Neuropsychiatric Manifestations of Scrub Typhus

Opisthotonic posturing in Guillian-Barre syndrome

INTRODUCTION

Here we report a child of Gullian Barre syndrome (GBS) with opisthotonic posturing and we subsequently detected Scrub typhus in him.

CASE REPORT

An 11-year-old boy presented with progressive motor quadriparesis with transient bladder retention, bilateral facial weakness, diminished gag reflex, absent reflexes and his nerve conduction studies suggested Acute Motor Axonal Neuropathy (AMAN) GBS. His power gradually started recovering after one week. However, he had opisthotonus and signs of meningeal irritation. The child's CSF examination was consistent with GBS. His bacterial, fungal, tubercular microscopy and cultures and viral markers were negative. IgM for Borrelia and Leptospira and HIV ELISA were negative. IgM for scrub typhus, however, came out to be positive. Hence, we gave him azithromycin and he recovered almost completely in 3 months.

CONCLUSIONS

To our knowledge there is no previous report of opisthotonic posturing in GBS patients. This could be due to radicular involvement in immune mediated etiology of GBS.

The Spectrum of Neurological Manifestations in Scrub Typhus

BACKGROUND

Scrub typhus is a mite-borne zoonotic disease caused by Orientia tsutsugamushi and commonly presents with fever, rash, and eschar. Systemic complications develop later in the illness including, meningoencephalitis, pericardial effusion, myocarditis, and pneumonitis. In this article, we will be presenting different neurological manifestations of scrub typhus along with functional outcomes studied at a tertiary care center in New Delhi.

METHODS

This ambispective observational study was conducted at Army Hospital Research and Referral, New Delhi, during January 2018- January 2020. Febrile illness, serologically confirmed as scrub typhus and developing neurological complications were included. A predesigned clinical proforma was recorded for demographics, clinical features, neurological examination, supported with laboratory and/or radiology evaluation, and functional outcomes using the modified Rankin Scale (mRS).

RESULTS

In our cohort of 7 patients' majority were male (71%) with mean age at presentation being 42.5 years. Eschar was present in only 2 cases (28%) and a syndromic clinical diagnosis of meningoencephalitis was made in 3 (43%), acute flaccid quadriparesis in 2 (28%); and symptomatic seizure and parkinsonism in 1 patient each (14%). CSF showed lymphocytic pleocytosis with protein elevation in 57% cases. Systemic dysfunction was noted in the form of thrombocytopenia (57%), hyponatremia (42%), elevated transaminases (57%). Symptoms resolved with Doxycycline ± Rifampicin therapy in all cases, with good functional outcomes in majority of (89%) cases.

CONCLUSION

Neurological complications in scrub typhus have a wide spectrum involving meninges, encephalon, basal ganglia, cranial, and peripheral nerves. High index of suspicion with early serological testing (ELISA) is a must in undifferentiated fevers. Timely initiation of appropriate therapy leads to good clinical outcomes, in majority of cases with neurological involvement.

Microbes and Mental Illness: Past, Present, and Future

A review of the association between microbes and mental illness is performed, including the history, relevant definitions, infectious agents associated with mental illnesses, complex interactive infections, total load theory, pathophysiology, psychoimmunology, psychoneuroimmunology, clinical presentations, early-life infections, clinical assessment, and treatment. Perspectives on the etiology of mental illness have evolved from demonic possession toward multisystem biologically based models that include gene expression, environmental triggers, immune mediators, and infectious diseases. Microbes are associated with a number of mental disorders, including autism, schizophrenia, bipolar disorder, depressive disorders, and anxiety disorders, as well as suicidality and aggressive or violent behaviors. Specific microbes that have been associated or potentially associated with at least one of these conditions include Aspergillus, Babesia, Bartonella, Borna disease virus, Borrelia burgdorferi (Lyme disease), Candida, Chlamydia, coronaviruses (e.g., SARS-CoV-2), Cryptococcus neoformans, cytomegalovirus, enteroviruses, Epstein-Barr virus, hepatitis C, herpes simplex virus, human endogenous retroviruses, human immunodeficiency virus, human herpesvirus-6 (HHV-6), human T-cell lymphotropic virus type 1, influenza viruses, measles virus, Mycoplasma, Plasmodium, rubella virus, Group A Streptococcus (PANDAS), Taenia solium, Toxoplasma gondii, Treponema pallidum (syphilis), Trypanosoma, and West Nile virus. Recognition of the microbe and mental illness association with the development of greater interdisciplinary research, education, and treatment options may prevent and reduce mental illness morbidity, disability, and mortality.

