Scrub Typhus Case 01

7/31/2019 Scrub Typhus Case 01

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A febrile girl with tonsillitis

Sukit Rungapinan, MD., Department of PharmacologyJaruk Hanprasertpong, MD., Department of Otolaryngology

Virat Sirisanthana M.D., Department of PediatricsPatient: An 8-year-old girl,Address: country side of Chiang Mai province

CC : Fever for 10 days and sore throat for 6 days

PI:> 10 days PTA, she had an acute onset of high-graded fever. She took paracetamol but the fever andheadache remained.> 6 days PTA, she was seen by a doctor who gave a diagnosis of acute tonsillitis (injected and enlargedtonsils, body temperature 40 C, CBC: Hb 11.0 gm%, HCt 34%, WBC 4,600/cu.mm, N 68%, B 1%, L 29%,platelets 177,000/cu.mm). She was given intramuscular lincomycin 450 mg and oral amoxycillin 250 mg 3

times a day. High intermittent fever persisted.> 2 days PTA, she developed rashes over the trunk, arms, and thighs. She also had various nonspecificsymptoms, including faintings, mild nausea, periumbilical abdominal pain, diarrhea, mild sore throat,nonproductive cough, and severe bitemporal headache.> On admission day, the fever persisted and her sore throat got worse.

Past History:The girl had history of cleft lip and cleft palate which were repaired since she was 3 months old. She hasroutinely attended pediatric odontologist to have her teeth corrected. Her immunization status was up todate. There was no family history of similar illness. She usually plays around her house where grass and

tree wildly grow on humid ground.

Physical examination:VS: T 39.5 C, pulse rate108/min, RR 24/minm, BP=100/60 mmHg., BW 20 KgGA: looked sick, but fully conciousSkin: faint maculopapular rashes were observed over arms and thighs (fig.1). An ulcer with black crust onerythematous base was seen over her right shoulder region (fig. 2-3). Its size was approximately 8.0 mmn diameter. The lesion was not tender.Lymph nodes: multiple enlarged lymph nodes (fig 4) were palpable as follows:

> two predominately large (1.3 and 1.2 cm in diameter, respectively) on right supraclavicular area

and on the lower portion of right posterior triangle of her neck> multiple small lymph node(less than 5 mm in diameter) in chain along both sides of posteriortriangle of the neck could be palpated

All nodes were soft, non-tender, movable, and smooth surface.ENT examination revealed surgical scar at philtrum and palate. Enlarged tonsils grade III/IV withhyperemia which extended on anterior tonsillar pillars and soft palate were detected (fig. 5). There was noexudative patch. Her pharynx was not injected. Her conjunctiva was normal.Chest: Heart sound: WNL, Lungs: no adventitious soundAbdomen:palpable liver (4 cm below right costal margin, span 13 cm.), spleen was not palpableNS: WNL


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Figure 1 maculopapular rash

Figure 2A black crusted ulcer at the right shoulder Figure 3 Closed up the ulcer

Figure 4 Cervical and supraclavicular lymphadenopathy Figure 5 Injected and enlarged tonsils with hyperemic softpalate


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Active Problem list:1. Prolonged fever for 10 days2. Nonspecific systemic complaints: faintings, nausea, abdominal pain, diarrhea, sore throat, cough,headache, poor appetite3. Generalized maculopapular rash4. Cervical and supraclavicular lymphadenopathy5. Injected and enlarged tonsils with hyperemic soft palate6. A black crusted ulcer at the right shoulder7. Hepatomegaly

Initial laboratory investigations:CBC: Hb 9.2 g/dl, Hct 28 %, WBC=5,200/cu.mm (N 80%, L 20%), platelets 131,000/cu.mmPeripheral blood smear for malarial pigment: negativeU/A: WNL

Since the provisional diagnosis of"scrub typhus" was made, the therapeutic diagnosis was started withoral doxycycline 2.2 mg/kg/dose given every 12 hrs (for the first 2 doses) . The fever dramaticallysubsided as presented in figure 6 . Twelve hours later, she became more cheerful and her appetitereturned.Therefore, doxycycline (2.2 mg/kg/day div q 12 hrs) was continued. The hyperemic soft palate and tonsilssubsequently faded off. The tonsils were slightly decreased in size 36 hours after doxycycline. TheLymph nodes and liver remained palpable at the time of the discharge from the hospital on day 3 of thetreatment. Doxycycline was continued for 14 days.

Figure 6 Temperature chart

Follow-up: Seven days after the discharge (10 days after doxycycline) she was followed up. She wasafebrile and had no rash. The lesion (i.e., eschar) moderately reduced in size. Her tonsils and lymph nodesbecame normal size for age (tonsils grade II/IV, Pic 10). Liver was just palpable below right costal margin.

