The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus

Recent Threat of Scrub Typhus in India: A Narrative Review

Scrub typhus is an endemic illness transmitted by vectors and induced by bacteria. It is the most common and severe rickettsial disease. There are many more cases every year with a significant case fatality rate. Despite being a serious public health threat in India, it is uncertain how widespread and burdensome scrub typhus is. The scarcity of statistical information and pertinent health records on scrub typhus in the outbreak region demonstrates that there is still a significant knowledge gap about this neglected illness. Clinical manifestations of this illness include kidney failure, disability, and severe kidney failure. Undifferentiated symptoms, late diagnosis, and treatment failure are all responsible for deaths. Knowing about this disease is important from a public health point of view due to difficulties in specific diagnosis and a shortage of laboratory services in so many places. India is known to have scrub typhus cases, and doctors should be aware of this potentially dangerous but easily curable illness. The disease is highly difficult to identify clinically from other acute afebrile infections due to common symptoms and a paucity of the lesion in the Indian population. The mainstay of diagnosis is antibody-based serological testing. Within the first week of symptoms, scrub typhus can be diagnosed using molecular and serological tests. Our objective is to identify how severe scrub typhus is in India and to investigate the current epidemiology, etiology, complications, management, and treatment of the disease in both long-established endemic regions and new infection foci.

Atrial Fibrillation in Scrub Typhus: A Series of Four Cases

Scrub typhus, also known as bush typhus, is an acute febrile zoonosis caused by Orientia tsutsugamushi, transmitted by the bite of chigger mite. Patients with scrub typhus can have many different presentations such as acute hearing loss, interstitial pneumonitis, acute respiratory distress syndrome, myocarditis, pericarditis, meningoencephalitis, acute renal failure, acute hepatic failure, and septic shock. The occurrence of multi-organ dysfunction is responsible for high mortality seen in scrub typhus patients. Cardiovascular involvement can also occur in the form of arrhythmia, which leads to an increase in mortality in these patients, and if associated with ischemic heart disease and acute heart failure, it leads to higher mortality. The early use of antibiotics and telemetry monitoring along with aggressive management of patients can decrease the complications and mortality seen in these patients. This study describes a series of four scrub typhus patients with new-onset atrial fibrillation who were managed with either direct current (DC) cardioversion, amiodarone, or diltiazem.

Clinical characteristics and risk factors for severe scrub typhus in pediatric and elderly patients

Background

Scrub typhus (ST) is a life-threatening infectious disease if appropriate treatment is unavailable. Large discrepancy of clinical severity of ST patients was reported among age groups, and the underlying risk factors for severe disease are unclear.

Methods

Clinical and epidemiological data of ST patients were collected in 55 surveillance hospitals located in Guangzhou City, China, from 2012 to 2018. Severe prognosis and related factors were determined and compared between pediatric and elderly patients.

Results

A total of 2,074 ST patients including 209 pediatric patients and 1,865 elderly patients were included, with a comparable disease severity rate of 11.0% (95% CI 7.1%–16.1%) and 10.3% (95% CI 9.0%–11.8%). Different frequencies of clinical characteristics including lymphadenopathy, skin rash, enlarged tonsils, etc. were observed between pediatric and elderly patients. Presence of peripheral edema and decreased hemoglobin were the most important predictors of severe illness in pediatric patients with adjusted ORs by 38.99 (9.96–152.67, p<0.001) and 13.22 (1.54–113.50, p = 0.019), respectively, while presence of dyspnea and increased total bilirubin were the potential determinants of severe disease in elderly patients with adjusted ORs by 11.69 (7.33–18.64, p<0.001) and 3.17 (1.97–5.11, p<0.001), respectively. Compared with pediatric patients, elderly patients were more likely to receive doxycycline (64.8% v.s 9.9%, p<0.001), while less likely to receive azithromycin therapy (5.0% v.s 41.1%, p<0.001).

Conclusion

The disease severity rate is comparable between pediatric and elderly ST patients, while different clinical features and laboratory indicators were associated with development of severe complications for pediatric and elderly patients, which is helpful for diagnosis and progress assessment of disease for ST patients.