Retrospective analysis of clinico-laboratory parameters, outcome and predictors of scrub typhus co- infection in covid-19 affected children

The objective of this study was to describe clinico-laboratory parameters, outcome and predictors of scrub typhus co- infection in COVID-19 affected children. Ours was a retrospective analysis done in a tertiary care pediatric COVID facility. COVID-19 positive children in the age group of 1 month to 12 years who were tested for scrub typhus co-infection between May to August 2020 were included in the study. In all positive cases, clinical, laboratory, treatment and outcome data were analyzed. Relevant data were compared between scrub typhus confirmed, and suspected but negative patients. All six patients with co-infection had fever for >5 days and four had features of cerebral involvement. These had lymphocytic pleocytosis in cerebrospinal fluid (CSF) analysis and two had eschar. Screening for scrub typhus in persistently febrile children residing in highly endemic areas is highly recommended.

A Case Series of Scrub Meningoencephalitis from a Tertiary Care Center in North India

Scrub typhus infection is reemerging leading cause of acute febrile illnesses in post-rainy or monsoon season in Southeast Asia. It is caused by Orientia tsutsugamushi and spread by the bite of chiggers, larval forms of trombiculid mites. The clinical picture can range from simple acute febrile illness to multiorgan dysfunction. Neurological manifestations also vary from aseptic meningitis, meningoencephalitis, cerebral infarction, acute disseminated encephalomyelitis, transverse myelitis, and psychiatric manifestations. Here, we present a case series of eight cases of scrub meningoencephalitis diagnosed based on clinical, laboratory, and radiological criteria.

A case of acute encephalitis syndrome and cranial nerve palsy secondary to scrub typhus: A rare presentation from Western Nepal

Key Clinical Message

This case report highlights the importance of considering scrub typhus as a differential diagnosis for acute encephalitis with cranial nerve palsy in the region of the tsutsugamushi triangle.

Abstract

Scrub typhus is a zoonotic rickettsiosis caused by the bacterium Orientia tsutsugamushi. This disease is endemic to a region called the tsutsugamushi triangle that extends from Southeast Asia to the Pacific Ocean. We report a 17-year-old girl from western Nepal who presented with fever, headache, vomiting, and altered sensorium, as well as bilateral lateral rectus palsy, dysphagia, regurgitation of food, dysarthria, and left-sided upper motor neuron type facial palsy. Following laboratory and imaging tests, the patient was diagnosed with scrub typhus and was treated successfully with high-dose dexamethasone and doxycycline. This case highlights the importance of considering scrub typhus in the differential diagnosis of encephalitis with cranial nerve palsy, especially in the region of the tsutsugamushi triangle. It also emphasizes the need for timely diagnosis and treatment of scrub typhus to prevent the development of various complications and ensure earlier recovery of patients.

A Study of the Profile of Scrub Typhus in a Tertiary Care Hospital in Jharkhand: An Underestimated Problem

Background and objective

Scrub typhus (ST) is a rickettsial infection caused by Orientia tsutsugamushi, which is transmitted by the bite of the larval stage (chiggers) of trombiculid mites. Although it presents as an acute undifferentiated febrile illness (AUFI), its course can be complicated with acute respiratory distress syndrome, acute kidney injury (AKI), myocarditis, meningoencephalitis, hepatitis, multi-organ dysfunction syndrome (MODS), and ultimately death. This study aimed to evaluate the epidemiological features, clinical profile, laboratory features, and clinical outcomes of cases of scrub typhus and identify the predictors of disease severity.

Methods and materials

This study is a retrospective observational study that included confirmed cases of scrub typhus admitted in the medical wards and critical care unit (CCU) of Tata Main Hospital (TMH) from January 1, 2019, to December 31, 2021. The case records of patients were analyzed for demographic characteristics, clinical features, treatment, and outcomes, which included length of stay (LOS), complications, and mortality. The required odds ratio (OR) was calculated, univariate and binary regression analyses were done, and a p-value of <0.05 was considered statistically significant.

