[Guillan-Barré syndrome following scrub typus: two case reports]

Opisthotonic posturing in Guillian-Barre syndrome

INTRODUCTION

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

CASE REPORT

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

CONCLUSIONS

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

Guillain-Barre syndrome following scrub typhus: a case report and literature review

BACKGROUND

Scrub typhus is an acute infectious disease caused by Orientia tsutsugamushi. Guillain-Barre syndrome (GBS) is an autoimmune-mediated peripheral neuropathy with a frequent history of prodromal infections, but GBS associated with scrub typhus is very rare.

CASE PRESENTATION

We report a 51-year-old male patient who developed dysarthria and peripheral facial paralysis following the cure of scfrub typhus. CSF examination and electrophysiological findings suggested a diagnosis of GBS. After treatment with intravenous immunoglobulin, the patient's neurological condition improved rapidly.

CONCLUSIONS

Scrub typhus infection is likely to be a potential predisposing factor in GBS, while scrub typhus-associated GBS has a favorable prognosis.

Clinical and laboratory findings in scrub typhus associated Guillain-Barré syndrome in South Korea

BACKGROUND AND AIMS

Scrub typhus is an endemic disease in the fall season that occurs in a limited number of places known as the Tsutsugamushi Triangle. Peripheral neuropathy is a common complication of scrub typhus. Herein, we encountered several patients with ascending paralysis after scrub typhus infection, who were diagnosed with Guillain-Barré syndrome (GBS). We aimed to investigate the clinical and laboratory characteristics of patients who developed GBS after scrub typhus.

METHODS

Patients were retrospectively recruited from six nationwide tertiary centers in South Korea from January 2017 to December 2021. Patients who had been clinically diagnosed with GBS and confirmed to have scrub typhus via laboratory examination and/or the presence of an eschar before the onset of acute limb paralysis were included. The GBS-associated clinical and electrophysiological characteristics, outcomes, and scrub typhus-associated features were collected.

RESULTS

Of the seven enrolled patients, six were female and one was male. The median time from scrub typhus infection to the onset of limb weakness was 6 (range: 2-14) days. All patients had eschar on their bodies. Four patients (57.1%) were admitted to the intensive care unit and received artificial ventilation for respiratory distress. At 6 months, the median GBS disability score was 2 (range, 1-4) points.

INTERPRETATION

Patients with scrub typhus-associated GBS have a severe clinical presentation and require intensive treatment with additional immunotherapies. Therefore, GBS should be included in the differential diagnosis when peripheral neuropathies develop during scrub typhus treatment. Notably, scrub typhus is associated to GBS.

Rare neurological and neuropsychiatric manifestations of scrub typhus: a case series of 10 cases

INTRODUCTION

Scrub typhus is a potentially life-threatening but curable disease that can produce multi-organ failure. Neurological manifestations in scrub typhus have gained attention recently, where the entire neural axis except the myoneural junction can be involved. Although the pathogenesis of neurological involvement has not been established, immune-mediated mechanisms are suspected. This article reports the clinicopathological features of scrub typhus cases presenting several rare neurological and neuropsychiatric manifestations.

METHODS

Three hundred fifty-four serologically confirmed scrub typhus cases were admitted to the Department of General Medicine of Burdwan Medical College and Hospital (West Bengal, India) between May 2018 and May 2022. There were 50 patients who had predominantly neurological manifestations. Of these 50 cases, ten patients presented with extremely rare neurological manifestations.

RESULTS

We report 10 cases of scrub typhus (four men and six women) who presented with complex neurological pictures (posterior reversible encephalopathy syndrome, Opalski syndrome, parkinsonism, cerebellitis, isolated opsoclonus, acute transverse myelitis, myositis, polyradiculoneuropathy with cranial neuropathy, acute transient behavioral changes, and fibromyalgia). Immune-mediated mechanisms might have mediated the pathogenesis of most cases following scrub typhus infection.

CONCLUSION

From a clinicopathological point of view, each case was unique in its presentation and treatment response. In any acute onset neurological disorders associated with febrile illness in the tropics or subtropics, scrub typhus infection should be included in the differential diagnosis, despite the absence of eschar and unremarkable neuroimaging findings. This otherwise curable disease may result in multi-organ dysfunction syndrome and death if the diagnosis is delayed.

Acute cerebellar ataxia and peripheral neuropathy due to an atypical infection

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

Neurological facets of scrub typhus: A comprehensive narrative review

Scrub typhus is one of the most frequent causes of acute febrile illness in South and South-east Asian countries. Neurological features accompany 20% of scrub typhus infections, and may affect the central or peripheral nervous system, and sometime, may even occur in combination. Of late, its recognition among clinicians has increased with widening detection of its cutaneous hallmark, called eschar. Multiple mechanisms underlie neurological involvement, including direct invasion (meningitis, encephalitis), vasculitis (myositis) or immune-mediated mechanisms (opsoclonus, myoclonus, optic neuritis, Guillain–Barre syndrome). Despite an immunological basis for several neurological manifestations, response to doxycycline is remarkable, although immune therapy may be necessary for severe involvement. Scientific literature on scrub typhus neurology chiefly emanates from case reports, case series and small studies, and a comprehensive review is warranted to aid clinicians in recognising neurological involvement. This review aims at enriching this gap, and summarises clinical features, laboratory findings, and treatment options for various neurological facets of scrub typhus.