1
|
Treatment outcomes of oral doxycycline versus intravenous azithromycin in adults hospitalized with scrub typhus: A retrospective study using inverse probability treatment weighting (IPTW) propensity analysis. Travel Med Infect Dis 2022; 52:102525. [PMID: 36549418 DOI: 10.1016/j.tmaid.2022.102525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Only a few well-designed studies that have investigated the effectiveness of azithromycin in treating adult patients hospitalized with scrub typhus are currently available. The purpose of our study was to compare the effects of intravenous azithromycin administration with those of oral doxycycline, and to evaluate cardiovascular death associated with intravenous azithromycin in adult patients hospitalized with scrub typhus. METHODS This retrospective study investigated Korean National Infectious Disease Cohort Collaborative-registered scrub typhus-infected patients who were hospitalized between January 1, 2013, and December 31, 2021, and who were ≥18 years old. The primary outcome was time to fever clearance and the secondary outcomes were treatment failure, relapse, scrub typhus-related death, or azithromycin-related cardiovascular death. To address any indication bias, inverse probability of treatment weighting (IPTW) analysis was performed. Times to fever clearance between the doxycycline and azithromycin groups were compared using log-rank tests and Kaplan-Meier curves. RESULTS A total of 326 consecutive patients with laboratory-confirmed scrub typhus were included in this study of whom 109 were treated with azithromycin and 217 with doxycycline. Using IPTW, there were no statistically significant differences in the following end points between the azithromycin and doxycycline groups: median time to fever clearance (3 days vs. 3 days, P = 0.649), treatment failure (0.71% vs. 0.42%, P = 0.702), relapse (0.0% vs. 0.0%), and scrub typhus-related death (5.12% vs. 0.0%, P = 0.155). No azithromycin-related cardiovascular deaths occurred. In the sensitivity analyses, there were no significant changes in effect size. CONCLUSIONS Our study showed that the therapeutic effects and safety of intravenous azithromycin are comparable to those of oral doxycycline administration in patients hospitalized with scrub typhus. A well-designed randomized controlled trial may help further evaluate the most adequate route of administration, dose and duration of treatment with azithromycin.
Collapse
|
2
|
Unni S, Eswaradass SKC, Krishnan Nair H, Anandan S, Mani I, Eswaradass PV. Scrub Typhus Meningoencephalitis: Review of Literature and Unique Diagnostic & Management Challenges in Resource-Limited Settings. Cureus 2022; 14:e26369. [PMID: 35911355 PMCID: PMC9329600 DOI: 10.7759/cureus.26369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Abstract
Scrub typhus is a zoonotic febrile illness caused by Orientia tsutsugamushi and transmitted by Leptotrombidium larvae. Scrub typhus often presents with nonspecific clinical features, and ranges in severity from mild illness to multiorgan failure and fatality. The disease is primarily found in the Asia-Pacific rim, including India, Pakistan, Thailand, Malaysia, Korea, and China. Due to frequent limitations in healthcare resources in many of these countries, the diagnosis and management of scrub typhus meningoencephalitis pose unique challenges. This review focuses on the epidemiology, clinical features, diagnostic testing, and management modalities in such resource-limited settings. Exercising a high index of clinical suspicion and timely diagnostic tests and management strategies are vital to prevent life-threatening complications of this treatable illness.
Collapse
|
3
|
Guccione C, Rubino R, Colomba C, Anastasia A, Caputo V, Iaria C, Cascio A. Rickettsiosis with Pleural Effusion: A Systematic Review with a Focus on Rickettsiosis in Italy. Trop Med Infect Dis 2022; 7:tropicalmed7010011. [PMID: 35051127 PMCID: PMC8777742 DOI: 10.3390/tropicalmed7010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/29/2021] [Accepted: 01/10/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Motivated by a case finding of Mediterranean spotted fever (MSF) associated with atypical pneumonia and pleural effusion in which Rickettsia conorii subsp. israelensis was identified by molecular methods in the pleural fluid, we wanted to summarize the clinical presentations of rickettsiosis in Italy by systematic research and to make a systematic review of all the global cases of rickettsiosis associated with pleural effusion. Methods: For the literature search, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. We chose to select only the studies published in last 25 years and confirmed both with serological and molecular assays. Results: Human cases of rickettsiosis in Italy were reported in 48 papers describing 2831 patients with very different clinical presentations; the majority was MSF accounted to R. conorii and was reported in Sicily. Pleural effusion associated with infection with microorganisms belonging to Rickettsiales was described in 487 patients. It was rarely associated with microorganisms different from O. tsutsugamushi; also rarely, cases of scrub typhus were reported outside Southeast Asia and in the largest majority, the diagnosis was achieved with serology. Conclusions: MSF, especially when caused by R. conorii subsp. israelensis, may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis
Collapse
Affiliation(s)
- Cristoforo Guccione
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (C.G.); (C.C.); (A.A.); (V.C.)
| | - Raffaella Rubino
- Infectious and Tropical Disease Unit, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy;
| | - Claudia Colomba
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (C.G.); (C.C.); (A.A.); (V.C.)
| | - Antonio Anastasia
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (C.G.); (C.C.); (A.A.); (V.C.)
| | - Valentina Caputo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (C.G.); (C.C.); (A.A.); (V.C.)
| | - Chiara Iaria
- Infectious and Tropical Disease Unit—ARNAS Civico, 90127 Palermo, Italy;
| | - Antonio Cascio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (C.G.); (C.C.); (A.A.); (V.C.)
