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 ~  Abstract
 ~ Introduction
 ~ Material and Methods
 ~ Results
 ~ Discussion
 ~ Conclusions
 ~  References
 ~  Article Tables

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  Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 32  |  Issue : 3  |  Page : 247-250
 

Recent outbreak of scrub typhus in North Western part of India


1 Department of Microbiology, Mahatma Gandhi Medical College, Jaipur, Rajasthan, India
2 Department of Medicine , Mahatma Gandhi Medical College, Jaipur, Rajasthan, India

Date of Submission27-May-2013
Date of Acceptance06-Nov-2013
Date of Web Publication10-Jul-2014

Correspondence Address:
Sweta Gupta
Department of Microbiology, Mahatma Gandhi Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.136552

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 ~ Abstract 

Background: Scrub typhus usually affects previously healthy active persons and if undiagnosed or diagnosed late, may prove to be life-threatening. Diagnosis of scrub typhus should be largely based on a high index of suspicion and careful clinical, laboratory and epidemiological evaluation. Objective: To describe the diverse clinical and laboratory manifestations of scrub typhus diagnosed in Mahatma Gandhi Medical College and Hospital, Jaipur. Materials and Methods: All cases of febrile illness diagnosed as scrub typhus over a period of 3 months were analysed. Diagnosis was based on ELISA test for antibody detection against 56 kDa antigen. Results: Forty-two cases of scrub typhus were seen over a period of 3 months (October, 2012-December, 2012). Common symptoms were high grade fever of 4-30 days duration, cough, haemoptysis and breathlessness. Eschar was not seen even in a single patient. Liver enzymes were elevated in nearly all cases (95.9%). Multiple organ dysfunction syndrome (MODS) was present in 16.66% of our patients (7 out of 42). Hypotension (6 patients, 14.2%), renal impairment (9 out of 15 patients, 60%), acute respiratory distress syndrome (4 patients, 9.52%) and meningitis (4 patients, 9.52%) were some of the important complications. There was a dramatic response to doxycycline in nearly all the patients, but initially when the disease was not diagnosed, seven patients had died. Conclusion: Scrub typhus has emerged as an important cause of febrile illness in Jaipur. Empirical treatment with doxycycline is justified in endemic areas.


Keywords: 56 kDa antigen, eschar, scrub typhus


How to cite this article:
Sinha P, Gupta S, Dawra R, Rijhawan P. Recent outbreak of scrub typhus in North Western part of India. Indian J Med Microbiol 2014;32:247-50

How to cite this URL:
Sinha P, Gupta S, Dawra R, Rijhawan P. Recent outbreak of scrub typhus in North Western part of India. Indian J Med Microbiol [serial online] 2014 [cited 2019 Sep 15];32:247-50. Available from: http://www.ijmm.org/text.asp?2014/32/3/247/136552



 ~ Introduction Top


Scrub typhus is a zoonotic disease transmitted by the larval mites (chiggers) of Leptotrombidium deliense group. Man is accidentally infected when he encroaches the mite-infested areas, known as the mite islands. However, the infection can occur in diverse habitats like seashore, rice fields and even semi-deserts. [1]

Orientia tsutsugamushi, the agent of scrub typhus, a strict intracellular bacterium is endemic to a geographically distinct region, the so-called tsutsugamushi triangle, which includes Japan, Taiwan, China and South Korea. [2] In India, the disease had occurred among troops during World War II in Assam and West Bengal, and in the 1965 Indo-Pak war. There was a resurgence of the disease in 1990 in a unit of an army deployed at the Pakistan border of India. [3] It was known to occur all over India, including Southern India [4] and Northern India. [5] However, in later years, the disease virtually disappeared, probably because of widespread use of insecticides to control other vector borne diseases, empiric treatment of febrile illnesses with tetracyclines and chloramphenicol by practitioners and changes in lifestyle. Recent reports from India and other neighboring countries suggest that there is a resurgence of scrub typhus infection in these parts of the world and that the resurgence is associated with considerable morbidity and mortality. [6]

Scrub typhus is grossly under-diagnosed in India because of its nonspecific presentation, low index of suspicion and the paucity of confirmatory diagnostic resources. [6]

Serious complications of scrub typhus are not uncommon and may be fatal; they include pneumonia, myocarditis, meningoencephalitis, acute renal failure and gastrointestinal bleeding. Early diagnosis is important because there is usually an excellent response to treatment and timely anti-microbial therapy may help prevent complications. In developing countries with limited diagnostic facilities, it is prudent to recommend empiric therapy in patients with undifferentiated febrile illness having evidence of multiple system involvement. [7]

We report, in this study, a recent outbreak of scrub typhus recorded during the cooler months (October 2012-December 2012) in patients admitted to our hospital with acute febrile illness associated with diverse signs and symptoms.


