Once Forgotten Now Re-emerging: Scrub Typhus Infection in Pediatric Patients From North West India

Background Scrub typhus is an important cause of acute febrile illness in children. It is one of the re-emerging infections in the Asia Pacific region. It is caused by the gram-negative bacteria Orientia tsutsugamushi and is spread by the bite of trombiculid mites. The initial symptomatology is nonspecific with fever, headache, vomiting, etc. The presence of eschar is said to be pathognomic. It is a systemic illness, and vasculitis is the basic pathogenic mechanism. Materials and methods A retrospective observational study was conducted in two medical colleges and associated hospitals of western Uttar Pradesh (UP) and Rajasthan, India. Case files of 21 confirmed cases of scrub typhus admitted from April 2021 to October 2022 were reviewed. Scrub typhus was suspected in children with acute undifferentiated fever, and suggestive signs and symptoms were confirmed serologically with IgM enzyme-linked immunoassay (ELISA). Demographic and clinical details were noted. Results During the study period, a total of 335 cases of acute undifferentiated fever were seen, and 6.2% of them were diagnosed as having scrub typhus infection on detailed investigation. The most common symptom was fever in 100% of them, vomiting in 57.1%, abdomen pain in 42.8%, and diarrhea in 19%. Maculopapular, erythematous rash was present in 19% of cases. None of the patients had eschar. Microvascular leakage was the main complication in 28.5%. Unusual complications seen were empyema and valvulitis in 4.7% of patients. Conclusion Scrub typhus is also seen in urban setups and in dry arid areas like Rajasthan and North West UP. So, relevant investigations should be a part of the evaluation in pediatric patients with acute undifferentiated fever. Eschar can be absent, and empyema and valvulitis are some uncommon complications. A high degree of suspicion and early diagnosis are essential as an undiagnosed infection is rapidly fatal.

Tiger Stripes in Carditis of Rheumatic Origin

"Tiger stripes" or "Zebra stripes" are multiple band-like signals noted on Doppler spectral recordings and have been associated with intracardiac oscillating structures. They have been attributed to flail prosthetic valve leaflet, native valve regurgitation without flail leaflet, papillary muscle rupture in acute coronary syndrome, and possibly Lambl's excrescences. To our knowledge, there is only one case report in the English literature that had identified this sign in rheumatic carditis. We present the case of a 14-year-old boy, who was known to have rheumatic heart disease and presented with worsening dyspnea of recent onset. His antistreptolysin O, C-reactive protein, and erythrocyte sedimentation rate titer were raised. Echocardiography revealed severe eccentric mitral regurgitation with multiple high-intensity signals (tiger stripes) on continuous wave (CW) Doppler. The patient was managed as rheumatic carditis with steroids. Repeat echocardiography after 1 month showed the resolution of tiger stripes. Upon tapering, steroids patient's symptoms worsened and echocardiography revealed the reappearance of tiger stripes. We propose that these high-intensity signals in spectral Doppler reflect valvulitis and are the echocardiographic counterpart of musical overtones. We suggest that these signals on CW Doppler in a patient with established rheumatic heart disease be taken as a marker of carditis and the patient should be managed accordingly. We refer to this sign as a "Fingerprint sign" due to its resemblance to it and to differentiate it from Tiger strips because of its dynamic nature. This sign can be used to identify and follow carditis in a rheumatic scenario.

Acute rheumatic fever - A pathological analysis of clinically missed cases

Background

Acute rheumatic fever (ARF) and its post-inflammatory sequel chronic rheumatic heart disease (RHD) are endemic in the Indian setting. Despite the updated Jones criteria, many cases of ARF remain undiagnosed or are missed.

Aims

This study aims to analyze pathological profiles of such cases and their importance in context of clinical presentation and Jones criteria.

Materials and Methods

A 22-year retrospective observational study of ARF was conducted in the Department of Pathology in a tertiary care institute. The cases were categorized as 1. Those fulfilling and 2. those partially or not fulfilling the Jones Criteria. Based on the autopsy findings, the lesions were classified as categorized mitral stenosis and/or regurgitation (MS ± MR) and pure mitral regurgitation (MR).

Statistical Analysis

Nil.

Results

In 22 years, among 697 cases of autopsied cases of RHD, there were 59 cases (8.5%) of ARF. Among them, seven cases fulfilled the Jones criteria; five of them were clinically diagnosed. The remaining 52 cases (88.1%, 34 with MS ± MR and 18 with MR) did not fulfill or partially fulfilled the Jones criteria and were not diagnosed. A total of 18 patients (30.5%) had the first attack of ARF, whereas recurrences were noted in the remaining patients (69.5%).

Conclusions

The study indicates that the typical manifestations of ARF under Jones criteria may not be present, especially in cases with recurrence. Hence, a presumptive or possible diagnosis of ARF can be made with presence of minor criteria or strong clinical suspicion in such cases.

Uncontrollable movements of right upper and lower extremities in a child: A diagnostic puzzle

We describe a case of a 9-year-old child who presented with uncontrollable, involuntary movements associated with a recent streptococcal infection and echocardiographic evidence of valvulitis. These findings are consistent with the diagnosis of Sydenham's chorea, a rare but important movement disorder and one of the major "Jones criteria" for the diagnosis of acute rheumatic fever. Because of its rarity, patients with Sydenham's chorea often are misdiagnosed as having a behavioral or psychiatric illness. Early recognition and appropriate management can prevent the potential severe sequelae associated with acute rheumatic fever.

Acute Systemic Lupus Erythematous and Antiphospholipid Syndrome With Cardiac Complications

This case illustrates the potential for multiple cardiovascular complications in acute systemic lupus erythematous with antiphospholipid syndrome. (Level of Difficulty: Beginner.).