- Infectious and Tropical Disease Unit, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy;
- Correspondence: ; Tel.: +39-091-2389-0632
| |
Collapse
|
4
|
Salaveria K, Smith S, Liu YH, Bagshaw R, Ott M, Stewart A, Law M, Carter A, Hanson J. The Applicability of Commonly Used Severity of Illness Scores to Tropical Infections in Australia. Am J Trop Med Hyg 2021; 106:257-267. [PMID: 34662860 PMCID: PMC8733535 DOI: 10.4269/ajtmh.21-0615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/31/2021] [Indexed: 01/03/2023] Open
Abstract
Many patients with leptospirosis, melioidosis, and rickettsial infection require intensive care unit (ICU) admission in tropical Australia every year. The multi-organ dysfunction associated with these infections results in significantly elevated severity of illness (SOI) scores. However, the accuracy of these SOI scores in predicting death from these tropical infections is incompletely defined. This retrospective study was performed at Cairns Hospital, a tertiary-referral hospital in tropical Australia. All patients admitted to ICU with laboratory-confirmed leptospirosis, melioidosis, and rickettsial disease between January 1, 1999 and June 30, 2020, were eligible for the study. The ability of Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Scores (SAPS) II, and Sequential Organ Failure Assessment (SOFA) scores to predict death before ICU discharge was evaluated. Overall, 18 (12.1%) of the 149 included patients died: 15/74 (20.3%) with melioidosis, 2/54 (3.7%) with leptospirosis and 1/21 (4.8%) with rickettsial disease. However, the APACHE II, APACHE III, SAPS II, and SOFA scores significantly overestimated the case-fatality rate of all the infections; the disparity between the predicted and observed mortality was most marked in the cases of leptospirosis and rickettsial disease. Commonly used SOI scores significantly overestimate the case-fatality rate of melioidosis, leptospirosis, and rickettsial infections in Australian ICU patients. This may be at least partly explained by the unique pathophysiology of these infections, particularly leptospirosis and rickettsial disease. However, SOI scores may still be useful in facilitating the comparison of disease severity in clinical trials that examine patients with these pathogens.
Collapse
Affiliation(s)
- Kris Salaveria
- Department of Intensive Care, Cairns Hospital, Cairns, Queensland, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Yu-Hsuan Liu
- Department of Intensive Care, Cairns Hospital, Cairns, Queensland, Australia
| | - Richard Bagshaw
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Markus Ott
- Department of Intensive Care, Cairns Hospital, Cairns, Queensland, Australia
| | | | - Matthew Law
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Angus Carter
- Department of Intensive Care, Cairns Hospital, Cairns, Queensland, Australia
- James Cook University, Cairns Campus, Cairns, Queensland, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
| |
Collapse
|
5
|
Khemka A, Sarkar M, Basu A, Dey PP, Chowdhoury SR, Mandal K. Predictors of Severity of Scrub Typhus in Children Requiring Pediatric Intensive Care Admission. J Pediatr Intensive Care 2021; 11:247-253. [DOI: 10.1055/s-0041-1723947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/03/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractObjective of our study was to determine the clinical characteristics and laboratory profile of scrub typhus patients requiring pediatric intensive care admission and to find out risk factors for the severity of illness. This was a cross-sectional observational study conducted on 1-month to 12-year-old children admitted with scrub typhus in a tertiary care pediatric intensive care unit (PICU). Relevant demographic, clinical, laboratory, treatment, and outcome-related data were documented. The severity of the disease was measured in the form of multiple organ dysfunction syndrome (MODS). With further correlation, and univariate and multivariate analyses, factors associated with severe disease were identified. During the study period, out of 586 PICU admission, 62 patients (10.6%) were diagnosed with scrub typhus. The mean age was 63.85 ± 52.78 months, where infants constituted 32.3% of the total population. Fever was present in 100% of the cases. Common indications of PICU admission were: respiratory distress 42 (67.7%), altered sensorium 41 (66.1%), convulsion 37 (59.7%), and shock 31 (50%). Total number of patients with MODS was 40 (64.5%). The case fatality rate was 8%. On multivariate analysis, infant age group (p = 0.02), altered sensorium (p = 0.001), reduced urine output (p = 0.02), thrombocytopenia (p = 0.001), raised C-reactive protein (p = 0.004), hyponatremia (p = 0.005), hypoalbuminemia (p = 0.01), deranged international normalized ratio (p = 0.02), and hyperferritinemia (p = 0.02) came out to be independent factors in predictability for development of MODS. Multiorgan dysfunction is a life-threatening manifestation of scrub typus in children, which necessitates PICU admission. Infant age group, presence of altered sensorium, reduced urine output, thrombocytopenia, elevated inflammatory markers, coagulopathy, hypoalbuminemia, and hyponatremia predict risk for MODS.
Collapse
Affiliation(s)
- Arpita Khemka
- Department of Pediatrics, Medical College & Hospital, Kolkata, West Bengal, India
| | - Mihir Sarkar
- Department of Pediatrics, Medical College & Hospital, Kolkata, West Bengal, India
| | - Ankika Basu
- Department of Pediatrics, Medical College & Hospital, Kolkata, West Bengal, India
| | - Partha Pratim Dey
- Ghatal Sub-Divisional Hospital, Paschim Medinipur, West Bengal, India
| | | | - Kalyanbrata Mandal
- Department of Pediatrics, Coochbehar Government Medical College, Coochbehar, West Bengal, India
| |
Collapse
|
6
|
Oh JH, Lim JH, Cho AY, Lee KY, Sun IO. Clinical significance of hypoalbuminemia in patients with scrub typhus complicated by acute kidney injury. PLoS One 2021; 16:e0247584. [PMID: 33630937 PMCID: PMC7906298 DOI: 10.1371/journal.pone.0247584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/09/2021] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ju Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Ji Hye Lim
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - A. Young Cho
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Kwang Young Lee
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - In O. Sun
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
- * E-mail:
| |
Collapse
|
7
|
Clinical Characteristics and Predictors of Severity of Pediatric Scrub Typhus in a Tertiary Level Hospital in South India. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2020. [DOI: 10.5812/pedinfect.92752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
8
|
Soundararajan S, Viswanathan S, Jain D, Krishnamurthy V, Gayathri MS. Acute Parkinsonism and Cerebral Salt-wasting-related Hyponatremia in Scrub Typhus. Cureus 2020; 12:e6706. [PMID: 32117657 PMCID: PMC7029825 DOI: 10.7759/cureus.6706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Scrub typhus is a multisystem disease, and the respiratory system is commonly involved. Scrub typhus-related parkinsonism has been reported in three patients previously, and none of them underwent a lumbar puncture. Cerebral salt wasting is generally observed in vascular emergencies of the brain. We report a patient with acute parkinsonism and cerebral salt wasting syndrome, a combination of which has not been previously reported in scrub typhus. A 50-year-old farmer presented with an acute febrile illness of two weeks' duration and a one-day history of parkinsonism symptoms. His workup revealed hypoosmolar hyponatremia, increased urinary sodium excretion, hepatorenal and hematological dysfunction, and normal findings on cerebrospinal fluid examination. Clinical and biochemical improvement was noticed with the institution of doxycycline. Empirical doxycycline may be needed in patients with acute parkinsonism following an acute febrile illness in areas endemic for scrub typhus. Better biochemical facilities in resource-poor tropical countries would help in evaluating the etiology of hyponatremia due to infectious causes.
