The Eschar Size and Early Inoculation Lesion of Tsutsugamushi Disease on Jeju Island, Korea

Ocular inflammation in tsutsugamushi disease - a case report

A 64-year-old male, working at a mountain site in Taitung County, suffered from primary open angle glaucoma (POAG) post trabeculectomy with well-controlled intraocular pressure (IOP) in both eyes (OU). He presented with headache accompanied by red eyes (OU) for 10 days. Physical examination revealed fever up to 38.2°C, neck stiffness, one eschar at the left forearm and another at the left ankle. Abnormal laboratory data indicated bacterial infection with central nervous system involvement. Ophthalmic examination showed elevated IOP, moderate conjunctival congestion, subconjunctival hemorrhage, anterior uveitis, cotton-wool spots on the retina and multiple white dots on the temporal retina (OU). Under the impression of uveitis in tsutsugamushi disease with atypical meningitis, oral doxycycline, anti-glaucoma and anti-inflammation eye drugs were prescribed. IOP returned to 12 mmHg and anterior uveitis subsided. The lesions of cotton-wool spots on the retina disappeared within 2 weeks, but multiple white dots remained persistently on the temporal retina.

A case of scrub typhus with meningitis as the onset: Case report and literature review

RATIONALE

Scrub typhus is a naturally occurring acute febrile disease caused by Orientia tsutsugamushi. Although it can cause multiple organ dysfunction, central nervous system infections are uncommon.

PATIENT CONCERNS

A 17-year-old male presented with a 5-day history of fever and headaches. The MRI of the head revealed thickness and enhancement of the left temporal lobe and tentorium cerebelli, indicating potential inflammation.

DIAGNOSES

The patient was diagnosed with a central nervous system infection.

INTERVENTIONS

Ceftriaxone and acyclovir were administered intravenously to treat the infection, reduce fever, restore acid-base balance, and manage electrolyte disorders.

OUTCOMES

Despite receiving ceftriaxone and acyclovir as infection therapy, there was no improvement. Additional multipathogen metagenomic testing indicated the presence of O tsutsugamushi infection, and an eschar was identified in the left axilla. The diagnosis was changed to scrub typhus with meningitis and the therapy was modified to intravenous doxycycline. Following a 2-day therapy, the body temperature normalized, and the fever subsided.

CONCLUSIONS

The patient was diagnosed with scrub typhus accompanied by meningitis, and doxycycline treatment was effective.

LESSION

Rarely reported cases of scrub typhus with meningitis and the lack of identifiable symptoms increase the chance of misdiagnosis or oversight. Patients with central nervous system infections presenting with fever and headache unresponsive to conventional antibacterial and antiviral treatment should be considered for scrub typhus with meningitis. Prompt multipathogen metagenomic testing is recommended to confirm the diagnosis and modify the treatment accordingly.

Tick-Borne Rickettsiosis and Tsutsugamushi Disease Recorded in 313

Tsutsugamushi disease was first described in China by Hong Ge in 313. In his book Zhouhou Beiji Fang, three eschar-associated febrile diseases were described: Shashidu, Zhongxidu, and Shegongdu. Shashidu was identified as being identical to tsutsugamushi disease in Japan: it occurred in riverside areas, exhibited an eschar, and was transmitted by tiny red "sand lice". The nature of Zhongxidu remains unknown, but we propose that it is another type of Orientia tsutsugamushi infection: it occurred in mountainous areas, an eschar was observed, and the causative vector was not identified. Moreover, Zhongxidu would have predated Shashidu by five centuries; thus, the first documentation of tsutsugamushi disease would date back 2.2 millennia. O. tsutsugamushi infection without eschar has not been identified in ancient Chinese literature and may be included in Shanghan. Several ancient Chinese books describe that Shegongdu occurs following a Shegong bite. Shegong is described as a bug resembling a cockroach or cicada with a crossbow-like structure, possibly the hypostome and unfolded palps of tick, in its mouth. Thus, Shegong refers to an engorged tick and Shegongdu is a tick-borne rickettsiosis. However, due to a lack of entomological knowledge, these findings have not been recognized for the past 1.7 millennia.

