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Narayanasamy DK, Arun Babu T, Fredrick J, Kittu D. Clinical profile and outcomes of pediatric scrub typhus associated with elevated hepatic transaminases. Indian J Gastroenterol 2023; 42:347-354. [PMID: 37213043 DOI: 10.1007/s12664-023-01350-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 02/02/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Hepatic transaminase (HT) elevation is frequently seen in children with scrub typhus (ST), but the clinical implication of this common finding is not known. OBJECTIVE To describe the clinical profile and outcome of pediatric ST with elevated hepatic transaminase. METHODS In this prospective cohort study, all children < 12 years of age presenting with fever for ≥ 5 days and positive immunoglobulin M (IgM) serology for ST were included. Clinical findings, laboratory features and outcomes of children with elevated HT were compared with those who had normal HT. RESULTS Of 560 ST positive children included, 257 (45.8%) had associated HT elevation. The common age group affected was 5 to 12 years of age (54.9%). Most of the children came during the second week of fever (68.5%) with mean duration of fever of 9.1 days. The common initial presenting symptoms were cough (77.8%), vomiting (65%) and myalgia (59.1%) and signs were hepatomegaly (64.2%), splenomegaly (57.6%) and generalized lymphadenopathy (54.1%). Eschar was seen in 49.8% of children. Thrombocytopenia (58%) and anemia (49%) were the frequently seen laboratory abnormalities. Severe forms of ST were seen in 45.5% children, of which pneumonia was most common. The fever clearance time (48 ± 19.2 h) and mean duration of hospital stay (6.7 ± 3.3 days) were prolonged in these children. On logistic regression analysis, generalized lymphadenopathy (p = 0.002), ascites (p = 0.037), thrombocytopenia (p < 0.001) and hypoalbuminemia (p = 0.023) were found to be associated with HT elevation in these children. CONCLUSIONS Hepatic transaminase (HT) levels increase with the duration of untreated fever and is found to be associated with severe forms of scrub typhus. Children with elevated HT have delay in fever defervescence and their duration of hospital stay was prolonged.
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Affiliation(s)
- Dinesh Kumar Narayanasamy
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Karaikal, 605 006, India
| | | | - Jean Fredrick
- Mahatma Gandhi Medical College and Research Institute, Puducherry, 607 402, India
| | - Devi Kittu
- Indira Gandhi Medical College and Research Institute, Puducherry, 605 009, India
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Abstract
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.
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Seroprevalence and Clinical Features of Scrub Typhus among Febrile Patients Attending a Referral Hospital in Kathmandu, Nepal. Trop Med Infect Dis 2021; 6:tropicalmed6020078. [PMID: 34068402 PMCID: PMC8163188 DOI: 10.3390/tropicalmed6020078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 01/10/2023] Open
Abstract
(1) Background: Scrub typhus (ST) is endemic to Nepal. It is often underdiagnosed and misdiagnosed due to non-specific clinical presentation coupled with limited microbiological facilities, leading to adverse clinical outcomes. This study aimed to assess the seroprevalence of scrub typhus in febrile patients attending Sukraraj Tropical and Infectious Disease Hospital (STIDH), Nepal, from August 2018 to April 2019. (2) Materials and Method: Blood/serum samples and clinical and demographic data of adult febrile patients (≥19 years) who attended or were referred to the hospital were collected after obtaining written informed consent from the participants excluding immunocompromised individuals. Collected blood/serum samples were subjected to hematological, biochemical, and serological tests. A serological test for scrub typhus was performed using the ImmuneMed scrub typhus rapid diagnostic test kit. Data generated were analyzed using SPSS software version 24.0. (3) Results: Amongst the 2070 febrile patients, 462 (22.3%) were seropositive to at least one etiological agent of febrile illnesses (scrub typhus: 253 cases, dengue: 101 cases, leptospirosis: 9, brucellosis: 52, malaria: 9 and kala-azar: 20 cases). Scrub typhus accounted for 12.2% (n = 253) of total febrile illnesses followed by dengue (4.9%, n = 101). Mixed seropositivity of scrub typhus with dengue, brucellosis, and typhoid was found in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. Among 253 scrub typhus patients, 53.4% were female. Among the 154 patients, the most common symptoms were fever (100%), headache (79.2%), sweating (70.1%), breathing difficulty (51.3%), redness of the eye (43.5%), and pathognomonic eschar was observed in 9.1% patients. Fifty percent of scrub typhus patients had low platelet count and >30% of patients had an elevated level of liver enzymes (such as serum glutamic oxaloacetic transaminase (SGPT) and serum glutamic pyruvic transaminase (SGOT). (4) Conclusion: Scrub typhus is a considerable cause of febrile illness in Nepal. Females apparently have a higher chance of acquiring scrub typhus. ST presents nonspecific clinical presentation. The diagnostic dilemma of typhus patients can be minimized by the early monitoring of ST-associated symptoms. The country's health system needs to be strengthened for early outbreak detection, and immediate response actions against scrub typhus to control the future outbreak of ST.
