A case of acute renal failure, rhabdomyolysis and disseminated intravascular coagulation associated with scrub typhus

Scrub Typhus- An Underestimated Infectious Disease Attributable to Community Acquired Acute Kidney Injury

Acute Kidney Injury (AKI) associated with Scrub typhus is an emerging health problem which is more common in the tropics including India. This study intended to find out the occurrence of Scrub typhus among the Community Acquired Acute Kidney Injury patients in a tertiary care hospital in Assam, North East India. AKI patients with acute febrile illness admitted to Gauhati Medical College and Hospital, Guwahati, Assam were included in the study and demographic characteristics along with clinical features were recorded. The detection of Scrub typhus was done by IgM Enzyme Linked Immunosorbent Assay (ELISA) test (Optical Density > 0.5) and polymerase chain reaction (PCR) analysis. Routine haematological and biochemical tests were performed. Molecular characterization of Orientia tsutsugamushi was done followed by phylogenetic analysis. The Graph Pad Prism software 9 was used for statistical analysis. Out of 221 AKI patients admitted to hospital, 45 patients (20.4%) were confirmed to be Scrub typhus positive and among them, 4 cases were co-infected with leptospirosis. Majority of Scrub typhus positive AKI patients were in Stage I (82.2%) under KDIGO guideline. "Karp" was the predominant circulating serotype. The study showed cases of Scrub typhus associated Acute Kidney Injury was high and mortality was 11.1%. Hence, in this region, further studies need to be done with large number of population and more emphasis need to be given on differential diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12088-023-01137-x.

Scrub typhus-associated acute kidney injury: A study from a South Indian Tertiary Care Hospital

Infections including scrub typhus contribute to a significant proportion of community-acquired acute kidney injury (AKI) in the tropics. Scrub typhus infection now requires global attention since disease outbreaks are being reported across continents. We intended to study the clinical profile, renal involvement, and parameters predicting renal involvement in scrub typhus infection. This is a retrospective study. The medical records of all patients who were admitted and treated for scrub typhus infection for a study period of two years (from September 2015 to August 2017) were analyzed, and salient clinical features and laboratory results were collected from the hospital data. Statistical analysis was done from the collected data. Our study had 272 patients including 81 children. Adults constituted 70.96% (n = 193) and the remaining 29.04% (n = 81) were pediatric population. Among adults, females constituted 62.7% (n = 121) and males 37.3% (n = 72). The mean age of the adult population was 45.7 ± 15 years and that of pediatric patients was 8.56 ±5.1 years. 18.7% of adult cases and 3.70% of pediatric cases had AKI. Renal replacement therapy was required in 3.67% of adult cases. Mortality was 4.14% in adults and 1.23% in children. Hypotension, pulmonary involvement, central nervous system involvement, multiorgan dysfunction syndrome, increased total counts, elevated aspartate transaminase levels, and hypoalbuminemia predicted AKI in our adult population. Scrub typhus should be considered as a differential in cases presenting with fever and AKI. Outcomes of scrub typhus infection in terms of mortality seem to be improving in this region.

Clinical manifestations of scrub typhus

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

Renal Manifestation in Scrub Typhus during a Major Outbreak in Central Nepal

Renal involvement and acute kidney injury (AKI) are common clinical manifestations seen in scrub typhus, a vector-borne tropical disease. There are no data on renal manifestation in scrub typhus in Nepal. We conducted a prospective study to analyze the incidence, urinary abnormalities, course, severity, outcome, and the predictors of AKI in patients with scrub typhus during a major outbreak in Central Nepal. Total 1398 patients admitted with acute febrile illness were subjected for Scrub Typhus Detect™ Immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) test, of which 502 (35.90%) patients tested positive and were included in the study. Mean age of the patients was 30.37 ± 18.81 years (range, 1-79 years) with 26.29% in the pediatric age group. Female-to-male ratio was 1.26:1. Mean duration of fever was 6.8 ± 3.1 days. Mean IgM ELISA value for scrub typhus was 2.17 ± 1.70 without difference in AKI and non-AKI groups (2.17 ± 1.76 vs. 2.16 ± 1.62; P = 0.94). Urinary abnormalities were seen in 42.3% of patients. Mean serum creatinine was 1.37 ± 0.69 mg/dl with significant difference in two groups (1.85 ± 0.87 vs. 1.03 ± 0.17; P = 0.003). AKI was seen in 35.8% of patients with majority having Stage 1 AKI (68.3%) followed by Stage 2 (34.1%) and Stage 3 (1.2%). Hemodialysis was required for 3.94% of patients. In 54% of patients, AKI occurred in fifth and sixth day of fever. ICU admission was required for 18.73% of patients and 8.57% required ventilator support. Mortality rate was 1.79%, which was higher among patients with AKI (2.96% vs. 1.0%; P = 0.106). Multivariate analysis revealed that the presence of pneumonia, shock, and acute respiratory distress syndrome predicted the development of AKI.

Activation of the coagulation cascade in patients with scrub typhus

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.

Acute kidney injury due to tropical infectious diseases and animal venoms: a tale of 2 continents

South and Southeast Asia and Latin American together comprise 46 countries and are home to approximately 40% of the world population. The sociopolitical and economic heterogeneity, tropical climate, and malady transitions characteristic of the region strongly influence disease behavior and health care delivery. Acute kidney injury epidemiology mirrors these inequalities. In addition to hospital-acquired acute kidney injury in tertiary care centers, these countries face a large preventable burden of community-acquired acute kidney injury secondary to tropical infectious diseases or animal venoms, affecting previously healthy young individuals. This article reviews the epidemiology, clinical picture, prevention, risk factors, and pathophysiology of acute kidney injury associated with tropical diseases (malaria, dengue, leptospirosis, scrub typhus, and yellow fever) and animal venom (snakes, bees, caterpillars, spiders, and scorpions) in tropical regions of Asia and Latin America, and discusses the potential future challenges due to emerging issues.