Collapse
Affiliation(s)
- Sunitha Soundararajan
- General Medicine, Indira Gandhi Medical College and Research Institute, Pondicherry, IND
| | - Stalin Viswanathan
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, IND
| | - Dheeraj Jain
- General Medicine, Indira Gandhi Medical College & Research Institute, Pondicherry, IND
| | | | | |
Collapse
|
9
|
Nallasamy K, Gupta S, Bansal A, Biswal M, Jayashree M, Zaman K, Williams V, Kumar A. Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India. Indian J Crit Care Med 2020; 24:445-450. [PMID: 32863638 PMCID: PMC7435082 DOI: 10.5005/jp-journals-10071-23445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction Children with scrub typhus may present with one or more organ failures. Identifying the predictors of severe disease and need for pediatric intensive care unit (PICU) admission would help clinicians during outbreak seasons. Materials and methods This observational study included 160 children admitted to the emergency department (ED) with scrub typhus confirmed by polymerase chain reaction (PCR) between January 2013 and December 2015. Demographic, clinical, and laboratory data were collected and predictors for PICU admission were identified. Results There was a seasonal trend with peak presentation in post-monsoon months between August and October. Mean (SD) age at presentation was 6.8 (3.2) years. Fever was present in all with a median (IQR) duration of 9 (6–11) days. Respiratory distress (42%), altered sensorium (24%), hepatomegaly (93%), splenomegaly (57%), and lymphadenopathy (54%) were other features. Rash and eschar were noted in 24% each. Thrombocytopenia (83%), hypoalbuminemia (63%), and hyponatremia (62%) were common laboratory abnormalities. Meningoencephalitic presentation was noted in 29%; acute kidney injury (AKI) (16%), acute respiratory distress syndrome (ARDS) (11%), and myocarditis (3%) were other organ dysfunctions. Sixty-six (41%) children required PICU admission. Intensive care needs include invasive ventilation (n = 27, 17%), vasoactive drugs therapy for hemodynamic support (n = 43, 27%), osmotherapy to treat raised intracranial pressure (n = 27, 17%), and renal replacement therapy (n = 3, 2%). Mortality was 8.8%. On multivariable analysis, lymphadenopathy, respiratory distress, shock, elevated lactate, and meningoencephalitis predicted the requirement of PICU admission. Conclusion Scrub typhus presents with organ dysfunction during post-monsoon months. We identified predictors of intensive care in children with scrub typhus admitted to ED. Clinical significance Our results would help clinicians identify severe cases and prioritize resources. How to cite this article Nallasamy K, Gupta S, Bansal A, Biswal M, Jayashree M, Zaman K, et al. Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India. Indian J Crit Care Med 2020;24(6):445–450.
Collapse
Affiliation(s)
- Karthi Nallasamy
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalu Gupta
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Bansal
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manisha Biswal
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamran Zaman
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vijai Williams
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhay Kumar
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
10
|
Sharma A, Mishra B. Rickettsial disease existence in India: resurgence in outbreaks with the advent of 20thcentury. INDIAN JOURNAL OF HEALTH SCIENCES AND BIOMEDICAL RESEARCH KLEU 2020. [DOI: 10.4103/kleuhsj.kleuhsj_162_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
11
|
Pathak S, Chaudhary N, Dhakal P, Shakya D, Dhungel P, Neupane G, Shrestha S, Regmi S, Kurmi OP. Clinical profile, complications and outcome of scrub typhus in children: A hospital based observational study in central Nepal. PLoS One 2019; 14:e0220905. [PMID: 31408484 PMCID: PMC6692021 DOI: 10.1371/journal.pone.0220905] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/25/2019] [Indexed: 11/18/2022] Open
Abstract
Background Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. Methods A prospective observational study was carried out in children aged 1–16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. Results All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. Conclusions Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome.
Collapse
Affiliation(s)
- Santosh Pathak
- Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal
| | - Nagendra Chaudhary
- Department of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal
- * E-mail:
| | - Prativa Dhakal
- Department of Woman's Health and Development, School of Nursing, Chitwan Medical College, Bharatpur, Nepal
| | - Disuja Shakya
- Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal
| | - Prativa Dhungel
- Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal
| | | | - Sandeep Shrestha
- Department of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal
| | - Shanti Regmi
- Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal
| | - Om P. Kurmi
- Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Canada
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, Canada
| |
Collapse
|
12
|
Lim HK, Wang JM. Scrub Typhus: Seven-Year Experience and Literature Review. J Acute Med 2018; 8:99-108. [PMID: 32995211 PMCID: PMC7517964 DOI: 10.6705/j.jacme.201809_8(3).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/24/2017] [Accepted: 01/17/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND Scrub typhus, an emerging rickettsial disease caused by Orientia tsutsugamushi, is a clinically important endemic disease on Taiwan. METHODS From January 1, 2007, to December 31, 2013, 156 patients diagnosed with scrub typhus were admitted to Taitung MacKay Memorial Hospital. Demographic data, clinical features, laboratory results, and outcomes of patients were retrospectively analyzed. RESULTS Among 156 cases, 150 survived (96%) and six died (4%). There were 111 males (71%) and 45 females (29%) with a mean age of 47.8 years. The most common clinical features were fever (100%), general malaise (77%), chill (74%), headache (59%), and eschar (55%). No seasonal pattern was observed, with peaks in November and January. The average time to defervescence after appropriate antibiotics for the 150 surviving patients was 2.45 days. The significant risk factors were a delay of initial appropriate antibiotics use within 24 hrs, increased C-reactive protein (CRP), and liver cirrhosis. CONCLUSION Scrub typhus, a growing and emerging disease, is considered in the differential diagnosis of fever of unknown origin, and its diagnosis may be missed if it is not considered owing to its nonspecific clinical presentation. It is important to have a high index of suspicion and to increase awareness in endemic areas. Prompt diagnosis and early treatment with appropriate antibiotics are vital.