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Trung NV, Hoi LT, Dien VM, Huong DT, Hoa TM, Lien VN, Van Luan P, Lewycka SO, Choisy M, Bryant JE, Nadjm B, Rogier van Doorn H, Richards AL, Van Kinh N. Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015-2017. Emerg Infect Dis 2019; 25. [PMID: 30882318 PMCID: PMC6433017 DOI: 10.3201/eid2504.180691] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Scrub typhus was the predominant rickettsial disease diagnosed among hospitalized patients with acute undifferentiated fever in northern Vietnam. Rickettsioses are endemic to Vietnam; however, only a limited number of clinical studies have been performed on these vectorborne bacteria. We conducted a prospective hospital-based study at 2 national referral hospitals in Hanoi to describe the clinical characteristics of scrub typhus and murine typhus in northern Vietnam and to assess the diagnostic applicability of quantitative real-time PCR assays to diagnose rickettsial diseases. We enrolled 302 patients with acute undifferentiated fever and clinically suspected rickettsiosis during March 2015–March 2017. We used a standardized case report form to collect clinical information and laboratory results at the time of admission and during treatment. We confirmed scrub typhus in 103 (34.1%) patients and murine typhus in 12 (3.3%) patients. These results highlight the need for increased emphasis on training for healthcare providers for earlier recognition, prevention, and treatment of rickettsial diseases in Vietnam.
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Rajapakse S, Weeratunga P, Sivayoganathan S, Fernando SD. Clinical manifestations of scrub typhus. Trans R Soc Trop Med Hyg 2018; 111:43-54. [PMID: 28449088 DOI: 10.1093/trstmh/trx017] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/11/2017] [Indexed: 01/10/2023] Open
Abstract
The mite-borne rickettsial zoonosis scrub typhus is widely prevalent in parts of Southeast and Far East Asia, and northern Australia. The disease is an acute febrile illness, associated with rash and often an eschar, which responds dramatically to treatment with antibiotics. In some cases it results in a serious illness leading to multiple organ involvement and death. The disease manifestations are thought to result from a systemic vasculitis, caused by both direct effects of the organisms as well as an exaggerated immune response, although little is understood about its pathogenesis. A wide spectrum of clinical manifestations, affecting nearly every organ system, have been described with scrub typhus. Some of these manifestations are serious and life threatening. In this systematic review, we summarise the typical and atypical manifestations of scrub typhus reported in the literature. Awareness of these unusual manifestations will hopefully guide clinicians towards diagnosing the condition early, and initiating early appropriate antibiotics and other supportive measures.
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Affiliation(s)
- Senaka Rajapakse
- Tropical Medicine Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Praveen Weeratunga
- University Medical Unit, National Hospital, Regent Street, Colombo 08, Sri Lanka
| | - Sriharan Sivayoganathan
- Tropical Medicine Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
| | - Sumadhya Deepika Fernando
- Department of Parasitology, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 08, Sri Lanka
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Jang MS, Park JB, Lee KH, Jang JY, Yang MH, Kim JH, Hwangbo H, Lee TG, Suh KS. Histopathologic Finding of Perieschar Lesions in Tsutsugamushi Disease Shows Lymphocytic Vasculitis Mimicking Angiocentric Lymphoma. Ann Dermatol 2018; 30:29-35. [PMID: 29386829 PMCID: PMC5762473 DOI: 10.5021/ad.2018.30.1.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 01/10/2023] Open
Abstract
Background Tsutsugamushi disease is an acute, febrile, infectious disease caused by Orientia tsutsugamushi. Several studies investigating the histopathologic findings of eschars in tsutsugamushi disease reported leukocytoclastic vasculitis and neutrophil infiltration as the major findings. However, these findings may result from secondary changes following tissue necrosis. The histopathologic findings of perieschar lesions may be important to understand the primary changes associated with tsutsugamushi disease. Objective To investigate characteristic histopathologic features of perieschar lesions and suppose the mechanism of vascular pathophysiological changes associated with tsutsugamushi disease. Methods We analyzed histopathological slides of perieschar lesions in 12 patients diagnosed with tsutsugamushi disease. Results In the epidermis, exocytosis of mononuclear cells (75.0%) and basal vacuolar changes (66.7%) were frequent. In the dermis, perivascular, interstitial, and perineural mononuclear cell infiltration (100.0%, 83.3%, and 83.3%, respectively), as well as thrombosis (83.3%), atypical lymphocyte infiltration (91.7%), and mitotic figures (83.3%) were commonly seen. Lymphocytic vasculitis and mononuclear cell infiltration around eccrine glands were found in all cases, but eosinophil infiltration was only found in one patient (8.3%). However, the characteristic findings of eschar lesions, such as leukocytoclastic vasculitis and neutrophil infiltration, were not found in perieschar lesions. Conclusion The major histopathologic findings in the perieschar lesions of tsutsugamushi disease were lymphocytic vasculitis and atypical lymphocytic infiltration, mimicking lymphoma. Therefore, we suggest that this lesion should be added to the list of pseudolymphomas. To observe these characteristic histopathologic features, we also recommend that skin biopsies should be performed on perieschar lesions, not eschar lesions.