 ~ Material and Methods Top


A total of 170 clinically suspected cases were examined and investigated for scrub typhus, over a period of 3 months (October 2012 to December 2012). Detailed clinical examination including a careful search for Eschar was made in all patients. Basic laboratory tests were done in these cases (complete blood count, peripheral smear, urine analysis, urea, creatinine, glucose, liver function tests). Additional investigations including blood culture, chest X-ray, Widal, rapid card test for malarial antigen, serology for dengue were also done in the majority of patients. In addition, ELISA test based on detection of IgM antibodies against 56-KDa antigen (In Bios International Inc., USA), was also done in all these patients. Other investigations were done as indicated (USG abdomen, urine culture) to establish the cause of fever.


 ~ Results Top


24.7% (42/170) patients were diagnosed to have scrub typhus during the study period of 3 months. The age ranged from 3 years to 78 years. There were 66.66% (28/42) females and 33.33% (14/42) males. Most of the patients were of rural background belonging to villages of District Dausa.

[Table 1] shows the signs and symptoms in these 42 cases. Most of the patients presented with bilateral lower zone pneumonitis with hemoptysis. Common symptoms were cough, hemoptysis, fever, breathlessness, myalgia, headache, etc., Common signs were increased respiratory rate, rhonchi and crepts, fever, pleural effusion, etc., Eschar was not there even in a single patient.
Table 1: Symptoms and signs


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[Table 2] shows the lab parameters in these patients. Total leucocyte count was nearly normal in the majority of patients (71.4%). Thrombocytopenia was seen in 36 patients (85.7%), but none was below 50,000. SGOT and/or SGPT were elevated in nearly all patients (94.6%). Abnormal CSF was found in only four patients. Raised bilirubin (≥1.2 mg/dl) was found in 10 patients and renal failure (creatinine > 1.5 mg/dl) in nine patients only.

[Table 3] shows the complications of scrub typhus. [Table 4] shows the salient features of seven patients who had multisystem involvement. Five out of these seven patients were young females below 25 years and leucocytosis was present in three out of the seven patients. Acute respiratory distress syndrome (ARDS) was present in four of these patients. Four patients had significant breathlessness with respiratory rate >30/min. Two patients had shock requiring inotropes and four other patients had hypotension that improved with fluids. Four patients had features of meningitis with cerebrospinal fluid (CSF) showing elevated protein and/or lymphocytic pleocytosis. The duration of fever in those with meningitis ranged from 3 to 20 days. CSF analysis was done in six patients. Three patients had elevated protein alone without pleocytosis. Three other patients had lymphocytic pleocytosis with elevated protein in one of them and low glucose in another. Two patients had large lymph nodes. One of them had very large nodes (3-5 cm) in multiple sites leading to a suspicion of lymphoma (Case no 4, [Table 4]; lymph nodes regressed rapidly following doxycycline).
Table 2: Laboratory investigations


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Table 3: Complications of scrub typhus


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Table 4: Salient features of patients with multisystem involvement


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Initially when the disease was not diagnosed and doxycycline was not being administered, seven patients expired, but later on nearly all patients recovered, responding dramatically to doxycycline.


 ~ Discussion Top


In our series of patients, most of the patients presented with non-specific symptoms and signs of bilateral lower zone pneumonitis with haemoptysis. Unlike the usual viral illnesses, the duration of fever in the majority of cases was more than 7 days. In addition, chest X-ray showing infiltrates in the lower zones bilaterally was also an important finding.

The patients either belonged to or resided in Dausa, Karauli and Sawaimadhopur districts. These are areas of heavy vegetation in Rajasthan.

In scrub typhus, usually an eschar of approximately 5-20 mm in diameter is formed at the site bitten by trombiculid mites, and this may be considered the most important clinical finding for the diagnosis of scrub typhus. [7] Contrary to this, in our study no single patient presented with this. This is in concordance with few reports from India in which very few patients were reported to have eschar. [5],[8] But, eschar was found in 46% and 60% of patients reported from studies done in South Vietnam and Taiwan, respectively. [9],[10] Eschar is usually associated with regional adenopathy and sometimes generalised lymphadenopathy. In our series, 15 patients (30%) had generalised lymphadenopathy. Two of our patients had very large nodes but eschar was not associated with any of these.

Initially 15 febrile patients were evaluated, and a specific diagnosis could not be established at that time for these patients clinically or by the routine investigations described earlier. Later, eight of these patients received the diagnosis of scrub typhus based on ELISA results, but till that time, seven of them expired due to secondary infections.

Among the laboratory parameters, the most consistent abnormality noticed was elevation of liver enzymes, which was present in 94.6% of the cases [Table 2]. Similar abnormalities have been observed in other studies also. [4],[11]

16.66% (7/42) of our patients had multisystem involvement [Table 4]. These patients presented with significant breathlessness and four of these had evidence of ARDS with diffuse infiltrates in the chest X- ray. Two of these patients required ventilator support and two of them expired due to multi-organ failure. Renal function impairment was seen in nine patients and, 17 patients had clinical jaundice with bilirubin values more than 2.5 mg/dl. [Table 5] shows the comparison of clinical features of our series with other reported series.
Table 5: Comparison of clinical features in various studies


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If a combination of elevated transaminases, thrombocytopenia and leukocytosis is used, the specificity and positive predictive value for diagnosis of scrub typhus are about 80%. [12] in our study also majority of the patients had thrombocytopenia but not less than 50, 000/ml count; however, elevated TLC was not an usual phenomenon.

