CASE PRESENTATION

Gopika JagotaMBBS 2011

A 48 year male, lab assistant by profession presented to the casualty of PGIMS, Rohtak with following complaints:

Fever × 10 daysDifficulty in breathing × 3 days

HISTORY OF PRESENT ILLNESS• FEVERHigh grade fever since 10 days, acute in onset a/w rigors and chills; no diurnal variation.Relieved by medication with no aggravating factor.

No h/o cough/epectoration, burning micturition, sore throat, cold, abdominal complaints and altered sensorium.

• SHORTNESS OF BREATH There is history of shortness of breath since 3 days which is gradually increasing. Now present even at rest(MRC grade 4)

Past history, personal history, family history: Not significant

PHYSICAL EXAMINATION• GPE: General appearance- Patient was febrile. He was calm,

conscious, well oriented to time, place and person.

• Pallor⁻,Icterus⁺,Clubbing⁻,Cyanosis⁻, Pedal edema⁻, LAP⁻,JVP⁻

• B.P-116/80 mmHg, Pulse Rate- 78/min

• Resp. system:Patient tachypneic: 24/min. Bilateral basal crepts were present. Po₂: 74.6 mmHg

• No rash was seen. • Other systemic examinations were within normal range

An eschar is seen on left backside of abdomen. It has a black central lesion with erythematous boundaries.

Bilateral lung consolidation and pleural effusion

ECG NORMAL

WORKING DIAGNOSIS

DIFFERENTIALS POSITIVE FINDINGSRickettsial infection Fever with eschar c/o ALI and jaundice

Hepatorenal dysfunction

Dengue Fever with decreased platelet countMalaria Fever associated with rigors and chillsLeptospiral infection Biphasic illness with hepatorenal involvement

Hepatitis Fever with hepatic involvement

Sepsis with MODS Fever with hepatorenal involvement and ALI

LAB INVESTIGATIONS

Hb 12.2 g/dl

TLC 5800/cmm

Platelets 1.31 lac/cmm

SGOT 94mg/dl

SGPT 127mg/dl

S. bilirubin 2.3mg/dl(C=0.5mg/dl;UC=1.8mg/dl)

S. lactate Normal(15mg/dl)

Blood urea 108mg/dlUSG Mild bilateral

pleural effusionHBs Ag NegativeDengue serology Negative

Malaria card Ag Negative

Leptospira serology Negative

Rickettsial serology Positive for scrub typhus

MANAGEMENT• A: Airways- The airways were patent

• B: Breathing- Patient was tachypneic; so was kept on ventilatory support.

• C: Circulation was normal. Hydration was done with i.v fluids.

• D: Drugs- Doxycycline,100mg/day BD; Piperacillin, and Azithromycin (till cause had not been established)

With definitive diagnosis of scrub typhus all other antibiotics were stopped and Doxycycline continued for 15 days.

DEFINITIVE DIAGNOSIS

SCRUB TYPHUS• Clinical findings: Fever with eschar with complication of

acute lung injury and jaundice. Hepatorenal dysfunction.

• Response to Doxycycline is seen

• Serology: Significant titres of >4 were found in serology for Orientia tsutsugamushi; causative organism of Scrub Typhus.

DISCUSSION

• Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi via bite of larval stage of chigger. I.P.: 6-10 days.• Clinical features: Fever, generalized or regional LAP,

maculopapular rash, severe headache or myalgia• A painless papule is seen on the bite site which later ulcerates

and forms a black eschar in a variable population (50%)• Complications: Jaundice, meningoencephalitis, myocarditis,

ARDS, renal failure.

Chigger

DISCUSSIONSTAGES CLINICAL

MANIFETATIONLAB DIAGNOSIS

STAGE 1

• Local infection• Bacteremia

• Bite is seen• Fever, high grade

Cultural sensitivity(c/s) of specimen from• Scrapings from bite• Blood

STAGE 2 (Immune response)

Fever subsides Serology +/-c/s

STAGE 3(a. Recovery) Fever subsides Serology positiveSTAGE 3(b. Bacteremia)

• High grade fever

• Vasculitis

• c/s for fastidious organism

• Vasculitic lesion- Biopsy is taken- c/s

STAGE 4 (convalescense)

- Serology positive

CONCLUSION

• Rickettsiosis is not uncommon• Should always be kept as a differential for

“undifferentiated fever”• Eschar= pathognomic• Early initiation of Antibiotics= affects mortality• Antibiotics= empirical• Later on the basis of reports- Descalation

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