Concurrent Infection with SARS-CoV-2 and Orientia tsutsugamushi during the COVID-19 Pandemic in the Maldives

The COVID-19 pandemic was the worst public-health crisis in recent history. The impact of the pandemic in tropical regions was further complicated by other endemic tropical diseases, which can cause concurrent infections along with COVID-19. Here, we describe the clinical course of a patient with concurrent COVID-19 and scrub typhus infection. The patient's de-identified clinical data were retrieved retrospectively. The patient had progressive breathlessness at the time of presentation and was hospitalized for COVID-19. Respiratory examination revealed dyspnea, tachypnea, and coarse crepitations bilaterally over the entire lung field. Oxygenation was impaired, and a PaO2/FiO2 ratio of 229 suggested acute respiratory distress syndrome. Laboratory tests indicated leukocytosis, thrombocytopenia, ferritinemia, hypoalbuminemia, and transaminitis. Upon revaluation for persistent fever, physical examination revealed an eschar in the right antecubital fossa. Serology further confirmed scrub typhus, with IgM and IgG antibody positivity. A remarkable clinical recovery was achieved with doxycycline. The COVID-19 pandemic might have masked endemic tropical diseases. Clinicians working in endemic regions must always consider common tropical diseases that may present as a co-infection, as in our case. Travel and exposure history are critical guides for narrowing down a differential diagnosis. Early diagnosis and treatment can prevent complications.

Buerger's Disease May be a Chronic Rickettsial Infection with Superimposed Thrombosis: Literature Review and Efficacy of Doxycycline in Three Patients

Buerger's disease (BD) is a chronic inflammatory vasculitis of unknown etiology. The infectious etiology of BD was proposed by Buerger in 1914. Furthermore, there are scattered reports insisting that BD may be related to rickettsial infection, first asserted by Goodman since 1916, followed by Giroud and other French investigators from the 1940s through the 1960s, Nicolau in the 1960s, Bartolo (1980s), and Fazeli (2010s). However, their causal relationship has hardly been accepted because rickettsial infections are known to be acute febrile, vector-borne illnesses, whereas BD is a chronic afebrile illness. In this article we review the relevant literature on the chronic nature of Rickettsia and Orientia infections and on the rickettsial etiology of BD. Excellent initial responses to doxycycline in three patients with BD are briefly described. Based on these findings, we hypothesize that BD patients acquired a rickettsial infection far before the onset of BD. Over years, the infected area expands to become a segment of the infected vessel. Subsequently, thrombus develops on the luminal surface of the infected endothelial cells, which produces the vascular obstructive manifestations of BD. Collectively, it is postulated that BD is a chronic infection with a member of the family Rickettsiaceae with superimposed thrombosis.

A case of Henoch-Schönlein purpura associated with scrub typhus

BACKGROUND

Henoch-Schönlein purpura (HSP) may be caused by several allergens. However, to date, HSP caused by Orientia tsutsugamushi has not been reported. Here, we report an unusual rash with features of HSP caused by Orientia tsutsugamushi.

CASE PRESENTATION

A man visited a tertiary hospital with bilateral symmetrical purpura and fever. He presented with an eschar in the left popliteal fossa and proteinuria. He was diagnosed with tsutsugamushi disease by indirect fluorescent antibody and positive polymerase chain reaction tests. Purpura biopsy demonstrated a feature of leukocytoclastic vasculitis and IgA deposition in dermal vessels, indicative of HSP.

CONCLUSIONS

When examining patients with unique rashes, such as in this case, we suggest investigating out-door activities and evidence of mite bites. Furthermore, differential diagnosis of tsutsugamushi disease should be considered when necessary.

Erythematous Patch in Tsutsugamushi Disease – An Atypical Form of Eschar

Tsutsugamushi disease is caused by the bacterium, Orientia tsutsugamushi and transmitted by chigger mites. In addition to the typical dark eschar, various forms of the eschar, including papules and vesicles, develop at chigger bite sites. Macular lesions were reported only in a human inoculation study; the inoculation lesions relapsed as erythematous macules or erythema-based papules concomitant with fever relapse. Herein, we report an erythematous patch as an inoculation lesion in two patients with tsutsugamushi disease, which, additionally, displayed a central small circle of 1 mm in diameter, possibly a chigger bite site, and desquamation around the circle during doxycycline therapy.