Collapse
Affiliation(s)
- Hwee-Kheng Lim
- Taitung MacKay Memorial Hospital Division of Infectious Diseases, Department of Medicine Taitung Taiwan
| | - Jinn-Ming Wang
- Taitung MacKay Memorial Hospital Division of Urology, Department of Surgery Taitung Taiwan
| |
Collapse
|
13
|
van Eekeren LE, de Vries SG, Wagenaar JFP, Spijker R, Grobusch MP, Goorhuis A. Under-diagnosis of rickettsial disease in clinical practice: A systematic review. Travel Med Infect Dis 2018; 26:7-15. [PMID: 29486240 DOI: 10.1016/j.tmaid.2018.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/14/2018] [Accepted: 02/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rickettsial diseases present as acute febrile illnesses, sometimes with inoculation eschars. METHODS We performed a systematic review of studies published between 1997 and 2017 to assess the underestimation of non-eschar rickettsial disease (NERD) relative to eschar rickettsial disease (ERD), as a cause of acute fever in patients with rickettsial diseases that commonly present with eschar(s): scrub typhus (ST), Mediterranean spotted fever (MSF), and African tick-bite fever. We compared ERD/NERD ratios according to study design: 'complete approach' studies, with testing performed in all patients with 'unspecified febrile illness'; versus 'clinical judgement' studies, with testing performed if patients presented with specific symptoms. RESULTS In 'complete approach' studies, ERD/NERD ratios were significantly lower, suggesting a considerable under-diagnosis of NERD in 'clinical judgement' studies. Based on these results, we estimate that the diagnosis of rickettsial disease was missed in 66.5% of patients with ST, and in 57.9% of patients with MSF. CONCLUSIONS Study design influences the reported eschar rates in ST and MSF significantly. NERD is likely to be a vastly underdiagnosed entity, and clinicians should consider and test for the disease more often. PROSPERO REGISTRATION NUMBER CRD 42016053348.
Collapse
Affiliation(s)
- Louise E van Eekeren
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Sophia G de Vries
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Jiri F P Wagenaar
- Leptospirosis Reference Center, Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - René Spijker
- Medical Library, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands.
| |
Collapse
|
14
|
Wiedermann CJ, Wiedermann W, Joannidis M. Causal relationship between hypoalbuminemia and acute kidney injury. World J Nephrol 2017; 6:176-187. [PMID: 28729966 PMCID: PMC5500455 DOI: 10.5527/wjn.v6.i4.176] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/21/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Our meta-analysis published in 2010 provided evidence that low levels of serum albumin (hypoalbuminemia) are a significant independent predictor of acute kidney injury (AKI) and death following AKI. Since then, a large volume of additional data from observational clinical studies has been published further evaluating the relationship between serum albumin and AKI occurrence. This is an updated review of the literature to re-evaluate the hypothesis that hypoalbuminemia is independently associated with increased AKI risk. Eligible studies published from September 2009 to December 2016 were sought in PubMed (MEDLINE) and forty-three were retained, the great majority being retrospective observational cohort studies. These included a total of about 68000 subjects across a diverse range of settings, predominantly cardiac surgery and acute coronary interventions, infectious diseases, transplant surgery, and cancer. Appraisal of this latest data set served to conclusively corroborate and confirm our earlier hypothesis that lower serum albumin is an independent predictor both of AKI and death after AKI, across a range of clinical scenarios. The body of evidence indicates that hypoalbuminemia may causally contribute to development of AKI. Furthermore, administration of human albumin solution has the potential to prevent AKI; a randomized, controlled study provides evidence that correcting hypoalbuminemia may be renal-protective. Therefore, measurement of serum albumin to diagnose hypoalbuminemia may help identify high-risk patients who may benefit from treatment with exogenous human albumin. Multi-center, prospective, randomized, interventional studies are warranted, along with basic research to define the mechanisms through which albumin affords nephroprotection.
Collapse
|
15
|
Zhao D, Zhang Y, Yin Z, Zhao J, Yang D, Zhou Q. Clinical Predictors of Multiple Organ Dysfunction Syndromes in Pediatric patients with Scrub Typhus. J Trop Pediatr 2017; 63:167-173. [PMID: 27697827 DOI: 10.1093/tropej/fmw066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Scrub typhus can produce multiple organ dysfunction syndrome (MODS). Early recognition of the patients at risk of MODS would be helpful in providing timely management and reducing the mortality. In all, 449 children with scrub typhus were enrolled at three hospitals in Yunnan, China from January 2010 to January 2015. The patients' clinical status of organ system dysfunction was evaluated on the day of discharge from hospital by using standard criteria. The patients were classified into MODS present (64 cases, 14.3%) or MODS absent (385 cases, 85.7%). Multivariate logistic regression analyses revealed that the prognostic factors for MODS included skin rash (odds ratio, OR = 3.3, p = 0.037), time interval form treatment to defervescence (OR = 1.2, p = 0.035), hemoglobin (OR = 0.54, p = 0.041), platelet counts (OR = 0.06, p < 0.001), aspartate-aminotransferase (OR = 4.7, p = 0.011) and total bilirubin (OR = 2.3, p = 0.013). By describing risk factors resulting in MODS in pediatric scrub typhus, our study provides clinicians with important information to improve the clinical monitoring and prognostication of MODS.