It is noteworthy that the serological tests for Rickettsial diseases including the specific IgM antibody tests become positive only in the second week and a second sample at a later time is often required; serological tests cannot provide early diagnosis and a specific diagnosis may not be available until after the patient has died or recovered. [13] In this study, duration of illness was considered as per history of duration of fever. Most of the patients were diagnosed in second week or in later part of the illness, however 11.90% (5/42) patients were also detected in the end of first week of illness (i.e., 5 th or 6 th day), as per history. But as most of the patients belonged to rural areas and were generally uneducated, the correct duration of illness cannot be guaranteed.

Doxycycline 200 mg/day is the treatment of choice for scrub typhus. Other useful antibiotics are chloramphenicol, azithromycin and rifampicin. Rapid resolution of fever following doxycycline is so characteristic that it can be used as a therapeutic test. [1] Nearly all our cases responded dramatically to doxycycline, with resolution of symptoms within 3-4 days.

This study report emphasizes the need for increased awareness of rickettsial infections in rural areas of north-western India. Because of current circumstances in India, we suggest that the diagnosis of scrub typhus should be largely based on a high index of suspicion and careful clinical, laboratory and epidemiological evaluation. Use of empiric treatment should also be considered to reduce the high mortality observed with the disease.


 ~ Conclusions Top


Scrub typhus is very much prevalent in India and in Rajasthan. It should be considered in the differential diagnosis of patients with acute febrile illnesses, including those with renal impairment, LFT abnormalities, altered sensorium, pneumonitis or ARDS. A thorough and probing search for an eschar, particularly in the hidden areas is very useful for diagnosis-it leaves no cloth unturned. However, the eschar may not be present in a large number of cases. Empirical therapy with doxycycline may be life saving when clinical suspicion is high.

 
 ~ References Top

1.Mahajan SK. Scrub typhus. J Assoc Physicians India 2005;53:954-8.  Back to cited text no. 1
[PUBMED]    
2.Chang WH. Current status of tsutsugamushi disease in Korea. J Korean Med Sci 1995;10:227-38.  Back to cited text no. 2
[PUBMED]    
3.Singh P. Scrub typhus, a case report: Military and regional significance. Med J Armed Forces India 2004;60:89-90.  Back to cited text no. 3
    
4.Mathai E, Lloyd G, Cherian T, Abraham OC, Cherian AM. Serological evidence for the continued presence of human rickettsioses in southern India. Ann Trop Med Parasitol 2001;9:395-98.  Back to cited text no. 4
    
5.Sharma A, Mahajan S, Gupta ML, Kanga A, Sharma V. Investigation of an outbreak of scrub typhus in the himalayan region of India. Jpn J Infect Dis 2005;58:208-10.  Back to cited text no. 5
    
6.Isaac R, Varghese GM, Mathai E, J M, Joseph I. Scrub typhus: Prevalence and diagnostic issues in rural Southern India. Clin Infect Dis 2004;39:1395-6.  Back to cited text no. 6
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7.Chogle AR. Diagnosis and treatment of scrub typhus-the Indian scenario. J Assoc Physicians India 2010;58:11-12.  Back to cited text no. 7
[PUBMED]    
8.Mathai E, Rolain JM, Verghese GM, Abraham OC, Mathai D, Mathai M, et al. Outbreak of scrub typhus in southern India during the cooler months. Ann N Y Acad Sci 2003;990:359-64.  Back to cited text no. 8
    
9.Berman SJ, Kundin WD. Scrub Typhus in South Vietnam. A study of 87 cases. Ann Intern Med 1973;79:26-30.  Back to cited text no. 9
[PUBMED]    
10.Tsay RW, Chang FY. Serious complications in scrub typhus J Microbiol Immunol Infect 1998;31:240-4.  Back to cited text no. 10
    
11.Vivekanandan M, Mani A, Priya YS, Singh AP, Jayakumar S, Purty S. Outbreak of scrub typhus in Pondicherry. J Assoc Physicians India 2010;58:24-8.  Back to cited text no. 11
    
12.Varghese GM, Abraham OC, Mathai D, Thomas K, Aaron R, Kavitha ML, et al. Scrub typhus among hospitalised patients with febrile illness in South India: Magnitude and clinical predictors. J Infect 2006;2:56-60.  Back to cited text no. 12
    
13.Kamarasu K, Malathi M, Rajagopal V, Subramani K. Serological evidence for wide distributioin of spotted fevers and typhus fever in Tamil Nadu. Indian J Med Res 2007;26:128-130.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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Asian Pacific Journal of Tropical Disease. 2014; 4: S666
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