The study investigated different clinical features and risk factors for severe disease between pediatric and elderly patients with scrub typhus. We found that significantly higher frequencies of lymphadenopathy, skin rash, enlarged tonsils, etc. were observed in pediatric patients than elderly patients. Other non-specific signs, subjective complaints, and chest radiographic abnormality were overpresented in elderly patients. Risk factors for severe disease between pediatric and elderly patients with scrub typhus were different. Presence of peripheral edema and decreased hemoglobin were the most important factors for pediatric patients, while presence of dyspnea and increased total bilirubin for elderly patients. These findings reminded medical workers to acknowledge this important difference and to adopt an age specific method in the differential diagnosis and risk assessment for scrub typhus.

Clinical significance of hypoalbuminemia in patients with scrub typhus complicated by acute kidney injury

Background

This study aimed to investigate the clinical significance of hypoalbuminemia (HA) in patients with scrub typhus complicated by acute kidney injury (AKI).

Methods

From 2009 to 2018, 611 patients were diagnosed with scrub typhus. We divided the patients into two groups [normoalbuminemia (NA) vs. HA] based on the serum albumin level of 3.0 g/dL and compared the incidence, clinical characteristics, and severity of AKI based on the RIFLE classification between the two groups.

Results

Of the total 611 patients, 78 (12.8%) were categorized into the HA group. Compared to patients in the NA group, patients in the HA group were older (73 ± 9 vs. 62 ± 14 years, P<0.001). The HA group had a significantly longer hospital stay (9.6 ± 6.2 vs 6.2 ± 3.1 days, p<0.001) and a higher incidence of complications in respiratory and cardiovascular systems. Furthermore, AKI developed significantly more in patients in the HA group (58% vs. 18%, p<0.001) as compared to the NA group. The overall incidence of AKI was 23.1%; of which, 14.9%, 7.0%, and 1.2% of cases were classified as Risk, Injury, and Failure, respectively. The serum albumin level correlated with AKI severity (3.4 ± 0.5 vs 3.0 ± 0.5 vs 2.6 ± 0.3, p<0.05). In a multivariate logistic regression analysis for predicting AKI, age, presence of co-morbidities such as chronic kidney disease, total bilirubin, leukocytosis, and hypoalbuminemia were significant predictors for AKI.

Conclusion

Serum albumin level is helpful to predict the development and severity of scrub typhus-associated AKI.

Orientia tsutsugamushi: The dangerous yet neglected foe from the East

Orientia tsutsugamushi (OT), the causative agent of the vector-borne Scrub typhus zoonotic disease in humans, is a unique microorganism that exists in the Asia-Pacific region since a long time. In spite of its occurrence, the organism had been neglected until recent years. Humans are the accidental dead-end hosts of O. tsutsugamushi and display manifestations which are both severe and misleading. The vast antigenic diversity of OT and non-pathognomic symptoms of Scrub typhus, create hurdles in the clinical management of the disease and impede the OT-research. Many countries in the Asia-Pacific region have reported the resurgence of OT- infections and have raised concerns for its expanding distribution. This has triggered the development of advanced techniques for diagnosis and research on exploring a successful vaccine candidate to reduce the burden of the disease. Thus, the aim of this systematic review is to provide an update on the recent advances in the OT-research and highlight the key areas that have remained obscure and demand attention.

Diagnosis of severe scrub typhus infection by next-generation sequencing:a case report

Background

Scrub typhus is an acute febrile illness, which was caused by Orientia tsutsugamushi and transmitted through the bite of chiggers. The diagnosis of scrub typhus could be missed diagnosis due to the absence of the pathognomonic eschar.

Case presentation

A 76-year-old man was hospitalized with fever and kidney injury and was diagnosed of hemorrhagic fever with renal syndrome first. However, the situation of the illness deteriorated into refractory septic shock and multiple organ dysfunction rapidly,although the treatment of anti-sepsis was used in 3rd-5th day. Orientia tsutsugamushi was determined to be the causative pathogen by Next-generation sequencing of his plasma sample in 6th day. Then, the patient was treated with doxycycline and azithromycin and recovered quickly.

Conclusions

Next-generation sequencing was a new diagnostic technology and could identify scrub typhus in accurately and fast without the pathognomonic eschar.