Collapse
Affiliation(s)
- Dongying Zhao
- Xin Hua Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200092, China
| | - Yongjun Zhang
- Xin Hua Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200092, China.,MOE and Shanghai Key Laboratory of Children's Environmental Health, Shanghai, 200092, China
| | | | - Jing Zhao
- Longling People's Hospital, Yunnan, 678300, China
| | - Defeng Yang
- Longling People's Hospital, Yunnan, 678300, China
| | - Qun Zhou
- Baoshan People's Hospital, Yunnan, 678000, China
| |
Collapse
|
16
|
Methods of albumin estimation in clinical biochemistry: Past, present, and future. Clin Chim Acta 2017; 469:150-160. [PMID: 28410855 DOI: 10.1016/j.cca.2017.04.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 12/17/2022]
Abstract
Estimation of serum and urinary albumin is routinely performed in clinical biochemistry laboratories. In the past, precipitation-based methods were popular for estimation of human serum albumin (HSA). Currently, dye-binding or immunochemical methods are widely practiced. Each of these methods has its limitations. Research endeavors to overcome such limitations are on-going. The current trends in methodological aspects of albumin estimation guiding the field have not been reviewed. Therefore, it is the need of the hour to review several aspects of albumin estimation. The present review focuses on the modern trends of research from a conceptual point of view and gives an overview of recent developments to offer the readers a comprehensive understanding of the subject.
Collapse
|
17
|
Abstract
Respiratory failure is a serious complication of scrub typhus. In this prospective study, all patients with a diagnosis of scrub typhus were included from a single center Intensive Care Unit (ICU). Demographic, clinical characteristics, laboratory, and imaging parameters of these patients at the time of ICU admission were compared. Of the 55 scrub typhus patients, 27 (49%) had an acute respiratory failure. Seventeen patients had acute respiratory distress syndrome, and ten had cardiogenic pulmonary edema. Respiratory supported patients were older had significant chronic lungs disease and high severity illness scores (Acute Physiology and Chronic Health Evaluation-II and Sequential Organ Failure Assessment score). At ICU admission, these patients presented with more deranged laboratory markers, including high bilirubin, high creatine kinase, high lactate, metabolic acidosis, low serum albumin, and presence of ascites. The average ICU and hospital stay were 4.27 ± 2.74 and 6.53 ± 3.52 days, respectively, in the respiratory supported group. Three patients died in respiratory failure group, while only one patient died in nonrespiratory failure group.
Collapse
Affiliation(s)
- Jyoti Narayan Sahoo
- Department of Critical Care Medicine, Apollo Hospital, Hyderabad, Telangana, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Yogesh Harde
- Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
| |
Collapse
|
18
|
Kim HH, Chung JH, Kim DM, Yun NR, Lee J, Kwon YE, Yoon SH, Lee SI, Han MA. The clinical characteristics of pleural effusion in scrub typhus. BMC Infect Dis 2016; 16:278. [PMID: 27287396 PMCID: PMC4902952 DOI: 10.1186/s12879-016-1613-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 06/03/2016] [Indexed: 12/04/2022] Open
Abstract
Background The aim of this study is to identify the factors associated with the occurrence of pleural effusion and to investigate the characteristics of pleural effusion in scrub typhus. Methods We conducted a retrospective analysis of the medical records of scrub typhus patients between January 2004 and December 2011 at Chosun University Hospital in South Korea. A total of 445 scrub typhus patients were divided into the following two groups: without (n = 352) or with pleural effusion (n = 93). The data of 18 scrub typhus patients who underwent thoracentesis were summarized. Results Multivariate analysis demonstrated that the following factors were associated with the occurrence of pleural effusion in scrub typhus: older age (odds ratio [OR] = 1.029, P = 0.037, confidence interval [CI] = 1.002–1.056); male gender (OR = 1.924, P = 0.020, CI = 1.109–3.340); presence of heart failure (OR = 2.628, P = 0.039, CI = 1.052–6.565); and lower albumin (OR = 0.107, P ≤ 0.001, CI = 0.058–0.196). Most pleural effusion presentations were bilateral (88 %) and small (91 %). The effusion had transudate characteristics in 7 patients and exudate characteristics in 11 patients based on Light’s criteria. Conclusions This study provided the first data regarding the following four independent risk factors associated with the occurrence of pleural effusion: older age; male gender; the presence of heart failure; and lower albumin. The pleural effusion presentations in scrub typhus patients were bilateral and small in most cases, with transudate and/or exudate characteristics.
Collapse
Affiliation(s)
- Hyung Ho Kim
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Jong-Hoon Chung
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Dong-Min Kim
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea.
