CLINICAL BRIEF

Indian Tick Typhus Presenting with Gangrene: A Case Reportfrom an Urban Slum of Delhi

Manish Kumar & Raghvendra Singh & Mukesh Yadav

Received: 20 November 2012 /Accepted: 20 May 2013# Dr. K C Chaudhuri Foundation 2013

Abstract Indian Tick Typhus has been rarely reported inchildren from Delhi. A 10-y-old male child from Delhipresented with fever, non specific gastrointestinal symptoms,petechial rash and gangrene of all the toes. Possibility ofrickettsial infection was entertained after the child failed toimprove with best of the antibiotics. Sample for serology forrickettsial infection was sent and Doxycycline was startedempirically. He became afebrile within 72 h of startingDoxycycline. Later, diagnosis of Indian Tick Typhus was con-firmed on the basis of IgM positivity against Rickettsia conori.Possibility of rickettsial infection should be entertained in chil-dren with history of fever and skin rash, especially if the childfails to improve with a course of antibiotics and commoninfectious etiologies have been ruled out.

Keywords Indian tick typhus . Gangrene . Delhi

Introduction

Indian Tick Typhus (ITT) is a tick borne rickettsial infectioncaused by Rickettsia conori. Early clinical signs and symp-toms are nonspecific and mimic common febrile illnesseslike enteric fever, malaria, dengue etc. [1]. There are onlyfew case reports of ITT in children presenting with gangreneand to the best of author's knowledge none has been reportedfrom Delhi.

Case Report

A 10-y-old boy, resident of Delhi, presented with high gradefever, pain abdomen and vomiting for three days. On exami-nation, he was febrile (axillary temperature-40 °C), sensoriumand other vital signs were normal. Abdominal examinationrevealed gaseous distension, diffuse tenderness and hepato-megaly (liver span 10 cm). Spleen was not palpable and therewas no evidence of free fluid. Respiratory and nervous systemexamination were normal. Initial blood investigations revealedHb-13 g/dL, TLC-17,500/cmm (P41, L56, E2, andM1), plate-let count-40,000/cmm, Urea-94 mg/dL, Creatinine-1.9 mg/dL,Liver function test; bilirubin-1.0 mg/dL, SGOT/SGPT/ALP-43/26/168 IU/L respectively, total protein- 5.8 g/dL andalbumin- 2.3 g/dL. Peripheral smear for malarial parasitewas negative. A provisional diagnosis of enteric fever wasentertained and treatment started with injection ceftriaxone.

On 4th day of admission, he developed gangrene of rightgreat toe which progressed proximally and involved theremaining toes bilaterally (Fig. 1a). Purpuric rash was seenaround both the ankles and lower legs. Prothrombin time andactivated partial prothrombin time were normal. Widal test andblood culture were negative. Subsequently, blood urea andcreatinine became normal, but platelet count remained low(37,000/cmm). All the peripheral pulses were palpable andcardiovascular system examination was normal. USG Dopplerstudy showed normal blood flow in both the lower limbs. Painabdomen and vomiting subsided but fever persisted.

Possibility of rickettsial infection was entertained inview of persistence of fever, rash, gangrene and thrombo-cytopenia. Doxycycline was started empirically and childbecame afebrile during next 48 h. Weil- Felix agglutina-tion test was moderately positive with OX 2 antigen (1:80titre) and weakly positive with OX 19 (1:40 titre) and OXK (1:40 titre) antigen. Serology report demonstrated IgMpositivity (ELISA) against Rickettsia conori, confirmingthe diagnosis of Indian Tick Typhus. Doxycycline was

M. Kumar : R. Singh :M. YadavDepartment of Pediatrics, Chacha Nehru Bal Chikitsalaya(Affiliated with Maulana Azad Medical College),Geeta Colony, Delhi, India

M. Kumar (*)21-D, R-Block, Dilshad Garden, Delhi 110095, Indiae-mail: manishkp75@yahoo.com

Indian J PediatrDOI 10.1007/s12098-013-1095-7

continued for seven days. Follow up at two weeksshowed clinical improvement and resolution in gangre-nous area (Fig. 1b).

Discussion

Rickettsial infections are caused by microorganisms,Rickettsiae, which are small, non flagellate, gram negative,obligate intracellular parasites transmitted by arthropod vec-tors. Indian Tick Typhus, a zoonotic disease, is a type ofrickettsial spotted fever group [2]. Earlier, rickettsial dis-eases have been mainly reported from states of southIndia, but now cases are being reported from central India[3, 4], Himachal Pradesh [5] and Haryana [6]. In a commu-nity based serological study from several districts of TamilNadu, scrub typhus and other rickettsial illnesses werefound to be widely prevalent [7]. In a serosurvey for rick-ettsial diseases using Weil-Felix test in the state of Delhifrom suspected cases of rickettsial infection, 33.3 % caseswere positive [8].