Scrub typhus infection, not a benign disease: an experience from a tertiary care center in Northern India

Introduction

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. It is characterised by fever, rash, myalgia and diffuse lymphadenopathy. Most common complications are sepsis, shock, acute respiratory distress syndrome (ARDS), hepatitis, pre renal azotemia and multi organ dysfunction syndrome (MODS). Mortality rates range from 7–30% in untreated cases. Scrub typhus is endemic to a part of the world known as ‘the tsutsugamushi triangle’. River banks, grassy areas generally harbour scrub typhus infection; however, recently there has been an increase in prevalence of infection from dry regions like Haryana.

Objective

To assess the clinical spectrum and complications of scrub typhus infection at a tertiary care centre in North India.

Material and methods

An observational study was conducted on patients >14 years old with acute febrile illness >7 days duration, admitted indoor from emergency department, from July to November 2017. Suspected cases were tested for specific IgM antibodies against Orientia tsutsugamushi by ELISA.

Results

Among the 230 patients, screened for scrub typhus infection, 39 (16.95%) came out to be positive. Most common patient complaints were fever followed by cough and breathlessness, myalgia, nausea, vomiting and behavioral abnormality. 15% of patients required inotropic support initially and 48% had oxygen saturation of less than 90% at the time of presentation. Pleural effusion and crepitations were present in 41% of patients. Most common biochemical alterations were: abnormal liver function tests (95%), followed by thrombocytopenia, anemia, abnormal renal function tests, and hyponatremia. 12 patients (30.7%) were shifted to intensive care unit, 8 of which (20.5%) needed invasive mechanical ventilation and 4 patients (10.3%) underwent hemodialysis. Various complications were noted in 89.7% of cases, the most common being ARDS followed by sepsis, acute kidney injury (AKI) and meningitis. The mortality rate in this study was 18%.

Conclusions

This study emphasizes that scrub typhus infection is on a rampant resurgence and it is associated with significant complications. High degree of suspicion as well as development of effective measures to treat, control and prevent is critical to lower the disease burden.

A Case of Scrub Typhus complicated with a Splenic Infarction

We present a patient with scrub typhus complicated with a splenic infarction. A 40-year-old man visited the emergency medical center complaining of fever for the previous week. He had no past medical history, but reported engaging in outdoor activities. Examination revealed a maculopapular rash on his trunk and an eschar on his epigastrium. Abdominal computed tomography was performed to examine the cause of the tenderness on the left upper quadrant of his abdomen, which revealed a splenic infarct. The patient was diagnosed with scrub typhus based on the results of blood polymerase chain reaction testing, and genetic sequencing confirmed the presence of Orientia tsutsugamushi Boryong. His symptoms improved following doxycycline treatment.

Clinical manifestations of scrub typhus

The mite-borne rickettsial zoonosis scrub typhus is widely prevalent in parts of Southeast and Far East Asia, and northern Australia. The disease is an acute febrile illness, associated with rash and often an eschar, which responds dramatically to treatment with antibiotics. In some cases it results in a serious illness leading to multiple organ involvement and death. The disease manifestations are thought to result from a systemic vasculitis, caused by both direct effects of the organisms as well as an exaggerated immune response, although little is understood about its pathogenesis. A wide spectrum of clinical manifestations, affecting nearly every organ system, have been described with scrub typhus. Some of these manifestations are serious and life threatening. In this systematic review, we summarise the typical and atypical manifestations of scrub typhus reported in the literature. Awareness of these unusual manifestations will hopefully guide clinicians towards diagnosing the condition early, and initiating early appropriate antibiotics and other supportive measures.

Hemophagocytic Lymphohistiocytosis Associated with Scrub Typhus: Systematic Review and Comparison between Pediatric and Adult Cases