Results

Of the 42 confirmed cases, 38.1% were males and 61.9% were females. The average age of male patients was 12.6 ± 11.2 years, while that of females was 22 ± 19.3 years. Of the patients, 64.3% were in the age group of 1-20 years. The clinical manifestations in descending order were fever (71.2%), skin rash (19.1%), cough (16.7%), vomiting (28.6%), altered sensorium (23.8%), abdominal pain (23.8%), loose stools (14.3%), seizures (14.3%), anasarca (9.7%), breathlessness (9.7%), and melena (7.1%). Eschar was noted in 38.1% of patients. Swelling of the body (6.7%) and lymphadenopathy (10%) were seen exclusively in children. The common laboratory abnormalities observed were leukocytosis in 34.3% of cases; thrombocytopenia in 68.8% of cases, of which 25% of patients had platelets < 50,000/mm³; and transaminitis in 87.5% of cases. The ratio of AST/ALT of more than one was seen in 89.3% of patients, while it was less than one in 10.7% of patients. The average C-reactive protein (CRP) level was 10.9 ± 6.3 mg/dL. The complications noted were acute respiratory distress syndrome (ARDS) (16.7%), meningoencephalitis (21.4%), septic shock (14.3%), capillary leak syndrome (26.2%), thrombocytopenia (68.8%), transaminitis (87.5%), myocarditis (4.8%), disseminated intravascular coagulation (2.4%), and hypocalcemia (11.9%). The average length of stay (LOS) was 8.1 ± 4.2 days. Twenty-four (57.2%) patients required transfer to the critical care unit (CCU) for managing various complications. There was no mortality in this series, giving rise to the case fatality ratio (CFR) of 0.

Conclusion

Scrub typhus is a reemerging cause of acute febrile illness. The highest number of cases were found during the post-monsoon period and in those with rural backgrounds. It presents with varying clinical manifestations with or without eschar. Hence, a high degree of suspicion along with a thorough clinical examination is needed to diagnose this condition. The disease responds dramatically to doxycycline. One must be aware of its complications and atypical presentations, as a timely diagnosis can reduce the morbidity and mortality associated with this disease.

Scrub Typhus Meningoencephalitis: Review of Literature and Unique Diagnostic & Management Challenges in Resource-Limited Settings

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.

Neurological Manifestations of Scrub Typhus

PURPOSE OF REVIEW

The occurrence of cases of scrub typhus is on the rise in South Asian and Southeast Asian countries. The present review discusses neurological complications following scrub typhus to appraise clinicians practicing in endemic regions about considering this treatable disease in the differential diagnosis of acute febrile illnesses, especially when accompanied with clinical neurological features.

RECENT FINDINGS

While the association of aseptic meningitis, encephalitis, and meningoencephalitis with scrub typhus is well known, more recently described neurological syndromes associated with scrub typhus include acute disseminated encephalomyelitis, various cranial nerve palsies, cerebellitis, cerebrovascular diseases including cerebral venous sinus thrombosis, transverse myelitis, longitudinally extensive transverse myelitis, Guillain-Barré syndrome, opsoclonus-myoclonus syndrome, parkinsonism, and many more. Early diagnosis is key to successful treatment. While diagnostic confirmation is generally made by the detection of IgM antibody by either ELISA or indirect fluorescent antibody tests, conventional PCR using 56 kDa gene (cPCR) and loop-mediated isothermal amplification assay (LAMP assay), as well as a newly introduced metagenomic next-generation sequencing (mNGS), are currently available for detection of Orientia tsutsugamushi infection in clinically suspected cases. Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. The cutaneous hallmark of the disease is the "eschar." Scrub typhus results in multisystem involvement. Neurological compromise is present in about 20% of scrub typhus patients and affects both the central nervous system and the peripheral nervous system. The postulated underlying mechanisms include direct invasion of the organism, a vasculitis-like process, or an immune-mediated injury. Diagnosis of scrub typhus is confirmed by detection of O. tsutsugamushi IgM antibody in serum. Awareness among clinicians regarding the varied presentations of this disease is very important in order to reduce morbidity and mortality. Co-infection with dengue and/or chickungunya viruses may occur in endemic regions. The history of an acute febrile illness preceding the neurological illness is crucial. A very careful search for the eschar is essential; however, the absence of the skin lesion cannot exclude the diagnosis of scrub typhus. Neurological manifestations mostly respond to doxycycline therapy.

