Findings

Patients infected with O. tsutsugamushi, as Boryoung and Karp clusters, who had visited 6 different hospitals in southwestern Korea were prospectively compared for clinical features, complications, laboratory parameters, and treatment responses. Infected patients in the Boryoung cluster had significantly more generalized weakness, eschars, skin rashes, conjunctival injection, high albumin levels, and greater ESR and fibrinogen levels compared to the Karp cluster. The treatment response to current antibiotics was significantly slower in the Karp cluster as compared to the Boryoung cluster.

Conclusion

The frequency of occurrence of eschars and rashes may depend on the genotype of O. tsutsugamushi.

Delay in tetracycline treatment increases the risk of complications in Tsutsugamushi disease: data from the Japanese Diagnosis Procedure Combination database

OBJECTIVE

Tsutsugamushi disease (scrub typhus) is caused by Orientia tsutsugamushi, and has been endemic in Asia and Western Pacific islands. Though sporadic case reports have described the clinical consequences of this vector-borne disease, data on the actual incidence of complications or mortality are scarce. It also remains unclear how a delay in effective treatments affects the occurrence of complications associated with this Rickettsial disease.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database in Japan, we identified patients with Tsutsugamushi disease between July 1 and December 31 in 2007 and 2008. We examined location of hospitals, patient's age, sex, comorbidities, complications, inhospital deaths, date of admission, date of starting therapy with tetracyclines. A logistic regression was conducted to analyze the association between delay in effective treatments and the occurrence of complications.

RESULTS

A total of 210 cases were identified. Overall, 29 (13.8%) had at least one complication and two deaths were identified. Age was a significant risk factor for complications [odds ratio (OR), 1.48; 95% confidence interval (CI), 1.08-2.03; p=0.014, for a 10-year age increase]. Patients with ≥2 days delay in treatment with tetracyclines had a significantly higher risk of complications compared to those with no delay (OR, 2.71; 95% CI, 1.03-7.12; p=0.044).

CONCLUSION

Tsutsugamushi disease remains a threat to public health. Our study clearly indicates the importance of early diagnosis and immediate tetracycline treatment to prevent severe complications in Tsutsugamushi disease.

Scrub typhus-induced serious gastric ulcer bleeding

A 67-year-old woman presented with melena and general weakness. Upper gastrointestinal (GI) endoscopy revealed multiple ulcers and projectile bleeding in the stomach. She also complained of a 10-day history of a fever and was diagnosed with scrub typhus based on a positive result of the eschar polymerase chain reaction (PCR) testing. She fully recovered with endoscopic hemostasis, and administration of minocycline and omeprazole. In a patient with GI manifestations, scrub typhus, a condition with pathologically systemic vasculitis, should be considered in the possible background in endemic areas. The eschar PCR testing is a rapid and useful diagnostic tool to identify a specific strain.

[A case of scrub typhus with lung involvement]

A 65-year-old-woman complained of lumbago from the end of March 2008. Three weeks later, she visited a local clinic because of high fever, and she was given a diagnosis of urinary tract infection. Although levofloxacin was given, her condition did not improve and she was referred to the urology department of our hospital. Two days after hospitalization, she rapidly developed respiratory failure. Chest CT revealed bilateral pleural effusion, interlobular septal thickening, diffuse ground-glass opacities and mediastinal lymphadenopathy. We suspected scrub typhus because we noticed a localized necrotic skin lesion on her left lower leg. When minocycline was administered, both her clinical condition and radiographic imaging promptly improved. Because lung involvement with scrub typhus is very rare in Japan, we report this case of scrub typhus with various lung findings.

[A case of classical tsutsugamushi disease confirmed after an interval of 15 years in Akita Prefecture, Japan]

We report the confirmation of classical tsutsugamushi disease in August 2008. A 17-year-old woman seen for fever and eschar on the back reported having been bitten by an insect nine days earlier while fishing on the Omonogawa river. The suspected culprit was Leptotrombidium akamushi. During convalescence serum IgM and IgG antibody titers rose significantly against the Kato serotype antigen in indirect immunoperoxidase staining. Epidemiology, clinical symptoms and the antibodies detected suggested classical tsutsugamushi disease infection. Such disease transmitted by L. akamushi have not been reported since 1993 in Akita Prefecture. The public should thus be informed about Orientia tsutsugamushi prevention, in case such disease re-care in this area in the future.

Outbreak of scrub typhus in Pondicherry

AIM

To describe the diverse clinical and laboratory manifestations of scrub typhus diagnosed in Pondicherry Institute of Medical Sciences, Pondicherry.

MATERIALS AND METHODS

All cases of febrile illness diagnosed as scrub typhus over a period of 2 years were analysed. Diagnosis was based on the presence of the eschar and/or positive Weil Felix test with a titre of > 1:80.

RESULTS

Fifty cases of scrub typhus were seen over a period of 2 years (April 2006 and April 2008). Common symptoms were high grade fever of 7-14 days duration, nausea, vomiting, headache, myalgia, cough and breathlessness. Eschar was seen in 23 cases (46%) and the common sites were axilla, breast and groin. Weil Felix test was positive in 39 cases (78%). Liver enzymes were elevated in nearly all cases (95.9%). Multiple Organ Dysfunction Syndrome (MODS) was present in one third of our patients (17 out of 50, 34%). Hypotension (8 patients, 16%), renal impairment (6 patients, 12%), ARDS (4 patients, 8%) and meningitis (7 patients, 14%) were some of the important complications. There was a dramatic response to doxycycline in nearly all the patients.

CONCLUSION

Scrub typhus has emerged as an important cause of febrile illness in Pondicherry. Empirical treatment with doxycycline is justified in endemic areas.