Background: Scrub typhus is a mite-borne bacterial infection caused by Orientia tsutsugamushi. Hemophagocytic lymphohistiocytosis (HLH) is a potential severe complication. Most reported cases of HLH associated with scrub typhus were single cases or case series with a small sample sizes. Thus, no clear consensus exists on clinical manifestations and differences between pediatric and adult cases of this condition. Methods: a systematic search of English and Japanese articles from PubMed, PubMed Central, and Directory of Open Access Journals databases was performed from 3 December 2016 to 28 December 2017. The primary outcome was mortality in patients with HLH associated with scrub typhus; secondary outcomes were differences in clinical symptoms, laboratory findings, and treatment between pediatric and adult patients with HLH associated with scrub typhus. Results: thirty cases of HLH associated with scrub typhus were identified (age range: 2 months to 75 years; median age: 21.5 years, male:female ratio, 1:1). Eschar was frequently observed in the pediatric group (p = 0.017), whereas acute kidney injury was more prevalent in the adult group (p = 0.010). Two patients died of intracranial hemorrhage complicated with multiple organ failure; overall mortality rate was 6.7%. Conclusions: HLH associated with scrub typhus could be cured with remarkable improvement using single antibiotic therapy in approximately half the cases, with the mortality rate being relatively lower than that of HLH associated with other secondary causes.

A review of the global epidemiology of scrub typhus

Scrub typhus is a serious public health problem in the Asia-Pacific area. It threatens one billion people globally, and causes illness in one million people each year. Caused by Orientia tsutsugamushi, scrub typhus can result in severe multiorgan failure with a case fatality rate up to 70% without appropriate treatment. The antigenic heterogeneity of O. tsutsugamushi precludes generic immunity and allows reinfection. As a neglected disease, there is still a large gap in our knowledge of the disease, as evidenced by the sporadic epidemiologic data and other related public health information regarding scrub typhus in its endemic areas. Our objective is to provide a systematic analysis of current epidemiology, prevention and control of scrub typhus in its long-standing endemic areas and recently recognized foci of infection.

The Correlation of Endoscopic Findings and Clinical Features in Korean Patients with Scrub Typhus: A Cohort Study

Scrub typhus is an infectious disease caused by Orientia tsutsugamushi-induced systemic vasculitis, but the involvement of the gastrointestinal tract and the endoscopic findings associated with scrub typhus are not well understood. We performed a prospective study and recommend performing esophagogastroduodenoscopy (EGD) for all possible scrub typhus patients, regardless of gastrointestinal symptoms. Gastrointestinal symptoms, endoscopic findings and clinical severity based on organ involvement and ICU admission were analyzed. Gastrointestinal symptoms occurred in up to 76.4% of scrub typhus patients. The major endoscopic findings were ulcers (43/127, 33.9%). Interestingly, 7.1% (9/127) of the patients presented with esophageal candidiasis. There was no correlation between the presence or absence of gastrointestinal symptoms and the endoscopic grade (P = 0.995). However, there was a positive correlation between the clinical severity and the endoscopic findings (P = 0.001). Sixty-three percent of the patients presented with erosion or ulcers on prospectively performed endoscopic evaluations, irrespective of gastrointestinal symptoms. Gastrointestinal symptoms did not reflect the need for endoscopy. Scrub typhus patients could have significant endoscopic abnormalities even in the absence of gastrointestinal symptoms.

Is VEGF a marker of severity of scrub typhus infection?

Vascular endothelial growth factor (VEGF) and its receptors have been reported as severity markers of septicemia. Scrub typhus (ST) results in multi-organ dysfunction but the role of VEGF has not been evaluated. We report VEGF and its receptors in ST and its correlation with severity, outcome and laboratory findings. Thirty patients with ST diagnosed by solid phase immune chromatographic assay and Weil-Felix tests were included. Their clinical details, Glasgow Coma Scale (GCS), SOFA and modified Rankin Scale (mRS) scores and laboratory findings were noted. VEGF, VEGFR1 and VEGFR2 were done by ELISA at admission and repeated at 1 month. Outcome was defined at 1 month. Serum VEGF and VEGF-R1 levels were significantly higher and VEGFR2 was significantly lower in the ST patients compared to the controls. These levels significantly improved at 1 month. VEGF level correlated with SOFA score (p = 0.05) and SGPT (p = 0.04). VEGFR1 correlated with hemoglobin (p = 0.04), platelet count (p = 0.03), serum CK (p = 0.001), weakness (p = 0.04) and mRS score (p = 0.04). VEGFR2 did not correlate with any clinical or laboratory parameters. All the patients recovered with doxycycline. Serum VEGF and VEGFR1 levels increased in ST and suggest disease severity but do not predict outcome.