Spontaneous Splenic Rupture Caused by Scrub Typhus

Spontaneous rupture of the spleen is rarely described as a complication of scrub typhus infection. We report a previously healthy 74-year-old Thai female farmer who presented in Nakhon Ratchasima, Thailand, with a history of fever and malaise for 5 days, followed by abdominal pain for 1 day. An exploratory laparotomy was performed due to peritonitis. Operative findings revealed a ruptured spleen and hemoperitoneum. A splenectomy was performed afterward. Scrub typhus was confirmed by a 4-fold increase of IgM titer using an indirect immunofluorescence antibody assay and a positive result from the polymerase chain reaction targeting the 47- and 56-kDa genes in Orientia tsutsugamushi She responded well to intravenous chloramphenicol and defervesced within 24 hours without any complication.

Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India

BACKGROUND

Infection-related acute kidney injury (AKI) is an important preventable cause of morbidity and mortality in the tropical region. The prevalence and outcome of kidney involvement, especially AKI, in scrub typhus is not known. We investigated all patients with undiagnosed fever and multisystem involvement for scrub typhus and present the pattern of renal involvement seen.

METHODS

From September 2011 to November 2012, blood samples of all the patients with unexplained acute febrile illness and/or varying organ involvement were evaluated for evidence of scrub typhus. A confirmed case of scrub typhus was defined as one with detectable Orientia tsutsugamushi deoxyribonucleic acid (DNA) in patient's blood sample by nested polymerase chain reaction (PCR) targeting the gene encoding 56-kDa antigen and without any alternative etiological diagnosis. Renal involvement was defined by demonstration of abnormal urinalysis and/or reduced glomerular filtration rate. AKI was defined as per Kidney Disease: Improving Global Outcomes (KDIGO) definition.

RESULTS

Out of 201 patients tested during this period, 49 were positive by nested PCR for scrub typhus. Mean age of study population was 34.1±14.4 (range 11-65) years. Majority were males and a seasonal trend was evident with most cases following the rainy season. Overall, renal abnormalities were seen in 82% patients, 53% of patients had AKI (stage 1, 2 and 3 in 10%, 8% and 35%, respectively). The urinalysis was abnormal in 61%, with dipstick positive albuminuria (55%) and microscopic hematuria (16%) being most common. Acute respiratory distress syndrome (ARDS) and shock were seen in 57% and 16% of patients, respectively. Hyperbilirubinemia was associated with AKI (p = 0.013). A total of 8 patients (including three with dialysis dependent AKI) expired whereas rest all made uneventful recovery. Jaundice, oliguria, ARDS and AKI were associated with mortality. However, after multivariate analysis, only oliguric AKI remained a significant predictor of mortality (p = 0.002).

CONCLUSIONS

Scrub typhus was diagnosed in 24% of patients presenting with unexplained febrile illness according to a strict case definition not previously used in this region. Renal abnormalities were seen in almost 82% of all patients with evidence of AKI in 53%. Our finding is contrary to current perception that scrub typhus rarely causes renal dysfunction. We suggest that all patients with unexplained febrile illness be investigated for scrub typhus and AKI looked for in scrub typhus patients.

A case of scrub typhus requiring maintenance hemodialysis

Renal failure caused by scrub typhus is known to be reversible. In most cases, renal function is almost fully restored after appropriate antibiotic treatment. A 71-year-old man was diagnosed with scrub typhus complicated by renal failure. A renal biopsy revealed histopathologic findings consistent with acute tubulointerstitial nephritis. Renal function did not improve 18 months after discharge and the patient required continuous hemodialysis. Although severe renal failure requiring dialysis is a rare complication of scrub typhus, we describe a case of scrub typhus requiring maintenance hemodialysis. To the best of our knowledge, this is the first such report.

Scrub typhus associated acute kidney injury--a study from a tertiary care hospital from western Himalayan State of India

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.

Chronic intake of a phytochemical-enriched diet reduces cardiac fibrosis and diastolic dysfunction caused by prolonged salt-sensitive hypertension

Salt-sensitive hypertension is common in the aged population. Increased fruit and vegetable intake reduces hypertension, but its effect on eventual diastolic dysfunction is unknown. This relationship is tested in the Dahl Salt-Sensitive (Dahl-SS) rat model of salt-sensitive hypertension and diastolic dysfunction. Table grape powder contains phytochemicals that are relevant to human diets. For 18 weeks, male Dahl-SS rats were fed one of five diets: low salt (LS), a low salt + grape powder (LSG), high salt (HS), a high salt + grape powder (HSG), or high salt + vasodilator hydralazine (HSH). Compared to the HS diet, the HSG diet lowered blood pressure and improved cardiac function; reduced systemic inflammation; reduced cardiac hypertrophy, fibrosis, and oxidative damage; and increased cardiac glutathione. The HSH diet similarly reduced blood pressure but did not reduce cardiac pathogenesis. The LSG diet reduced cardiac oxidative damage and increased cardiac glutathione. In conclusion, physiologically relevant phytochemical intake reduced salt-sensitive hypertension and diastolic dysfunction.

Acute renal failure due to acute tubular necrosis caused by direct invasion of Orientia tsutsugamushi

We describe a scrub typhus patient with acute renal failure for whom a diagnosis was made based on serology as well as immunohistochemical (IHC) staining and an electron microscopic examination (EM) of a renal biopsy specimen. For our case, we demonstrated by IHC staining and EM that renal failure was caused by acute tubular necrosis due to a direct invasion of Orientia tsutsugamushi.

Acute scrub typhus in Northern Thailand: EKG changes

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.