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Affiliation(s)
- Min Soo Jang
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Jong Bin Park
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Kang Hoon Lee
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Ji Yun Jang
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Myeong Hyeon Yang
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Joon Hee Kim
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Hyun Hwangbo
- Department of Dermatology, Maryknoll Medical Center, Busan, Korea
| | - Taek Geun Lee
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
| | - Kee Suck Suh
- Department of Dermatology, Kosin University College of Medicine, Busan, Korea
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Lee HJ, Park CY, Park SG, Yoon NR, Kim DM, Chung CH. Activation of the coagulation cascade in patients with scrub typhus. Diagn Microbiol Infect Dis 2017; 89:1-6. [PMID: 28679481 DOI: 10.1016/j.diagmicrobio.2017.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 06/10/2017] [Accepted: 06/12/2017] [Indexed: 01/10/2023]
Abstract
This retrospective study aimed to evaluate the levels of coagulation factors and presence of disseminated intravascular coagulation (DIC) in patients with scrub typhus. We included patients confirmed to have scrub typhus at the Chosun University Hospital between September 2004 and December 2009. The DIC scores were evaluated in 365 patients and 36 healthy controls. The median concentrations of fibrinogen, d-dimer, and fibrin/fibrinogen degradation products (FDP) were compared between patients and healthy controls (p<0.001 for all tests). Patients with scrub typhus had longer prothrombin time and lower platelet counts than the controls. Major bleeding was observed in 18/365 patients with scrub typhus. Fifty-one (14.0%) patients presented with severe complications of scrub typhus. Overt DIC and thrombocytopenia (<100,000 platelets/mm3) were observed more frequently in patients with bleeding and severe illness. Furthermore, median platelet counts were low in both groups. Approximately 2.7% (n=10) and 16.4% (n=60) patients with scrub typhus had overt DIC, as defined by the International Society on Thrombosis and Hemostasis DIC score (DIC1) and the DIC-scoring template with a fibrinogen/C-reactive protein-ratio (DIC2), respectively. Three (16.7%) and 10 (55.6%) patients with bleeding had overt DIC, as defined by the DIC1 and DIC2, respectively. Seven (13.7%) and 26 (51%) patients with severe illness had overt DIC, as defined by DIC1 and DIC2, respectively. In conclusion, activation of the coagulation system is an important feature of scrub typhus and is correlated with severe disease, including bleeding. This is the first study to report a relationship between DIC and scrub typhus.
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Affiliation(s)
- Hee-Jeong Lee
- Department of Internal Medicine, Chosun University Hospital, Gwangju 501-717, Republic of Korea
| | - Chi-Young Park
- Department of Internal Medicine, Chosun University Hospital, Gwangju 501-717, Republic of Korea
| | - Sang-Gon Park
- Department of Internal Medicine, Chosun University Hospital, Gwangju 501-717, Republic of Korea
| | - Na-Ra Yoon
- Department of Internal Medicine, Chosun University Hospital, Gwangju 501-717, Republic of Korea
| | - Dong-Min Kim
- Department of Internal Medicine, Chosun University Hospital, Gwangju 501-717, Republic of Korea
| | - Choon-Hae Chung
- Department of Internal Medicine, Chosun University Hospital, Gwangju 501-717, Republic of Korea
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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.
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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
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Scrub typhus: radiological and clinical findings in abdominopelvic involvement. Jpn J Radiol 2017; 35:101-108. [DOI: 10.1007/s11604-016-0607-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/20/2016] [Indexed: 01/10/2023]
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Su TH, Liu CJ, Shu PY, Fu YH, Chang CH, Jao P, Kao JH. Associated factors and clinical implications of serum aminotransferase elevation in scrub typhus. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 49:941-946. [DOI: 10.1016/j.jmii.2014.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 09/30/2014] [Accepted: 10/07/2014] [Indexed: 01/10/2023]
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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.
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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
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Kang SJ, Jin HM, Won EJ, Cho YN, Jung HJ, Kwon YS, Kee HJ, Ju JK, Kim JC, Kim UJ, Jang HC, Jung SI, Kee SJ, Park YW. Activation, Impaired Tumor Necrosis Factor-α Production, and Deficiency of Circulating Mucosal-Associated Invariant T Cells in Patients with Scrub Typhus. PLoS Negl Trop Dis 2016; 10:e0004832. [PMID: 27463223 PMCID: PMC4963088 DOI: 10.1371/journal.pntd.0004832] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/17/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Mucosal-associated invariant T (MAIT) cells contribute to protection against certain microorganism infections. However, little is known about the role of MAIT cells in Orientia tsutsugamushi infection. Hence, the aims of this study were to examine the level and function of MAIT cells in patients with scrub typhus and to evaluate the clinical relevance of MAIT cell levels. METHODOLOGY/PRINCIPAL FINDINGS Thirty-eight patients with scrub typhus and 53 health control subjects were enrolled in the study. The patients were further divided into subgroups according to disease severity. MAIT cell level and function in the peripheral blood were measured by flow cytometry. Circulating MAIT cell levels were found to be significantly reduced in scrub typhus patients. MAIT cell deficiency reflects a variety of clinical conditions. In particular, MAT cell levels reflect disease severity. MAIT cells in scrub typhus patients displayed impaired tumor necrosis factor (TNF)-α production, which was restored during the remission phase. In addition, the impaired production of TNF-α by MAIT cells was associated with elevated CD69 expression. CONCLUSIONS This study shows that circulating MAIT cells are activated, numerically deficient, and functionally impaired in TNF-α production in patients with scrub typhus. These abnormalities possibly contribute to immune system dysregulation in scrub typhus infection.
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Affiliation(s)
- Seung-Ji Kang
- Department of Infectious Diseases, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Hye-Mi Jin
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Eun Jeong Won
- Department of Laboratory Medicine, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Young-Nan Cho
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Hyun-Ju Jung
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Yong-Soo Kwon
- Department of Pulmonary and Critical Care Medicine, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Hae Jin Kee
- Heart Research Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Jung-Chul Kim
- Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Uh Jin Kim
- Department of Infectious Diseases, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Hee-Chang Jang
- Department of Infectious Diseases, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Sook-In Jung
- Department of Infectious Diseases, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Seung-Jung Kee
- Department of Laboratory Medicine, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Yong-Wook Park
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
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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.