Acute Cholecystitis in Patients with Scrub Typhus

Acute cholecystitis is a rare complication of scrub typhus. Although a few such cases have been reported in patients with scrub typhus, the clinical course is not well described. Of 12 patients, acute cholecystitis developed in 66.7% (8/12) of patients older than 60 yr. The scrub typhus group with acute cholecystitis had marginal significant longer hospital stay and higher cost than the group without cholecystitis according to propensity score matching. Scrub typhus should be kept in mind as a rare etiology of acute cholecystitis in endemic areas because the typical signs of scrub typhus such as skin rash and eschar can present after the abdominal pain.

Duodenal Perforation Precipitated by Scrub Typhus

Scrub typhus is an acute febrile illness usually presenting with fever, myalgia, headache, and a pathognomonic eschar. Severe infection may lead to multiple organ failure and death. Gastrointestinal tract involvement in the form of gastric mucosal erosions and ulcerations owing to vasculitis resulting in gastrointestinal bleeding is common. This process may worsen a pre-existent asymptomatic peptic ulcer, causing duodenal perforation, and present as an acute abdomen requiring surgical exploration. We report the case of a patient with no previous symptoms or risk factors for a duodenal ulcer, who presented with an acute duodenal perforation, probably precipitated by scrub typhus infection.

Polyarthritis and massive small bowel bleed: An unusual combination in scrub typhus

Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin.

Neuritis and gastrointestinal hemorrhage in scrub typhus patients

A 78-year-old woman with scrub typhus exhibited gastric hemorrhage with multiple gastric ulcers. This is the first report to confirm pathologically the presence of not only vasculitis but also, neuritis. The results suggest the necessity of studies confirming neuritis as the cause of gastric ulcer and bleeding in scrub typhus.

Neuritis and gastrointestinal hemorrhage in scrub typhus patients

A 78-year-old woman with scrub typhus exhibited gastric hemorrhage with multiple gastric ulcers. This is the first report to confirm pathologically the presence of not only vasculitis but also, neuritis. The results suggest the necessity of studies confirming neuritis as the cause of gastric ulcer and bleeding in scrub typhus.

Splenic infarct due to scrub typhus

Scrub typhus is a mite borne infectious disease that has the potential to involve multiple organs and can be fatal. Involvement of the abdomen in the form of hepatitis, gastric ulcerations and pancreatitis are well-documented, the pathology being disseminated vasculitis. However involvement of the spleen in scrub typhus is extremely rare and is reported only in a few autopsy studies. We report the case of a 50-year-old lady who presented with fever and left upper quadrant abdominal pain due to a splenic infarct due to scrub typhus.

Scrub typhus meningitis or meningoencephalitis

Orientia tsutsugamushi induces vasculitis leading to symptoms of systemic organ invasion including meningitis and meningoencephalitis. We conducted a retrospective case-control study of scrub typhus patients to investigate the clinical and laboratory features of patients with scrub typhus meningitis or meningoencephalitis, and the therapeutic outcomes, and to determine the predictor factors. Cases were 22 patients with scrub typhus meningitis or meningoencephalitis, and controls were 303 patients without meningitis or meningoencephalitis. Multivariate analysis showed that the presence of pneumonitis was associated with the occurrence of scrub typhus meningitis and meningoencephalitis (odds ratio [OR] 8.9; P < 0.001; confidence interval [CI] 2.9-27.2). Although appropriate antimicrobials such as doxycycline agents were administered at an early stage, meningitis or meningoencephalitis still occurred in some cases. Physicians should be aware that meningitis or meningoencephalitis may develop during appropriate drug therapy such as doxycycline. Close observation and great care are essential for patients with risk factors, particularly pneumonitis.