| | - Na Ra Yun
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Jun Lee
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Yong Eun Kwon
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Sung Ho Yoon
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Seung Il Lee
- Department of Internal Medicine, Chosun University College of Medicine, 588 Seosuk-dong, Dong-gu, Gwangju, 501-717, South Korea
| | - Mi Ah Han
- Department of Preventive Medicine, Chosun University College of Medicine, Gwangju, Republic of Korea
| |
Collapse
|
19
|
Pediatric scrub typhus in Southern Kerala: An emerging public health problem. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2016. [DOI: 10.1016/j.cegh.2016.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
20
|
Lee H, Ji M, Hwang JH, Lee JY, Lee JH, Chung KM, Lee CS. Acute Cholecystitis in Patients with Scrub Typhus. J Korean Med Sci 2015; 30:1698-700. [PMID: 26539017 PMCID: PMC4630489 DOI: 10.3346/jkms.2015.30.11.1698] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/11/2015] [Indexed: 11/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Misuk Ji
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong-Hwan Hwang
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Ja-Yeon Lee
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Ju-Hyung Lee
- Department of Preventive Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Kyung Min Chung
- Department of Microbiology, Chonbuk National University Hospital, Jeonju, Korea
| | - Chang-Seop Lee
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Korea
- Research Institute of Clinical Medicine of Chonbuk National University-Chonbuk National University Hospital, Jeonju, Korea
| |
Collapse
|
21
|
Hamaguchi S, Cuong NC, Tra DT, Doan YH, Shimizu K, Tuan NQ, Yoshida LM, Mai LQ, Duc-Anh D, Ando S, Arikawa J, Parry CM, Ariyoshi K, Thuy PT. Clinical and Epidemiological Characteristics of Scrub Typhus and Murine Typhus among Hospitalized Patients with Acute Undifferentiated Fever in Northern Vietnam. Am J Trop Med Hyg 2015; 92:972-978. [PMID: 25778504 PMCID: PMC4426587 DOI: 10.4269/ajtmh.14-0806] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/20/2015] [Indexed: 01/31/2023] Open
Abstract
A descriptive study on rickettsiosis was conducted at the largest referral hospital in Hanoi, Vietnam, to identify epidemiological and clinical characteristics of specific rickettsiosis. Between March 2001 and February 2003, we enrolled 579 patients with acute undifferentiated fever (AUF), excluding patients with malaria, dengue fever, and typhoid fever, and serologically tested for Orientia tsutsugamushi and Rickettsia typhi. Of the patients, 237 (40.9%) and 193 (33.3%) had scrub and murine typhus, respectively, and 149 (25.7%) had neither of them (non-scrub and murine typhus [non-ST/MT]). The proportion of murine typhus was highest among patients living in Hanoi whereas that of scrub typhus was highest in national or regional border areas. The presence of an eschar, dyspnea, hypotension, and lymphadenopathy was significantly associated with a diagnosis of scrub typhus (OR = 46.56, 10.90, 9.01, and 7.92, respectively). Patients with murine typhus were less likely to have these findings but more likely to have myalgia, rash, and relative bradycardia (OR = 1.60, 1.56, and 1.45, respectively). Scrub typhus and murine typhus were shown to be common causes of AUF in northern Vietnam although the occurrence of spotted fever group rickettsiae was not determined. Clinical and epidemiological information may help local clinicians make clinical diagnosis of specific rickettsioses in a resource-limited setting.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Pham Thanh Thuy
- *Address correspondence to Pham Thanh Thuy, Infectious Disease Department, Bach Mai Hospital, 78 Giai Phong Road, Hanoi 84, Vietnam. E-mail:
| |
Collapse
|
22
|
Predictors of severity of scrub typhus in the Indian subcontinent. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2014. [DOI: 10.1016/s2222-1808(14)60705-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
23
|
Agarwal VK, Reddy GKM, Krishna MR, Ramareddy G, Saroj P, Bandaru VCSS. Predictors of scrub typhus: a study from a tertiary care center. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2014. [DOI: 10.1016/s2222-1808(14)60704-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
24
|
Kumar Bhat N, Dhar M, Mittal G, Shirazi N, Rawat A, Prakash Kalra B, Chandar V, Ahmad S. Scrub typhus in children at a tertiary hospital in north India: clinical profile and complications. IRANIAN JOURNAL OF PEDIATRICS 2014; 24:387-92. [PMID: 25755859 PMCID: PMC4339561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 04/13/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To study the clinical profile and complications of childhood scrub typhus. METHODS Prospective observational study of 66 children with scrub typhus, admitted to a tertiary hospital in north India, during the period between January 2011 and December 2012. The diagnosis was confirmed by serology. Findings : All children presented with fever. Other common symptoms were vomiting (56%), facial swelling (52%), cough (35%), abdominal pain (33%), breathlessness (29%) and decreased urine output (29%). High grade fever (>101 (o)F) was recorded in 91% of children. Other common signs were hepatomegaly, splenomegaly, edema, tender lymphadenopathy and hypotension, observed in 82%, 59%, 39%, 38% and 36% of cases, respectively. An eschar and a maculopapular rash each were observed in 20% of patients. Meningoencephalitis (30.3%), severe thrombocytopenia (27.2%), shock (25.8%), acute kidney injury (16.7%) and hepatitis (13.6%) were the most common complications observed in these children. Other common complications were acute respiratory distress syndrome, respiratory failure requiring ventilation, bronchopneumonia and myocarditis. Ninety percent of children became afebrile within 48 hours of initiating an appropriate antibiotic. Median time to defervescence was 22 hours. The overall mortality rate was 7.5%. Causes of death were refractory shock, meningoencephalitis, acute respiratory distress syndrome, bronchopneumonia, acute kidney injury and myocarditis. CONCLUSION Pediatricians should keep a high index of suspicion for scrub typhus in any febrile child having a maculopapular rash, hepatosplenomegaly, tender lymphadenopathy, thrombocytopenia and features suggestive of capillary leak. Pending serological confirmation, empirical therapy with doxycycline or azithromycin should be started, as delay in treatment would result in life threatening complications.
Collapse
Affiliation(s)
- Nowneet Kumar Bhat
- Department of Pediartics,Corresponding Author: Address: Department of Pediatrics, Himaliyan Institute of Medical Sciences, Doiwala, Dehradun, Uttarakhand, India
| | | | | | - Nadia Shirazi
- Department of Pathology, Himaliyan Institute of Medical Sciences, Swami Rama Himalayan University, Doiwala, Dehradun, Uttarakhand, India
| | | | | | | | | |
Collapse
|
25
|
Sriwongpan P, Patumanond J, Krittigamas P, Tantipong H, Tawichasri C, Namwongprom S. Validation of a clinical risk-scoring algorithm for severe scrub typhus. Risk Manag Healthc Policy 2014; 7:29-34. [PMID: 24600256 PMCID: PMC3933538 DOI: 10.2147/rmhp.s56974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of the study reported here was to validate the risk-scoring algorithm for prognostication of scrub typhus severity. METHODS The risk-scoring algorithm for prognostication of scrub typhus severity developed earlier from two general hospitals in Thailand was validated using an independent dataset of scrub typhus patients in one of the hospitals from a few years later. The predictive performances of the two datasets were compared by analysis of the area under the receiver-operating characteristic curve (AuROC). Classification of patients into non-severe, severe, and fatal cases was also compared. RESULTS The proportions of non-severe, severe, and fatal patients by operational definition were similar between the development and validation datasets. Patient, clinical, and laboratory profiles were also similar. Scores were similar in both datasets, both in terms of discriminating non-severe from severe and fatal patients (AuROC =88.74% versus 91.48%, P=0.324), and in discriminating fatal from severe and non-severe patients (AuROC =88.66% versus 91.22%, P=0.407). Over- and under-estimations were similar and were clinically acceptable. CONCLUSION The previously developed risk-scoring algorithm for prognostication of scrub typhus severity performed similarly with the validation data and the first dataset. The scoring algorithm may help in the prognostication of patients according to their severity in routine clinical practice. Clinicians may use this scoring system to help make decisions about more intensive investigations and appropriate treatments.