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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:
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Griffith M, Peter JV, Karthik G, Ramakrishna K, Prakash JAJ, Kalki RC, Varghese GM, Chrispal A, Pichamuthu K, Iyyadurai R, Abraham OC. Profile of organ dysfunction and predictors of mortality in severe scrub typhus infection requiring intensive care admission. Indian J Crit Care Med 2014; 18:497-502. [PMID: 25136187 PMCID: PMC4134622 DOI: 10.4103/0972-5229.138145] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background and Aims: Scrub typhus, a zoonotic rickettsial infection, is an important reason for intensive care unit (ICU) admission in the Indian subcontinent. We describe the clinical profile, organ dysfunction, and predictors of mortality of severe scrub typhus infection. Materials and Methods: Retrospective study of patients admitted with scrub typhus infection to a tertiary care university affiliated teaching hospital in India during a 21-month period. Results: The cohort (n = 116) aged 40.0 ± 15.2 years (mean ± SD), presented 8.5 ± 4.4 days after symptom onset. Common symptoms included fever (100%), breathlessness (68.5%), and altered mental status (25.5%). Forty-seven (41.6%) patients had an eschar. Admission APACHE-II score was 19.6 ± 8.2. Ninety-one (85.2%) patients had dysfunction of 3 or more organ systems. Respiratory (96.6%) and hematological (86.2%) dysfunction were frequent. Mechanical ventilation was required in 102 (87.9%) patients, of whom 14 (12.1%) were solely managed with non-invasive ventilation. Thirteen patients (11.2%) required dialysis. Duration of hospital stay was 10.7 ± 9.7 days. Actual hospital mortality (24.1%) was less than predicted APACHE-II mortality (36%; 95% Confidence interval 32-41). APACHE-II score and duration of fever were independently associated with mortality on logistic regression analysis. Conclusions: In this cohort of severe scrub typhus infection with multi-organ dysfunction, survival was good despite high severity of illness scores. APACHE-II score and duration of fever independently predicted mortality.
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Affiliation(s)
- Mathew Griffith
- Department of Internal Medicine, University of Colorado, Colorada, USA
| | - John Victor Peter
- Department of Critical Care, Associate Professor, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Gunasekaran Karthik
- Department of Critical Care, Registrar, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Kartik Ramakrishna
- Department of Critical Care, Registrar, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | - Rajamanickam C Kalki
- Department of Critical Care, Registrar, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - George M Varghese
- Department of Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Anugragh Chrispal
- Department of Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Critical Care, Associate Professor, Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Ramya Iyyadurai
- Department of Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
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Keller CA, Hauptmann M, Kolbaum J, Gharaibeh M, Neumann M, Glatzel M, Fleischer B. Dissemination of Orientia tsutsugamushi and inflammatory responses in a murine model of scrub typhus. PLoS Negl Trop Dis 2014; 8:e3064. [PMID: 25122501 PMCID: PMC4133189 DOI: 10.1371/journal.pntd.0003064] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 06/20/2014] [Indexed: 01/10/2023] Open
Abstract
Central aspects in the pathogenesis of scrub typhus, an infection caused by Orientia (O.) tsutsugamushi, have remained obscure. Its organ and cellular tropism are poorly understood. The purpose of this study was to analyze the kinetics of bacterial dissemination and associated inflammatory responses in infected tissues in an experimental scrub typhus mouse model, following infection with the human pathogenic strain Karp. We provide a thorough analysis of O. tsutsugamushi infection in inbred Balb/c mice using footpad inoculation, which is close to the natural way of infection. By a novel, highly sensitive qPCR targeting the multi copy traD genes, we quantitatively monitored the spread of O. tsutsugamushi Karp from the skin inoculation site via the regional lymph node to the internal target organs. The highest bacterial loads were measured in the lung. Using confocal imaging, we also detected O. tsutsugamushi at the single cell level in the lung and found a predominant macrophage rather than endothelial localization. Immunohistochemical analysis of infiltrates in lung and brain revealed differently composed lesions with specific localizations: iNOS-expressing macrophages were frequent in infiltrative parenchymal noduli, but uncommon in perivascular lesions within these organs. Quantitative analysis of the macrophage response by immunohistochemistry in liver, heart, lung and brain demonstrated an early onset of macrophage activation in the liver. Serum levels of interferon (IFN)-γ were increased during the acute infection, and we showed that IFN-γ contributed to iNOS-dependent bacterial growth control. Our data show that upon inoculation to the skin, O. tsutsugamushi spreads systemically to a large number of organs and gives rise to organ-specific inflammation patterns. The findings suggest an essential role for the lung in the pathogenesis of scrub typhus. The model will allow detailed studies on host-pathogen interaction and provide further insight into the pathogenesis of O. tsutsugamushi infection. Many details of the pathogenesis of scrub typhus, an infection caused by the intracellular bacterium Orientia tsutsugamushi that is endemic in Southeast Asia, have remained unclear until today. In this study, we present an experimental self-healing mouse model of scrub typhus based on footpad skin inoculation of the human pathogenic Karp strain of O. tsutsugamushi that shares many features with human infection. We established a novel quantitative PCR with increased sensitivity for the measurement of bacterial organ loads of infected mice. It was thereby shown that O. tsutsugamushi initially accumulated in the regional lymph node and subsequently spread to many organs with the highest bacterial loads found in the lung. The predominant host cells in the lung were macrophages located in the parenchymal interstitium, rather than endothelial cells. Our data also show unexpected organ-specific differences in the dynamics of macrophage activation. This mouse model will help to advance our understanding of scrub typhus pathogenesis.
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Affiliation(s)
| | | | - Julia Kolbaum
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | - Melanie Neumann
- Mouse Pathology Core Facility, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernhard Fleischer
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kim SY, Jang HJ, Kim H, Shin K, Kim MH, Lee K, Kim KU, Park HK, Lee MK. Patients with Acute Respiratory Distress Syndrome Caused by Scrub Typhus: Clinical Experiences of Eight Patients. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sun Young Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hang Jea Jang
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyunkuk Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kyunghwa Shin
- Department of Internal Medicine, Daedong Hospital, Busan, Korea
| | - Mi-Hyun Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Ki Uk Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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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.
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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.