Mild Encephalitis/Encephalopathy with Reversible Splenial Lesion Associated with Scrub Typhus in a Child: A Case Report

Background: Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a rare clinicoradiological syndrome characterized by transient mild encephalopathy and magnetic resonance imaging (MRI) findings of a reversible lesion in the splenium of the corpus callosum (SCC). Multiple causes have been proposed for the pathogenesis of MERS, with infection as the most pre-eminent. Case Presentation: We report the case of a 10-year-old girl with MERS due to scrub typhus. Her clinical manifestations of headache and drowsiness, together with lesions involving the SCC, as shown by MRI, and their complete resolution upon follow-up fulfilled the diagnosis of MERS. At the same time, the characteristic eschar of the skin and the positive Weil-Felix test result confirmed the existence of scrub typhus infection. Conclusions: To the best of our knowledge, we described the first pediatric case of MERS associated with scrub typhus. The case indicated that an MERS patient with fever should be considered as possibly having a scrub typhus infection. The characteristic black eschar of scrub typhus generally occurs after bite of mite that is important and useful to the doctor for making proper diagnosis.

Scrub Typhus Masquerading as Limbic Encephalitis

Scrub typhus, an acute febrile infectious disease prevalent in the 'tsutsugamushi triangle', is a mite-born rickettsial zoonosis, caused by Orientia tsutsugamushi. The clinical presentation is protean and involves multiple organ systems of the body, including central and peripheral nervous systems. We report a 22-year-old previously healthy Indian woman who presented with clinical (confusion, excessive sleepiness, cognitive dysfunction and focal seizures) and neuroimaging features of limbic encephalitis. After exclusion of common infectious, autoimmune and paraneoplastic causes, she was diagnosed with scrub typhus associated encephalitis, which responded to doxycycline and azithromycin therapy.

The Early Diagnosis of Scrub Typhus by Metagenomic Next-Generation Sequencing

Introduction: Scrub typhus is a mite-borne infection widespread in Southeast Asia, with clinical symptoms such as fever, chills, skin rash, eschar at the bite site, and other signs of acute febrile illness. The Rickettsia pathogen (Orientia tsutsugamushi) is always difficult to be diagnosed at an early stage by traditional clinical diagnostic methods, especially for patients without typical eschar. This greatly increases the mortality of patients with scrub typhus. A new approach should be introduced to improve its clinical diagnosis.

Methods: During May 2018 to March 2021, 13 samples from 10 patients with suspected scrub typhus were collected. Metagenomic next-generation sequencing (mNGS) and other diagnostic methods (including serology using Weil–Felix reaction and indirect immunofluorescence test (IIFT) for scrub typhus and respiratory tract profile IgM as well as culture for routine bacteria) were used to identify the pathogens in this study.

Results: The results of mNGS were all positive, with mapped reads of O. tsutsugamushi ranging from 1 to 460. Eight patients (80%) were diagnosed as scrub typhus. The other two were diagnosed as suspected scrub typhus due to the limited number of reads of the pathogen (one and two, respectively). According to clinical evidences, nine of the 10 patients were finally diagnosed as scrub typhus, except for patient 9 (suspected scrub typhus by mNGS with one specific reads of the pathogen) diagnosed as acute exacerbation of chronic obstructive pulmonary disease. For the five scrub typhus patients without typical eschar, mNGS gave all positive results (4–460 specific reads). For other methods, only Weil–Felix reaction of one patient detected the pathogen. In addition, the respiratory tract profile (IgM) detected various pathogens, but all were confirmed to be false positive.

Conclusions: mNGS performed better than conventional clinical methods to early diagnose scrub typhus. This approach can be routinely carried out for early and precise diagnosis in clinical infections, especially for those hard to be identified by traditional diagnostic methods.