Scrub typhus

Scrub typhus is an acute febrile illness caused by orientia tsutsugamushi, transmitted to humans by the bite of the larva of trombiculid mites. It causes a disseminated vasculitic and perivascular inflammatory lesions resulting in significant vascular leakage and end-organ injury. It affects people of all ages and even though scrub typhus in pregnancy is uncommon, it is associated with increased foetal loss, preterm delivery, and small for gestational age infants. After an incubation period of 6-21 days, onset is characterized by fever, headache, myalgia, cough, and gastrointestinal symptoms. A primary papular lesion which later crusts to form a flat black eschar, may be present. If untreated, serious complications may occur involving various organs. Laboratory studies usually reveal leukopenia, thrombocytopenia, deranged hepatic and renal function, proteinuria and reticulonodular infiltrate. Owing to the potential for severe complications, diagnosis, and decision to initiate treatment should be based on clinical suspicion and confirmed by serologic tests. A therapeutic trial of tetracycline or chloramphenicol is indicated in patients in whom the diagnosis of scrub typhus is suspected. The recommended treatment regimen for scrub typhus is doxycycline. Alternative regimens include tetracycline, chloramphenicol, azithromycin, ciprofloxacin, rifampicin, and roxithromycin. Treatment of pregnant women with azithromycin was successfully done without relapse and with favorable pregnancy outcomes. Hence, early diagnosis and treatment are essential in order to reduce the mortality and the complications associated with the disease. We searched the English-language literature for reports of scrub typhus in children, pregnant women, and non-pregnant patients with scrub typhus, using the MEDLINE/PubMed database, which includes citations from 1945 to the present time. We used the search terms 'scrub typhus', 'scrub typhus' and 'pregnancy', 'scrub typhus' and 'children', 'scrub typhus' and 'complications', 'scrub typhus' and 'treatment'.

Peritonitis in patients with scrub typhus

Various complications have been reported in scrub typhus cases including acute respiratory distress syndrome, encephalitis, pneumonia, pericarditis, acute renal failure, and acute hepatic failure. Few studies have reported on the gastrointestinal manifestations of scrub typhus. Typical gastrointestinal manifestations in patients with scrub typhus include abdominal pain, nausea, vomiting, hematemesis, melena, and diarrhea. The two cases presented in this study are the first reported cases of peritonitis associated with scrub typhus. This study shows that scrub typhus should also be included in the differential diagnosis of peritonitis in areas where Orientia tsutsugamushi is endemic.

A case of scrub typhus complicated by acute calculous cholecystitis

We report a case of acute calculous cholecystitis through scrub typhus. A 69-year-old woman presented with a history of general myalgia, fever, and right abdominal pain. She referred to our hospital for surgical treatment of clinically suspected acute cholecystitis. Physicians concluded the cause of cholecystitis as gall bladder (GB) stone and proper antibiotics treatment of scrub typhus was started later. The patient developed acute respiratory distress syndrome and multi organ failure through scrub typhus. Five days after admission, the patient was treated with proper antibiotics and discharged on the 13th day after starting doxycycline treatment without any sequelae. In areas endemic for tsutsugamushi disease, even though a patient with GB stone presents with symptoms of acute cholecystitis, careful history and physical examination are required to reveal the existence of eschars or skin eruptions.

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.

Comparison of conventional, nested, and real-time quantitative PCR for diagnosis of scrub typhus

Orientia tsutsugamushi is the causative agent of scrub typhus. For the diagnosis of scrub typhus, we investigated the performances of conventional PCR (C-PCR), nested PCR (N-PCR), and real-time quantitative PCR (Q-PCR) targeting the O. tsutsugamushi-specific 47-kDa gene. To compare the detection sensitivities of the three techniques, we used two template systems that used plasmid DNA (plasmid detection sensitivity), including a partial region of the 47-kDa gene, and genomic DNA (genomic detection sensitivity) from a buffy coat sample of a single patient. The plasmid detection sensitivities of C-PCR, N-PCR, and Q-PCR were 5 × 10(4) copies/μl, 5 copies/μl, and 50 copies/μl, respectively. The results of C-PCR, N-PCR, and Q-PCR performed with undiluted genomic DNA were negative, positive, and positive, respectively. The genomic detection sensitivities of N-PCR and Q-PCR were 64-fold and 16-fold (crossing point [Cp], 37.7; 426 copies/μl), respectively. For relative quantification of O. tsutsugamushi bacteria per volume of whole blood, we performed real-time DNA PCR analysis of the human GAPDH gene, along with the O. tsutsugamushi 47-kDa gene. At a 16-fold dilution, the copy number and genomic equivalent (GE) of GAPDH were 1.1 × 10(5) copies/μl (Cp, 22.64) and 5.5 × 10(4) GEs/μl, respectively. Therefore, the relative concentration of O. tsutsugamushi at a 16-fold dilution was 0.0078 organism/one white blood cell (WBC) and 117 organisms/μl of whole blood, because the WBC count of the patient was 1.5 × 10(4) cells/μl of whole blood. The sensitivities of C-PCR, N-PCR, and Q-PCR performed with blood samples taken from patients within 4 weeks of onset of fever were 7.3% (95% confidence interval [CI], 1.6 to 19.9), 85.4% (95% CI, 70.8 to 94.4), and 82.9% (95% CI, 67.9 to 92.8), respectively. All evaluated assays were 100% specific for O. tsutsugamushi. In conclusion, given its combined sensitivity, specificity, and speed, Q-PCR is the preferred assay for the diagnosis of scrub typhus.