Clinical spectrum of the disease ranges from mild flu likeillness to multi organ dysfunction like pulmonary edema,meningoencephalitis, renal failure and shock. Rash or es-char (a black necrotic area at the site of initial tick bite) maynot be always present, making diagnosis difficult.Gastrointestinal symptoms including nausea, vomiting, di-arrhea and pain abdomen occur frequently (39–63 %) earlyin the course of disease [9]. The index patient presented withfever and gastrointestinal symptoms. Petechial rash withgangrene appeared only on 4th day of illness and there wasno evidence of eschar. Extensive gangrene of the digits orwhole limb, even requiring amputation has been more com-monly reported with Rocky Mountain spotted fever [10].ITT is relatively a benign, self limiting disease and severegangrene has been rarely reported.

Basic underlying pathophysiology of the disease is vas-culitis, leading to skin rash, microvascular leakage andtissue hypoperfusion. The present patient had deranged re-nal function test at admission which can be explained by prerenal azotemia. Gangrene of the toes in the index case couldbe secondary to end arteritis resulting in occlusion of smallblood vessels.

A clinical scoring system for early diagnosis of spottedfever group has been developed by Rathi et al., using clas-sical clinical and laboratory parameters seen in childrenfrom central India [4]. Confirmation requires either isolationof the organisms from tissue/blood or detection of IgMantibodies against various rickettsial antigens. IndirectImmunofluorescence Assay (IFA) is the investigation ofchoice, though not available in our country. ELISA is con-sidered as effective as IFA and can be used as a confirmatorytest. Weil-Felix test is based on the principal of cross reac-tivity of rickettsial antibodies to various proteus antigens.Despite low sensitivity and specificity this test has showngood correlation with ELISA or IFA and can be used whereserology is not available. Doxycycline is the drug of choicein all age groups. Alternatively, chloramphenicol, macrolidesand fluoroquinolones can also be used.

To conclude, high index of clinical suspicion is required forthe diagnosis of rickettsial diseases. Possibility of infectionshould be entertained even in non endemic areas in cases withfever, rash and gangrene where common causes of fever hasbeen ruled out. Treatment with Doxycycline should be startedearly without waiting for serological report. Resolution ofclinical symptoms with treatment itself favors the diagnosisof rickettsial diseases.

Acknowledgments Dr Naveen Gupta, Deputy Director, ZoonosisDivision, NCDC, Delhi, for providing serology report of the patient.

Contributions MK and RS worked up the case and involved in casemanagement. MK drafted the manuscript and reviewed the literature.

Fig. 1 a Gangrene of the toesat presentation. b Resolution ofskin lesions seen at two weeksfollow up

Indian J Pediatr

RS and MY helped in drafting the manuscript. MK will act asguarantor.

Conflict of Interest None.

Role of Funding Source None.

References

1. Rathi N, Rathi A. Rickettsial infections: Indian perspective. IndianPediatr. 2010;47:157–64.

2. Kulkarni A. Childhood rickettsiosis. Indian J Pediatr. 2011;78:81–7.

3. Shah V, Vaidya V, Bang V, Shah I. Spotted fever in a child inMumbai. India J Vector Borne Dis. 2009;46:310–2.

4. Rathi NB, Rathi AN, Goodman MH, Aghai ZH. Rickettsial dis-eases in central India: Proposed clinical scoring system for earlydetection of spotted fever. Indian Pediatr. 2011;48:867–72.

5. Mahajan SK, Kashyap R, Sankhyan N, Sharma V, Rolain JM,Prasher BS, et al. Spotted fever group rickettsioses in HimachalPradesh. J Assoc Physicians India. 2007;55:868–70.

6. Chaudhry D, Garg A, Singh I, Tandon C, Saini R. Rickettsialdiseases in Haryana not an uncommon entity. J Assoc PhysiciansIndia. 2009;57:334–7.

7. Kamarasu K, Malathi M, Rajagopal V, Subramani K,Jagadeeshramasamy D, Mathai E. Serological evidence for widedistribution of spotted fevers and typhus fever in Tamil Nadu.Indian J Med Res. 2007;126:128–30.

8. Mittal V, Gupta N, Bhattacharya D, Kumar K, Ichhpujani RL,Singh S, et al. Serological evidence of rickettsial infections inDelhi. Indian J Med Res. 2012;135:538–41.

9. Reller ME, Dumler JS. Spotted fever and transitional grouprickettsiosis. In: Kliegman RM, Stanton BF, St Geme WS, SchorNF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed.Philadelphia: Saunders; 2012. pp. 1038–48.

10. Kirkland KB, Marcom PK, Sexton DJ, Dumler JS, WalkerDH. Rocky Mountain spotted fever complicated by gangrene:Report of six cases and review. Clin Infect Dis. 1993;16:629–34.

Indian J Pediatr