Scrub typhus: a reemerging infection

PURPOSE OF REVIEW

Scrub typhus, caused by Orientia tsutsugamushi, is a widely neglected disease which is gaining global momentum because of its resurgence patterns. The disease is now being reported in newer regions as well as areas previously endemic areas. In this review, we aim to comprehensively review the data available to assist physicians in making an accurate diagnosis and appropriate management of the disease.

RECENT FINDINGS

Several diagnostic tests have been developed for confirming scrub typhus. However, there is lack of clarity on which tests are most appropriate in a given clinical scenario. A recent study has demonstrated that in early disease (<7 days) when serological tests remain negative, the quantitative polymerase chain reaction is the most sensitive test. Among the serological tests, both IgM enzyme-linked immunosorbent assay as well as rapid diagnostic tests revealed excellent sensitivities and specificities.

SUMMARY

With the reemergence of scrub typhus, a high degree of clinical suspicion is required to appropriately diagnose this disease which presents as an acute febrile illness. It can progress to develop various complications leading to multi-organ dysfunction syndrome. Mild illness responds well to antibiotic treatment with doxycycline and azithromycin. Further studies are required to determine the most optimal therapy in severe scrub typhus infections and superiority of one drug over the other.

Association between scrub typhus encephalitis and diffusion tensor tractography detection of Papez circuit injury: A case report

BACKGROUND

It is difficult to restore the cognitive functions of patients with impaired cognition caused by brain injury. Diffusion tensor imaging can visualize the integrity of neural tracts in the white matter (WM) three-dimensionally. It is unclear whether encephalitis following scrub typhus damages the WM. For the first time, we aimed to report diffusion tensor tractography (DTT) findings in a chronic patient with cognitive impairment following scrub typhus encephalitis, which revealed injury to the Papez circuit of the WM.

CASE SUMMARY

A 70-year-old male patient was affected by encephalitis caused by scrub typhus that occurred 23 years ago. He had poor cognition and his clinical examination findings were as follows: Mini-Mental Status Examination score, 14; and handgrip strength (right/left, kg), 32.3/31.3. DTT revealed serious injuries of the left thalamocingulate tract and right mammillothalamic tract in the Papez circuit, and a partial injury of the anterior part of the fornix.

CONCLUSION

Using DTT, we found a relationship between cognitive impairment and the integrity of the Papez circuit following scrub typhus.

Scrub typhus with cerebral venous sinus thrombosis: a rare presentation

This is a rare presentation of scrub typhus with cerebral venous thrombosis. A 32-year-old woman presented with signs of raised intracranial tension. Examination revealed maculopapular skin rashes and an 'eschar' over the right thigh. Nuchal rigidity and bilateral papilloedema were found. Scrub typhus was diagnosed by the presence of IgM antibody in serum. CT scan of the brain showed cerebral oedema. MRI of the brain was normal. Magnetic resonance venography of the brain showed thrombosis of several venous sinuses. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis with raised protein level. Other causes of prothrombotic states were ruled out by doing specific test results. There was no history of hormonal contraception and prolonged bed rest. A case of scrub typhus complicated with meningoencephalitis and cerebral venous thrombosis was diagnosed. She responded to treatment with doxycycline, anticoagulants, antipyrectics and intravenous saline. Early identification of such atypical neurological involvement in scrub typhus was helpful in satisfactory outcome.

Acute cerebellar ataxia and peripheral neuropathy due to an atypical infection

This 18-year-old boy presented to the hospital with symptoms of cerebellar dysfunction preceded by an acute febrile illness with rash. Examination showed evidence of left-sided cerebellar dysfunction and polyneuropathy. Empirical treatment for leptospirosis and scrub typhus was initiated. MRI was normal. Other organ dysfunctions in the form of thrombocytopenia and transaminitis were also observed. He recovered without sequelae. A diagnosis of acute cerebellar ataxia and polyneuropathy due to scrub typhus was made.

Scrub typhus-related hepatotoxicity: The Indian scenario

In Scrunb Typhus, hepatotoxicity is an important, yet understudied, manifestation. We reviewed studies on scrub typhus, published in the last five years (2014-2019), which evaluated its clinico-epidemiological factors in India, and concentrated on its hepatic involvement. Nine studies were found, and no Indian study exclusively evaluated hepatic dysfunction. Thus, comments from a few international studies were also included. We conclude that liver dysfunction in the form of elevated serum transaminase levels is a common manifestation of scrub typhus, which may herald progress to fulminant hepatic failure.