Clinical significance of hypoalbuminemia in outcome of patients with scrub typhus

Background

This study was designed to investigate the clinical significance of hypoalbuminemia as a marker of severity and mortality in patients with Scrub typhus.

Methods

The patients with scrub typhus were divided into two groups based on the serum albumin levels; Group I (serum albumin <3.0 g/dL) and Group II (serum albumin ≥3.0 g/dL). The outcome of patients with hypoalbuminemia was compared with that of normoalbuminemia.

Results

Of the total 246 patients who underwent the study, 84 patients (34.1%) were categorized as Group I and 162 patients were (65.9%) as Group II. Group I showed significantly higher incidence of confusion (24.6% vs. 5.3%, p < 0.001), pulmonary edema (15.8% vs. 3.2%, p = 0.002), pleural effusion (22.8% vs. 11.1%, p = 0.03), arrhythmia (12.3% vs. 2.6%, p = 0.008) and non-oliguric acute renal failure (40.4% vs. 11.1%, p < 0.001) compared to group II. Hypoalbuminemic group had a higher APACHE II score (11.37 ± 5.0 vs. 6.94 ± 4.2, p < 0.001), longer hospital stay (19.9 ± 42.1 days vs 7.5 ± 13.8 days, p = 0.012), and higher hospital cost compared to Group II.

Conclusions

This study showed hypoalbuminemia in scrub typhus was closely related to the frequency of various complication, longer hospital stay, consequently the higher medical cost, necessitating more efficient management of patients, including medical resources.

Clinical and laboratory findings associated with severe scrub typhus

BACKGROUND

Scrub typhus is a mite-borne bacterial infection of humans caused by Orientia tsutsugamushi that causes a generalized vasculitis that may involve the tissues of any organ system. The aim of this study was to identify factors associated to severe complications from scrub typhus.

METHODS

We conducted this prospective, case-control study on scrub typhus patients who presented to the Department of Internal Medicine at Chosun University Hospital between September, 2004 and December, 2006. Cases were 89 scrub typhus patients with severe complications and controls were 119 scrub typhus patients without severe complications.

RESULTS

There were significant differences in the absence of eschar, white blood cell (WBC) counts, hemoglobin, albumin, serum creatinine, fibrinogen, C-reactive protein (CRP), and active partial thromboplastin time (aPTT) between the two groups. Multivariate analysis demonstrated that only the following four factors were significantly associated with the severe complications of scrub typhus: (1) age >or= 60 years (odd ratio [OR] = 3.13, P = 0.002, confidence interval [CI] = 1.53-6.41), (2) the absence of eschar (OR = 6.62, P = 0.03, CI = 1.22-35.8, (3) WBC counts > 10, 000/mm3 (OR = 3.6, P = 0.001, CI = 1.65-7.89), and (4) albumin <or= 3.0 g/dL (OR = 5.01, P = 0.004, CI = 1.69-14.86).

CONCLUSIONS

Our results suggest that clinicians should be aware of the potential for complications, when scrub typhus patients are older (>or= 60 years), presents without eschar, or laboratory findings such as WBC counts > 10, 000/mm3, and serum albumin level <or= 3.0 g/dL. Close observation and intensive care for scrub typhus patients with the potential for complications may prevent serious complications with subsequent reduction in its mortality rate.