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Lee JH, Lee JH, Chung KM, Kim ES, Kwak YG, Moon C, Lee CS. Dynamics of clinical symptoms in patients with scrub typhus. Jpn J Infect Dis 2013; 66:155-7. [PMID: 23514915 DOI: 10.7883/yoken.66.155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The clinical manifestations and complications of scrub typhus are variable. Few studies have examined the timeline of clinical symptoms after the appropriate antimicrobial agents have been administered. The most prevalent clinical manifestations are fever and cough, followed by headache, myalgia, eschar, skin rash, and nausea. Systemic symptoms are most severe during the early stages of illness (i.e., the first 5 days), but resolve slowly within 2 weeks. The associated skin rash is most severe during the first 8 days of infection, but it resolves slowly within 21 days.
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Affiliation(s)
- Jae-Hoon Lee
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Republic of Korea
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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.
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Scrub typhus: pathophysiology, clinical manifestations and prognosis. ASIAN PAC J TROP MED 2012; 5:261-4. [PMID: 22449515 DOI: 10.1016/s1995-7645(12)60036-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/27/2012] [Accepted: 03/15/2012] [Indexed: 01/10/2023] Open
Abstract
Scrub typhus is a zoonosis caused by the pathogen Orientia tsutsugamushi (O. tsutsugamushi). The disease has significant prevalence in eastern and Southeast Asia. Usually presenting as an acute febrile illness, the diagnosis is often missed because of similarities with other tropical febrile infections. Many unusual manifestations are present, and these are described in this review, together with an outline of current knowledge of pathophysiology. Awareness of these unusual clinical manifestations will help the clinician to arrive at an early diagnosis, resulting in early administration of appropriate antibiotics. Prognostic indicators for severe disease have not yet been clearly established.
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Gulati S, Maheshwari A. Dengue fever-like illnesses: how different are they from each other? ACTA ACUST UNITED AC 2012; 44:522-30. [PMID: 22506663 DOI: 10.3109/00365548.2012.669044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In tropical countries and possibly elsewhere, dengue fever can be confused with other common tropical infections like enteric fever, leptospirosis, typhus fever, malaria, etc. Many of these illnesses can present in significant numbers after rains, and because of similar early presentations, can cause confusion in decision-making. With global warming, these diseases can assume significant proportions even in non-endemic areas. Identifying these illnesses in a non-immune returning traveller is equally challenging. Recognition of these diseases is important to diagnose them and treat them early, in order to avoid potentially fatal complications. This review is an attempt to highlight important clinical and laboratory differences among dengue fever-like illnesses.
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Affiliation(s)
- Sameer Gulati
- Department of Internal Medicine, St Stephens Hospital, Tis Hazari, Delhi, India.
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Lee J, Kim DM, Yun NR, Byeon YM, Kim YD, Park CG, Kim MW, Han MA. A comparative study of hepatitis caused by scrub typhus and viral hepatitis A in South Korea. Am J Trop Med Hyg 2011; 85:873-7. [PMID: 22049041 DOI: 10.4269/ajtmh.2011.09-0703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
We compared clinical features and laboratory findings of 104 patients with hepatitis A and 197 patients with scrub typhus. Nausea, vomiting, abdominal pain, hepatomegaly, and jaundice were common in patient with hepatitis A, and fever and headache were significantly more common in patients with scrub typhus. At presentation, an alanine aminotransferase (ALT) level ≥ 500 U/L was observed in 1% of scrub typhus patients and in 87.5% of hepatitis A patients (P < 0.001). A bilirubin level ≥ 1.3 mg/dL was observed in 16.8% of scrub typhus patients and 90.4% of hepatitis A patients. The ALT:lactate dehydrogenase ratio was ≤ 5 in 97.4% of the patients with scrub typhus and > 5 in 95.2% of those with hepatitis A (P < 0.001). Fever, headache, rash, and eschar are findings that indicate scrub typhus. An ALT level ≥ 500 U/L (adjusted odds ratio = 0.011) a bilirubin level ≥ 1.3 (adjusted odds ratio = 0.024), an ALT:lactate dehydrogenase ratio > 5, and hepatomegaly are indications of viral hepatitis A.
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Affiliation(s)
- Jun Lee
- Department of Internal Medicine, Research Center for Resistant Cells, School of Medicine, Chosun University, Gwangju, South Korea.
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Chen HC, Chang HC, Chang YC, Liu SF, Su MC, Huang KT, Lin MC, Wang CC. Chest radiographic presentation in patients with scrub typhus. Trans R Soc Trop Med Hyg 2011; 106:48-53. [PMID: 22033144 DOI: 10.1016/j.trstmh.2011.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/12/2011] [Accepted: 09/12/2011] [Indexed: 01/10/2023] Open
Abstract
We conducted a retrospective study of the adult patients (age ≥18 years) with serologically confirmed scrub typhus admitted between January 1998 and December 2009 at Kaohsiung Chang Gung Memorial Hospital. There were 63 adult scrub typhus patients with chest radiographic examinations. A total of 147 chest radiographs were obtained and reviewed. The most frequent abnormal findings in this study were parenchymal infiltration with bilateral and lower lung predilection. The distribution of abnormal chest radiographs was observed more than 50% during the first week. Furthermore, the progressive change was frequently observed during the first week. There is a significant correlation among laboratory findings, clinical course, and outcome. Chest radiography may be a complementary tool to evaluate the clinical course of scrub typhus and chest radiographic examinations should be taken during the first week after the onset of illness.