Posterior reversible encephalopathy syndrome in scrub typhus fever

The clinical course of a 40-year-old female patient, who presented with acute febrile illness due to scrub typhus fever became complicated by seizures and posterior reversible encephalopathy syndrome (PRES), leading to a fatal outcome. She had normal blood pressure at admission; however, she later developed hypotension and shock. PRES is a syndrome of vasogenic cerebral oedema and accompanying neurological deficits resulting from the breakdown of blood-brain barrier due to high blood pressure or radical blood pressure changes. PRES is a clinico-radiographic diagnosis of heterogeneous aetiologies and is rare in the context of infections. Although there are many neurological manifestations in scrub typhus, to the best of our knowledge, PRES has never been reported.

[Infection associated cerebral vasculitis]

Infections are a frequent cause of cerebral vasculitis, important to diagnose because a specific treatment may be required. Infection-associated vasculitis can be caused by angiotropic pathogens (varicella zoster virus, syphilis, aspergillus). They can be associated with subarachnoidal meningitis (tuberculosis, pyogenic meningitis, cysticercosis). They can appear contiguously to sinuses or orbital infection (aspergillosis, mucormycosis). Finally, they also may be due to an immune mechanism in the context of chronic infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Cerebral vasculitis are severe conditions and their prognosis is directly linked to early recognition and diagnosis. Infectious causes must therefore be systematically considered ahead of cerebral vasculitis, and the appropriate investigations must be determined according to the patient's clinical context. We propose here an update on the infectious causes of cerebral vasculitis, their diagnosis modalities, and therapeutic options.

Chronic encephalopathy and locked-in state due to scrub typhus related CNS vasculitis

BACKGROUND

Scrub Typhus, prevalent in Asia-Pacific region, often has neurological manifestations in the setting of acute febrile illness, as acute encephalitis syndrome.

CASE REPORT

A 20-year-old female, from western Rajasthan, India presented with calf pain followed by nausea, vomiting, dizziness, and sequentially progressive weakness of limbs, anarthria and loss of bladder control over 10 days. MRI Brain showed T2-weighted and FLAIR hyperintense lesions in corpus callosum, subcortical and periventricular white matter, basal ganglia, thalamus, brainstem and cerebellum producing starry sky appearance with diffusion restriction. Serum IgM for Scrub typhus was positive and patient progressively improved over 3 weeks with doxycycline.

CONCLUSIONS

This report highlights an unusual presentation of scrub typhus with subacute onset and static course, quadriparesis and locked-in state for 2 months, suspected based on red flags on neuroimaging and reversal of deficits with appropriate treatment.

Scrub typhus manifesting with intracerebral hemorrhage: Case report and review of literature

Scrub typhus (ST), hitherto absent from many parts of India, is now recently being recognized as a significant cause of morbidity and mortality throughout the country. Its diverse clinical presentations, low of the index of suspicion by the treating physician, and lack of diagnostic testing in many parts of the country result in delayed treatment, leading to a host of complications. We here report such a complication, where ST manifested with a large intracerebral hemorrhage, of which, to the best of our knowledge, only nine cases have been reported in the English language worldwide. Family physicians, who are the often first point of contact for treatment of febrile illness, as ST typically manifests, need to be aware of this entity to prevent such catastrophic consequences.

A rare etiology behind isolated lateral rectus palsy: Scrub typhus

Scrub typhus (ST), a zoonotic disease, is currently being recognized as a significant contributor to the changing landscape of infectious diseases in India. As one of the important causes of febrile illness, in many parts of the country, general practitioners need to include it as part of the workup for cases of fever of unknown origin. While very amenable to early treatment with a simple regime of doxycycline, delayed diagnosis can result in a spectrum of complications. We report here one such complication of a case of ST manifesting with isolated lateral rectus palsy, which, to the best of our knowledge, has been reported only thrice in the world previously. Family physicians also need to be aware of the availability in India of affordable serological testing for ST that is useful for rapid and inexpensive diagnosis, leading to timely treatment.