Collapse
Affiliation(s)
- Pamornsri Sriwongpan
- Clinical Epidemiology Program, Faculty of Medicine, Chiang Mai University, Chiang Mai ; Department of Social Medicine, Chiangrai Prachanukroh Hospital, Chiang Rai
| | - Jayanton Patumanond
- Clinical Epidemiology Program, Faculty of Medicine, Thammasat University, Bangkok
| | | | | | | | - Sirianong Namwongprom
- Clinical Epidemiology Program, Faculty of Medicine, Chiang Mai University, Chiang Mai ; Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
26
|
Jang MO, Jang HC, Kim UJ, Ahn JH, Kang SJ, Jung SI, Shin HY, Park KH. Outcome of intravenous azithromycin therapy in patients with complicated scrub typhus compared with that of doxycycline therapy using propensity-matched analysis. Antimicrob Agents Chemother 2013; 58:1488-93. [PMID: 24366734 PMCID: PMC3957884 DOI: 10.1128/aac.01996-13] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/14/2013] [Indexed: 11/20/2022] Open
Abstract
There are no well-matched, controlled studies comparing azithromycin with doxycycline for the treatment of complicated scrub typhus. A retrospective propensity score-matched case-control study was performed for patients who presented with complicated scrub typhus and were treated with doxycycline or azithromycin between 2001 and 2011. Data on comorbidities, clinical manifestations, laboratory studies, treatments, and outcomes were extracted for analysis. The clinical characteristics and outcomes of the azithromycin-treated group (n=73) were compared to those of the doxycycline-treated group (n=108). Of 181 patients, 73 from each group were matched by propensity scores. There were no significant differences in baseline characteristics between the matched groups. The treatment success and survival rates were not significantly different (89% [65/73 patients] versus 96% [70/73 patients] and 96% [70/73 patients] versus 96% [70/73 patients], respectively [P>0.05]). No difference was observed in the time to defervescence or length of hospital stay between the two groups (P>0.05). In complicated scrub typhus patients (n=181), multivariate analysis showed that only APACHE II score was an independent risk factor for mortality (95% confidence interval, 1.11 to 1.56; P<0.001). Our data suggest that outcomes of azithromycin therapy are comparable to those of doxycycline therapy in patients with complicated scrub typhus.
Collapse
Affiliation(s)
- Mi-Ok Jang
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Hee-Chang Jang
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Uh Jin Kim
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Joon Hwan Ahn
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Seung-Ji Kang
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Sook-In Jung
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Hee-Young Shin
- Department of Biomedical Science, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious Disease, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| |
Collapse
|
27
|
Jang MO, Kim JE, Kim UJ, Ahn JH, Kang SJ, Jang HC, Jung SI, Park KH. Differences in the clinical presentation and the frequency of complications between elderly and non-elderly scrub typhus patients. Arch Gerontol Geriatr 2013; 58:196-200. [PMID: 24268946 DOI: 10.1016/j.archger.2013.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 10/25/2013] [Accepted: 10/26/2013] [Indexed: 01/18/2023]
Abstract
Age can affect the clinical features and severity of infectious disorders, such as scrub typhus. We performed this study to examine differences between elderly and non-elderly scrub typhus patients, and to identify risk factors predictive of disease outcomes. This retrospective study included patients admitted to a tertiary hospital with scrub typhus between 2001 and 2011. A total of 615 patients were enrolled in this study, 328 of which were >65 years of age. Of the elderly patients, 46.0% (151/328) experienced at least one complication compared to only 23.0% (66/287) in younger patients. A linear trend was observed between age and complication rates (p=0.002). The most common complication in elderly patients was acute kidney injury (75, 22.9%). Treatment failure was reported in 10 elderly patients (3.0%) compared to one non-elderly patient (0.3%). Mental confusion and dyspnea of clinical manifestations at admission were common in elderly patients. Frequency of fever, rash, and eschar were similar in both groups. The following four factors were significantly associated with severe scrub typhus in elderly patients: (1) white blood cell (WBC) counts>10,000/mm(3) (OR=2.569, CI=1.298-5.086), (2) MDRD GFR<60mL/min (OR=3.525, CI=1.864-6.667), (3) albumin≤3.0g/dL (OR=4.976, CI=2.664-9.294), and (4) acute physiology and chronic health evaluation II (APACHE II) score>10 points (OR=3.304, CI=1.793-60.87). Complications and mortality were more common in elderly patients, often associated with delays in diagnosis and treatment.