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Affiliation(s)
- Hung-Cheng Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Lee BJ, Chen CY, Hu SY, Tsan YT, Lin TC, Wang LM. Otalgia and eschar in the external auditory canal in scrub typhus complicated by acute respiratory distress syndrome and multiple organ failure. BMC Infect Dis 2011; 11:79. [PMID: 21450057 PMCID: PMC3079651 DOI: 10.1186/1471-2334-11-79] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Accepted: 03/30/2011] [Indexed: 01/10/2023] Open
Abstract
Background Scrub typhus, a mite-transmitted zoonosis caused by Orientia tsutsugamushi, is an endemic disease in Taiwan and may be potentially fatal if diagnosis is delayed. Case presentations We encountered a 23-year-old previously healthy Taiwanese male soldier presenting with the right ear pain after training in the jungle and an eleven-day history of intermittent high fever up to 39°C. Amoxicillin/clavulanate was prescribed for otitis media at a local clinic. Skin rash over whole body and abdominal cramping pain with watery diarrhea appeared on the sixth day of fever. He was referred due to progressive dyspnea and cough for 4 days prior to admission in our institution. On physical examination, there were cardiopulmonary distress, icteric sclera, an eschar in the right external auditory canal and bilateral basal rales. Laboratory evaluation revealed thrombocytopenia, elevation of liver function and acute renal failure. Chest x-ray revealed bilateral diffuse infiltration. Doxycycline was prescribed for scrub typhus with acute respiratory distress syndrome and multiple organ failure. Fever subsided dramatically the next day and he was discharged on day 7 with oral tetracycline for 7 days. Conclusion Scrub typhus should be considered in acutely febrile patients with multiple organ involvement, particularly if there is an eschar or a history of environmental exposure in endemic areas. Rapid and accurate diagnosis, timely administration of antibiotics and intensive supportive care are necessary to decrease mortality of serious complications of scrub typhus.
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Affiliation(s)
- Bor-Jen Lee
- Intensive Care Unit, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City, 00407, Taiwan
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Yoon HJ, Lee MS, Ki M, Ihm C, Kim D, Kim Y, Yoo SM. Does IL-17 play a role in hepatic dysfunction of scrub typhus patients? Vector Borne Zoonotic Dis 2010; 10:231-5. [PMID: 19485773 DOI: 10.1089/vbz.2008.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Scrub typhus is a zoonotic disease that is caused by Orientia tsutsugamushi. Although hepatic dysfunction occurred in 77-96.7% of the scrub typhus patients, its mechanism is unknown. IL-17 is a potent proinflammatory cytokine known for its role in several chronic disease conditions. Abundant IL-17 was found in conditions affected by microbial pathogens, including the synovial fluid of patients with Lyme arthritis or Chlamydia-induced reactive arthritis, Helicobacter pylori-infected gastric mucosa, and listeria infection. It is also suggested as a marker of acute hepatic injury. In our study, we postulated that IL-17 might be a cytokine with a role in hepatic dysfunction in scrub typhus. In September-November 2006, our study involved 43 patients with Boryong-type scrub typhus patients and 40 age- and sex-matched control healthy people. Scrub typhus was confirmed on the basis of immunofluorescence and a nested polymerase chain reaction assay. IL-17 was measured using human IL-17 immunoassay. We gathered the clinical and laboratory data by chart reviews. We used an independent t-test, Kolmogorov-Smirnov test, and correlation analysis. The IL-17 levels were significantly higher in scrub typhus patients than in the healthy group. Also, the patients with scrub typhus showed significantly higher aspartate aminotransferase and alanine aminotransferase levels, and lower hemoglobin levels than the healthy group. However, in our correlation analysis, we did not find any correlation between IL-17 and hepatic, kidney, and hemogram panels. The IL-17 level in patients with headaches was higher than in patients without headaches, showing a borderline significance. This suggests that IL-17 level might be a cause of a vasculitis-associated headache. More prospective, large-scale studies are needed about the mechanism of hepatic dysfunction and headaches in scrub typhus patients.
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Affiliation(s)
- Hee Jung Yoon
- Department of Internal Medicine, Eulji University School of Medicine, Daejon, Korea
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Kim DM, Kim SW, Choi SH, Yun NR. Clinical and laboratory findings associated with severe scrub typhus. BMC Infect Dis 2010; 10:108. [PMID: 20433689 PMCID: PMC2877676 DOI: 10.1186/1471-2334-10-108] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 04/30/2010] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Scrub typhus is a mite-borne bacterial infection of humans caused by Orientia tsutsugamushi that causes a generalized vasculitis that may involve the tissues of any organ system. The aim of this study was to identify factors associated to severe complications from scrub typhus. METHODS We conducted this prospective, case-control study on scrub typhus patients who presented to the Department of Internal Medicine at Chosun University Hospital between September, 2004 and December, 2006. Cases were 89 scrub typhus patients with severe complications and controls were 119 scrub typhus patients without severe complications. RESULTS There were significant differences in the absence of eschar, white blood cell (WBC) counts, hemoglobin, albumin, serum creatinine, fibrinogen, C-reactive protein (CRP), and active partial thromboplastin time (aPTT) between the two groups. Multivariate analysis demonstrated that only the following four factors were significantly associated with the severe complications of scrub typhus: (1) age >or= 60 years (odd ratio [OR] = 3.13, P = 0.002, confidence interval [CI] = 1.53-6.41), (2) the absence of eschar (OR = 6.62, P = 0.03, CI = 1.22-35.8, (3) WBC counts > 10, 000/mm3 (OR = 3.6, P = 0.001, CI = 1.65-7.89), and (4) albumin <or= 3.0 g/dL (OR = 5.01, P = 0.004, CI = 1.69-14.86). CONCLUSIONS Our results suggest that clinicians should be aware of the potential for complications, when scrub typhus patients are older (>or= 60 years), presents without eschar, or laboratory findings such as WBC counts > 10, 000/mm3, and serum albumin level <or= 3.0 g/dL. Close observation and intensive care for scrub typhus patients with the potential for complications may prevent serious complications with subsequent reduction in its mortality rate.