Acute Parkinsonism and Cerebral Salt-wasting-related Hyponatremia in Scrub Typhus

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.

Long-Segment Myelitis, Meningoencephalitis, and Axonal Polyneuropathy in a Case of Scrub Typhus

Scrub typhus, a mite-borne zoonotic disease, is endemic in several parts of India. It may cause multisystemic disease involving lungs, heart, spleen, liver, hematological system, and nervous system. Neurological involvement may include meningoencephalitis, cerebellitis, cranial nerve palsies, plexopathy, transverse myelitis, muscle dysfunction, neuroleptic malignant syndrome, parkinsonian syndrome, and Guillain–Barre syndrome. Here, we report a rare patient of scrub typhus, who developed meningoencephalitis followed by long-segment myelitis and axonal polyneuropathy, with hepatic, renal, hematological, and pulmonary involvement, following acute febrile illness with associated neurocysticercosis. He gained consciousness with a resolution of almost all of his complaints, with the exception of muscular power, which showed partial improvement following treatment with doxycycline, azithromycin, and steroids. What needs to be explored is whether the existence of neurological scrub typhus with neurocysticercosis is the coincidental price paid for living in the tropics or there is something more to it as in case of Japanese encephalitis and neurocysticercosis co-infection.

Clinical Profile of Scrub Typhus Meningoencephalitis among South Indian Children

Re-emerging scrub typhus is gaining recognition as an important cause of paediatric meningoencephalitis in tropics. We studied the clinical profile of scrub typhus meningoencephalitis (STME) in children <12 years. Of 270 serology-confirmed cases of scrub typhus, 14 (5%) had features consistent with STME and 9 (64%) of these children were between 5 and 12 years of age; 12 (85%) children presented to the hospital during the second week of illness. Fever, headache and altered sensorium were observed in all children, while meningeal signs, papilledema and seizures were observed in 8 (57%), 7 (50%) and 6 (43%) children, respectively. The mean CSF protein level, glucose level, cell count and percentage of lymphocytes were 75 mg/dl, 46 mg/dl, 41 cells and 86%, respectively. STME should be considered in febrile children from endemic area with neurological features, such as headache or altered sensorium. Lumbar puncture is mandatory to confirm STME and rule out close differential diagnosis, such as pyogenic and tubercular meningitis.

Anti-aquaporin-4 Antibody Positive Optic Neuritis Following Scrub Typhus in an Elderly Female

INTRODUCTION

Aquaporin-4 antibody (AQP4-Ab) is specific for neuromyelitis optica spectrum disorder (NMOSD) and so is helpful to distinguish NMOSD from other autoimmune diseases. Several viral infections may play a role in the onset of NMOSD.

CASE REPORT

We describe a case of a previous healthy 82-year-old woman who presented with acute visual loss occurring 3 weeks after scrub typhus. Physical examination showed a relatively afferent pupillary defect in the right eye and ophthalmoscopy revealed edema of the right optic disc. Enhanced magnetic resonance imaging revealed enhancement of the right optic nerve. Serological testing showed AQP4-Ab. After methylprednisolone pulse therapy followed by oral tapering of prednisolone, visual dysfunction was improved. Subsequently she experienced no attacks for 5 years.

CONCLUSIONS

Optic neuritis (ON) associated with scrub typhus is extremely rare. Our case support that scrub typhus could trigger ON in a lifelong asymptomatic patient with AQP4-Ab and AQP4-Ab should be considered in a very old age patient with suspected postinfectious inflammatory ON.

Hemophagocytic lymphohistiocytosis with neurological manifestations in an infant with scrub typhus: a rare fatal occurrence

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of unchecked activation of the immune system leading to phagocytosis of blood cells and proliferation of histiocytes in solid organs. HLH can be primary or secondary to infective, autoimmune and malignant conditions. Scrub typhus is an infective illness caused by Orientia tsutsugamushi, transmitted by mite. The illness ranges from mild fever with rash to severe multisystem illness. Scrub typhus has rarely been associated with secondary HLH. We report an infant with scrub typhus who progressed to develop HLH with central nervous system involvement with fatal outcome.