Massive small bowel bleeding caused by scrub typhus in Korea

A 79-year-old man was diagnosed with scrub typhus based on fever, eschar, skin rash and a markedly elevated serum tsutsugamushi antibody and doxycycline was started. Five days later, hematochezia developed and multiple small bowel ulcerations with hemorrhage were seen on colonoscopy. Despite intensive therapy, the massive hematochezia worsened and the distal small bowel was resected. Multiple ulcerated lesions were identified pathologically as vasculitis caused by scrub typhus. This is the first reported case of pathologically proven small bowel involvement in scrub typhus infection.

Scrub typhus mimicking deep neck infection

Scrub typhus is not uncommon in Asia and it is life threatening without correct treatment. The presentation of scrub typhus mimicking deep neck infection is rarely encountered by clinical physicians and delays the determination of the correct diagnosis. Here, we report a case of scrub typhus presenting symptoms like deep neck infection. The patient was admitted due to fever and a tender swelling on left side of his neck, which progressed to respiratory failure and acute renal failure under empirical use of ceftriaxone and metronidazole. After repetitive physical examinations, an eschar was found on his scalp. Finally he was successfully treated with tetracycline antibiotics.

Scrub typhus: clinical, pathologic, and imaging findings

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. The main pathologic change is focal or disseminated vasculitis caused by the destruction of endothelial cells and the perivascular infiltration of leukocytes. The diagnosis of scrub typhus is based on the patient's history of exposure, clinical features, and results of serologic testing. Regional and generalized lymphadenopathy is common. The pulmonary manifestations of scrub typhus include interstitial pneumonia, interstitial edema, and hemorrhage caused by vasculitis. Abdominal manifestations include splenomegaly, periportal edema, gallbladder wall thickening, and lymphadenopathy. Although the severity of scrub typhus varies considerably, involvement of the central nervous system is seen in almost all patients and can result in meningoencephalitis. A high degree of clinical suspicion and familiarity with the various radiologic manifestations of scrub typhus allow early diagnosis and timely initiation of appropriate therapy, and thereby may help reduce patient morbidity.

Clinical role of interstitial pneumonia in patients with scrub typhus: a possible marker of disease severity

Interstitial pneumonia (IP) frequently occurs in patients with scrub typhus, but its clinical significance is not well known. This study was designed to evaluate interstitial pneumonia as a marker of severity of the disease for patients with scrub typhus. We investigated clinical parameters representing the severity of the disease, and the chest radiographic findings for 101 patients with scrub typhus. We then compared these clinical factors between patients with and without IP. We also studied the relationship between IP and other chest radiographic findings. The chest radiography showed IP (51.4%), pleural effusion (42.6%), cardiomegaly (14.9%), pulmonary alveolar edema (20.8%), hilar lymphadenopathy (13.8%) and focal atelectasis (11.8%), respectively. The patients with IP (n=52) had higher incidences in episode of hypoxia (p=0.030), hypotension (p=0.024), severe thrombocytopenia (p=0.036) and hypoalbuminemia (p=0.013) than the patients without IP (n=49). The patients with IP also had higher incidences of pleural effusion (p<0.001), focal atelectasis (p=0.019), cardiomegaly (p<0.001), pulmonary alveolar edema (p=0.011) and hilar lymphadenopathy (p<0.001) than the patients without IP. Our data suggest that IP frequently occurs for patients with scrub typhus and its presence is closely associated with the disease severity of scrub typhus.

Paediatric scrub typhus in Thailand: a study of 73 confirmed cases

We studied 73 Thai children with scrub typhus (median age 9 years, range 3-14 years, male:female ratio 1.8:1). Most patients (86%) lived in rural areas. They presented with subacute fever (median, 9 d) with vomiting (35%), hepatomegaly (59%), splenomegaly (18%), and tachypnea (26%). Skin rash (7%), eschar (7%), and history of mite bite were rare. Blood leucocyte counts were usually normal but 19% of patients were thrombocytopenic. Twenty (22%) patients had pneumonia and six (8%) had neurological involvement. Defervescence occurred a median of 1 d and 3 d after initiation of doxycycline and chloramphenicol, respectively, and these responses were more rapid than in those who received other antibiotics or no treatment (P < 0.001). There was one death. Only 55% of the patients were initially diagnosed as having scrub typhus.