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Affiliation(s)
- Dong-Min Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chosun University School of Medicine, Gwangju City, Republic of Korea
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Wu KM, Wu ZW, Peng GQ, Wu JL, Lee SY. Radiologic Pulmonary Findings, Clinical Manifestations and Serious Complications in Scrub Typhus: Experiences From A Teaching Hospital in Eastern Taiwan. INT J GERONTOL 2009. [DOI: 10.1016/s1873-9598(10)70005-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Lai CH, Huang CK, Chen YH, Chang LL, Weng HC, Lin JN, Chung HC, Liang SH, Lin HH. Epidemiology of acute q Fever, scrub typhus, and murine typhus, and identification of their clinical characteristics compared to patients with acute febrile illness in southern taiwan. J Formos Med Assoc 2009; 108:367-76. [PMID: 19443290 DOI: 10.1016/s0929-6646(09)60080-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/PURPOSE In Taiwan, acute Q fever, scrub typhus, and murine typhus (QSM diseases) are the most common rickettsioses, but their epidemiology and clinical characteristics have not been clarified. Diagnosis of these three diseases based on clinical manifestations is difficult, and most of their reported characteristics are identified by describing the predominant manifestations, without being compared with other diseases. METHODS Serological tests for QSM diseases were examined simultaneously in patients suspected of the three diseases, regardless of which one was suspected. Clinical manifestations were recorded retrospectively from their charts. The characteristics of QSM diseases were identified by comparison with patients who had non-QSM diseases. RESULTS From April 2004 to April 2007, a total of 226 cases of suspected QSM diseases were included. One hundred (44.2%) cases were serologically confirmed as QSM diseases (68 acute Q fever, 23 scrub typhus, and 9 murine typhus), and 126 (55.8%) cases were non-QSM diseases. Only 33 cases (33.0%) of QSM diseases were initially suspected at the time of hospital visit, whereas 54 cases (42.9%) of non-QSM diseases were incorrectly suspected as QSM diseases. Cases of Q fever and scrub typhus were distributed over plain and mountain areas, respectively. By multivariate analysis, relative bradycardia (OR [95% CI], 2.885 [1.3-6.4]; p = 0.009), radiographic hepatomegaly (OR [95% CI], 4.454 [1.6-12.3]; p = 0.004), and elevated serum aminotransferases (OR [95% CI], 5.218 [1.2-23.1]; p = 0.029) were independent characteristics for QSM diseases, and leukocytosis (OR [95% CI], 0.167 [0.052-0.534]; p = 0.003) was negative for the diagnosis of QSM diseases. CONCLUSION In southern Taiwan, acute Q fever is the most common rickettsiosis. QSM diseases should be suspected in febrile patients who present with relative bradycardia, hepatomegaly, and elevated serum aminotransferases, but without leukocytosis.
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Affiliation(s)
- Chung-Hsu Lai
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital/I-Shou University, Taiwan
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Kim IH, Lee HB, Hwang JH, Kwon KS, Lee CS. Scrub typhus in patients with liver cirrhosis: a preliminary study. Clin Microbiol Infect 2009; 16:419-24. [PMID: 19624507 DOI: 10.1111/j.1469-0691.2009.02825.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Scrub typhus is a potentially fatal infectious disease caused by the organism Orientia tsutsugamushi. However, to date, there have been no clearly identified determinants or reports published on the clinical severity of scrub typhus in liver cirrhosis (LC) patients. This study was carried out by retrospectively reviewing medical records accumulated over 7 years at a tertiary hospital. Sixteen patients of 160 had underlying LC, and they were defined as 'cases'; those without underlying LC were defined as 'controls'. The duration of hospital stay (23.0 +/- 24.8 days for cases and 6.8 +/- 7.0 days for controls, p 0.020) and APACHE II scores (14.1 +/- 6.0 for cases and 7.2 +/- 4.6 for controls, p <0.001) were, respectively, significantly longer and significantly higher on admission in the cases than in the controls. Surprisingly, hospital mortality was significantly higher in the cases than in the controls (31.3% and 3.5%, respectively, p 0.001). Among the LC group, the highest Model for End-stage Liver Disease (MELD) score during hospitalization (MELD-Peak) (p 0.024) and the lowest blood sodium concentration during hospitalization (MELD-Na-Lo) (p 0.003) were higher in fatal cases than in the survivors (MELD-Na-to). Physicians should be aware of an adverse relationship between LC and scrub typhus, and patients with LC should be advised to avoid exposure to O. tsutsugamushi, particularly in endemic areas and epidemic seasons.
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Affiliation(s)
- I-H Kim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Shioi Y, Murakami A, Takikawa Y, Miyate Y, Tomichi N, Takayama K, Uesugi N, Sugai T. Autopsy case of acute liver failure due to scrub typhus. Clin J Gastroenterol 2009; 2:310-314. [PMID: 26192432 DOI: 10.1007/s12328-009-0087-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 04/05/2009] [Indexed: 01/10/2023]
Abstract
Scrub typhus (Tsutsugamushi disease) is an acute febrile disease caused by infection with Orientia tsutsugamushi transmitted by mites. Although patients with scrub typhus commonly display mild liver injury, few die of acute liver failure. We describe herein an autopsy case of acute liver failure due to scrub typhus, which was complicated by disseminated intravascular coagulation and showed rapid progression of liver injury just before death. Histopathological findings revealed submassive hepatocellular necrosis, inflammatory cell infiltration in Glisson's capsules, and sporadic fibrin thrombi in the hepatic sinusoids. Cause of death was primarily associated with acute liver failure related to disseminated intravascular coagulation.