Collapse
Affiliation(s)
- Mi-Ok Jang
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Ji Eun Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Uh Jin Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Joon Hwan Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Seung-Ji Kang
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Hee-Chang Jang
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Sook-In Jung
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwang-ju, Republic of Korea.
| |
Collapse
|
28
|
Vikrant S, Dheer SK, Parashar A, Gupta D, Thakur S, Sharma A, Kaushal SS, Kanga A. Scrub typhus associated acute kidney injury--a study from a tertiary care hospital from western Himalayan State of India. Ren Fail 2013; 35:1338-43. [PMID: 23952649 DOI: 10.3109/0886022x.2013.828257] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To report the clinical profile of acute kidney injury (AKI) associated with scrub typhus. METHODS Retrospective study of hospitalized patients of acute febrile illness who were diagnosed scrub typhus and had AKI. RESULTS 174 (35%) patients (75.9% female), mean age (41.4 ± 15.9 years) were studied. The laboratory abnormalities were: anemia (63.2%), leukocytosis (44.3%), thrombocytopenia (61.5%), hyponatremia (35.6%), hypernatremia (2.9%), and hypokalemia (12.1%), hyperkalemia (11.5%), hypoalbuminemia (56.9%), hepatic dysfunction (70%) and metabolic acidosis (28.7%). The complications of hypotension (5.7%), septic shock (3.4%), pneumonia (10.9%), acute respiratory distress syndrome (ARDS) (11.5%), meningoencephalitis (6.9%), encephalopathy (5.2%), gastrointestinal bleed (1.3%), myocarditis (3.4%), disseminated intravascular coagulation (2.9%) and multi organ failure (MOF) (10.3%) developed during course of hospitalization in these patients. Twenty-five (14.4%) patients required intensive care support (ICU) support and seven (4%) patients were dialyzed. 146 (83.9%) patients survived. Twenty-eight (16.1%) patients died. There was a significant difference in the age, various hematological & biochemical abnormalities, complications and need for ICU support in the non-survival group as compared the survival group. CONCLUSION This study shows that AKI in scrub typhus is common and a severe disease. Age, a shorter hospital stay, severities of leukocytosis, thrombocytopenia, azotemia, hypoalbuminemia, hepatic dysfunction and the complications of ARDS, encephalopathy, MOF and need for ICU support are the factors associated with mortality.
Collapse
|
29
|
Viswanathan S, Muthu V, Iqbal N, Remalayam B, George T. Scrub typhus meningitis in South India--a retrospective study. PLoS One 2013; 8:e66595. [PMID: 23799119 PMCID: PMC3682970 DOI: 10.1371/journal.pone.0066595] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/08/2013] [Indexed: 12/13/2022] Open
Abstract
Background Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports Methods A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness- a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits. Results Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol. Conclusion Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.
Collapse
Affiliation(s)
- Stalin Viswanathan
- Department of General Medicine, Indira Gandhi Medical College, Kathirkamam, Pondicherry, India.
| | | | | | | | | |
Collapse
|
30
|
Scrub typhus in children at a tertiary hospital in southern India: Clinical profile and complications. J Infect Public Health 2012; 5:82-8. [DOI: 10.1016/j.jiph.2011.11.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 09/28/2011] [Accepted: 11/02/2011] [Indexed: 01/09/2023] Open
|
31
|
Abstract
OBJECTIVE Scrub typhus is an important febrile disease in Asia, and antibiotics have been used to treat this disease. The purpose of this study was to generate large-scale evidence of the efficacy of different antibiotic regimens for treating scrub typhus using a meta-analysis. METHODS PubMed, Elsevier ScienceDirect, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang (Chinese) were searched to identify relevant articles. The data from eligible citations were extracted by two reviewers. All analyses were performed using the Cochrane Collaboration Review Manager 4.2 and Stata 10.0 software programs. RESULTS We conducted a meta-analysis of 17 separate studies that evaluated the efficacy of treatment with the different antibiotic regimens for scrub typhus. The median time (h) to clearance of fever in the azithromycin-treated group was longer than that in the chloramphenicol-treated group (weighted mean difference [WMD] = 12.66, 95% confidence interval [CI]: 2.26,23.06). Adverse events were 2.95 (95%CI: 1.32, 6.61) times more likely to occur in the azithromycin-treated group than in the chloramphenicol-treated group. The clearance time (days) for the main symptoms (including fever, headache, rash and lymphadenectasis) in the doxycycline-treated group was shorter than that in the chloramphenicol-treated group (WMD = -0.4, 95%CI: -0.53, -0.26) in five trials. Adverse drug events occurred significantly less frequently in the azithromycin-treated group than in the doxycycline-treated group (relative risk [RR] = 0.47, 95%CI: 0.31,0.71). CONCLUSION Doxycycline was found to act more quickly, but more adverse drug events occur when using this regimen compared to azithromycin and chloramphenicol.
Collapse
Affiliation(s)
- Yirong Fang
- School of Public Health, Anhui Medical University, China
| | | | | | | | | | | |
Collapse
|
32
|
Park SW, Lee CS, Lee CK, Kwak YG, Moon C, Kim BN, Kim ES, Kang JM, Oh MD. Severity predictors in eschar-positive scrub typhus and role of serum osteopontin. Am J Trop Med Hyg 2011; 85:924-30. [PMID: 22049051 DOI: 10.4269/ajtmh.2011.11-0134] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We prospectively evaluated severity predictors in terms of host, microorganism, and treatment factors in 153 eschar-positive scrub typhus patients. Severity was assessed with the Acute Physiology and Chronic Health Evaluation (APACHE) II score (< 10 versus ≥ 10) and predefined criteria of severe complications. Genotypes of Orientia tsutsugamushi were determined. Independent risk factors for severity (APACHE II score ≥ 10) were old age, diabetes mellitus, serum osteopontin > 100 ng/mL, and a group of underlying diseases (congestive heart failure, cerebrovascular disease, chronic liver disease, bronchial asthma, and chronic obstructive lung diseases). Anemia (≤ 10 g/dL) and C-reactive protein > 10 mg/dL were indicators of current severity. Neither the delay in antibiotics administration nor strain types (Boryong, Taguchi, or Kanda/Kawasaki) contributed to the severity. The risk factors for severe complications were similar. Serum osteopontin > 100 ng/mL had a negative predictive value of 96% for severe complications. This marker can be used to rule out severe disease status.
Collapse
Affiliation(s)
- Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | | | | | | | | | | | | | | | | |
Collapse
|