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Affiliation(s)
- Yoshihiro Shioi
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan.
| | - Akihiko Murakami
- Department of Endoscopy, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, 020-0066, Japan
| | - Yasuhiro Takikawa
- Department of Gastroenterology and Hepatology, School of Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Yoshiharu Miyate
- Department of Intensive Care Unit, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, 020-0066, Japan
| | - Nobukazu Tomichi
- Department of Pathology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, 020-0066, Japan
| | - Kazuo Takayama
- Department of Pathology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, 020-0066, Japan
| | - Noriyuki Uesugi
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Tamotsu Sugai
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan
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The difference in clinical characteristics between acute Q fever and scrub typhus in southern Taiwan. Int J Infect Dis 2009; 13:387-93. [DOI: 10.1016/j.ijid.2008.07.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 07/17/2008] [Accepted: 07/29/2008] [Indexed: 01/10/2023] Open
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Association of high Orientia tsutsugamushi DNA loads with disease of greater severity in adults with scrub typhus. J Clin Microbiol 2008; 47:430-4. [PMID: 19091812 PMCID: PMC2643668 DOI: 10.1128/jcm.01927-08] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Orientia tsutsugamushi, the cause of scrub typhus, is a major pathogen in the Asia-Pacific region. The severity of infection ranges from mild features to multiorgan failure and death. The aim of this prospective study was to define the O. tsutsugamushi loads in the blood samples of patients with scrub typhus on the day of hospital admission and to determine whether this was associated with disease severity. Quantitation was performed using a real-time PCR assay targeting the 16S rRNA gene of O. tsutsugamushi. A total of 155 patients with a confirmed diagnosis of scrub typhus had a median (interquartile range [IQR], range) O. tsutsugamushi DNA load in blood of 13 (0 to 334, 0 to 310,253) copies/ml. This included 74 patients who had undetectable bacterial loads. An analysis of bacterial load versus clinical features for all 155 patents demonstrated that duration of illness (P < 0.001), presence of eschar (P = 0.004), and concentrations of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase (P < 0.001 for all three) were positively correlated with bacterial load. Patients who died had a significantly higher bacterial load than those who survived (mean [standard deviation] values: 17,154 [12.7] versus 281 [5.2] copies/ml; P < 0.001). This study has demonstrated a relationship between bacterial load and disease severity in adults with scrub typhus.
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Madison G, Kim-Schluger L, Braverman S, Nicholson WL, Wormser GP. Hepatitis in Association with Rickettsialpox. Vector Borne Zoonotic Dis 2008; 8:111-5. [DOI: 10.1089/vbz.2007.0135] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Gul Madison
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, New York
| | - Leona Kim-Schluger
- Division of Gastroenterology, Department of Medicine, New York Medical College, Valhalla, New York
| | - Susan Braverman
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, New York
| | | | - Gary P. Wormser
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, New York
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Blacksell SD, Bryant NJ, Paris DH, Doust JA, Sakoda Y, Day NPJ. Scrub typhus serologic testing with the indirect immunofluorescence method as a diagnostic gold standard: a lack of consensus leads to a lot of confusion. Clin Infect Dis 2007; 44:391-401. [PMID: 17205447 DOI: 10.1086/510585] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 10/12/2006] [Indexed: 01/10/2023] Open
Abstract
A review was performed to determine the evidence base for scrub typhus indirect immunofluorescence assay (IFA) methodologies and the criteria for positive results. This review included a total of 109 publications, which comprised 123 eligible studies for analysis (14 publications included 2 substudies). There was considerable underreporting of the IFA methodology and seropositivity criteria used, with most studies using a defined cutoff titer rather than an increase in the titer in paired samples. The choice of positivity cutoff titer varied by country and purpose of the IFA test. This variation limits the comparability of seroprevalence rates between studies and, more seriously, raises questions about the appropriateness of the cutoffs for positive IFA results chosen for diagnosis of acute scrub typhus infection. We suggest that the diagnosis of scrub typhus using IFA should be based on a > or =4-fold increase in the titer in paired serum samples and should only be based on a single sample titer when there is an adequate local evidence base.
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Affiliation(s)
- Stuart D Blacksell
- Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
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Basnyat B, Belbase RH, Zimmerman MD, Woods CW, Reller LB, Murdoch DR. Clinical features of scrub typhus. Clin Infect Dis 2006; 42:1505-6. [PMID: 16619174 DOI: 10.1086/503680] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Watt G, Kantipong P, Jirajarus K, Wongsawat E, Waywa D, Suputtamongkol Y. Acute scrub typhus in Northern Thailand: EKG changes. Am J Trop Med Hyg 2003; 95:769-773. [PMID: 12236430 DOI: 10.4269/ajtmh.16-0088] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/07/2016] [Indexed: 01/10/2023] Open
Abstract
The electrocardiographic (EKG) manifestations of scrub typhus were prospectively evaluated in 29 adult patients who acquired Orientia tsutsugamushi infection in Chiang Rai, Northern Thailand. EKGs were normal in 22 of the 29 patients (76%); minor non-specific changes were found in the other 7 patients; ie ST segment/T wave changes (10%), U waves (7%), and premature ventricular contractions (4%). These results suggest that EKG changes in scrub typhus acquired in areas of diminished antibiotic susceptibility are similar to those observed in O. tsutsugamushi infection acquired elsewhere.
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Affiliation(s)
- George Watt
- Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | | | - Ekkarat Wongsawat
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Duangdao Waywa
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yupin Suputtamongkol
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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