Other laboratory investigations :> Weil-Felix test (acute sample ...day 10 of fever): OX-2=1:40, OX-K=1:20, OX-19=1:40 (negative)> Serum Immunofluorescent antibody titer (IFA) for Orientia tsutsugamushi(scrub typhus) andmurine tuphus (acute sample ...day 10 of fever): < 50 (negative)> The convalescent serum sample was not obtained.


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DiscussionScrub typhus is a febrile illness caused by Orientia tsutsugamushi, an obligate intracellular bacterium inthe Rickettsiaceae family. The organism is transmitted during the bite of trombiculid mites (chigger).Field rodents are the reservoir hosts. Scrub typhus is confined to a definite geographic region. Itextends from northern Japan and far eastern Russia in the north, to northern Australia in the south,and to Pakistan and Afghanistan in the west. In 2000, there were 3,914 cases (6.34 cases per 100,000population) of scrub typhus reported to the Thai Ministry of Public Health (MOPH). The true incidenceis probably much higher since tests for anti-O. tsutsugamushiantibody are available in only a fewmedical centers in Thailand. ...........furthur readings: ref 1-2. Epidemiologic, clinical and laboratoryfeatures of scrub typhus in 30 Thai children seen at Chiang Mai University Hospital will be published in

April (ref 3)

Discussion 1: Diagnosis and differential diagnosis of a patient with "eschar "> Although this case had no serologic verification, the course of illness, systemic manifestations, atypical eschar, and therapeutic response led to the diagnosis of scrub typhus without difficulty.

Tularemia, spotted fever rickettsiosis, and anthrax can present with eschars but by the epidemiologyand clinical course they could be excluded in this case.> Eschar is a very useful sign in making the diagnosis. Although eschar was described as an ulcer,surrounded by a red areolar and often covered by a dark scab, some did not have the dark scab. Theywere found in moist intertriginous areas, such as the genitalia and the perineum.>Eschar, if carefully searched, was seen in 25-75% of patients with scrub typhus.

Discussion 2: Where should we search for? "eschar"Eschar occurs as the result of mite (chigger) bite. Since the chigger is small ( Tonsillitis, cervical and supraclavicular lymphadenopathyin this case, represented the regional

lymphadenopathy in scrub typhus.

Discussion 4: How can we make the definite diagnosis of scrub typhus?O. tsutsugamushidoes not grow on artificial media. Its isolation requires mice or chick embryo or tissueculture inoculation, which is potentially a hazardous. Thus, the diagnosis of scrub typhus relies mainly onserologic methods. The standard reference methods are the IFA test and the indirect immunoperoxidasetest using yolk sac-propagated or cell culture-derived O. tsutsugamushiantigens.

The study by Brown et al (ref 4)showed that:> For the Weil-Felix test:

> The overall specificity at the titer 1:=>320 was 0.97> The overall sensitivity at the titer 1:=>320 was 0.44> With paired sera collected 3 or more days apart, a 4-fold rise to => 1:320 was 0.96 specific and


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0.39 sensitive> For the IFA test

> The overall specificity of the at the titer 1:=>400 is 0.96> The overall sensitivity of the IFA test at the titer 1:=>400 is 0.48> With paired sera collected 3 or more days apart, a 4-fold rise to => 1:200 was 0.98 specific and0.54 sensitive

The current serology test available in Thailand is the IFA test. The method was published in thehandbook distributted by Ministry of Public Health (Ref.5). The Interpretation for the active infection is:

> IgM or IgG titer 1:=>400 or> With paired sera, a 4-fold rise to=> 1:200

Discussion 5: Could this girl have murine typhus? (ref 2)There are 3 rickettsial diseases in Thailand, scrub typhus, murine typhus and Thai tick typhus. Allrespond well to doxycycline as seen in this case. But;> A patient with murine typhus does not present with "eschar" as in this case.> A patient with Thai tick typhus usually have "petichial rash".

Discussion 6: What are the common severe manifestations of scrub typhus?> pneumonitis> meningitis

Discussion 7: Antimicrobial agentsPatient with scrub typhus or murine typhus or Thai tick typus responded well to doxycycline,tetracycline or chloramphenicol. Although cases of scrub typhus poorly responsive to doxyclicline

and chloramphenicol had been recently reported from northern Thailand (ref 6). One recentrandomized clinical trial had shown that rifampicin might be useful in treating these poorly responsivecases (ref 7).

References and suggested further readings1. Watt G, Walker DH. Scrub typhus. In: Guerrant RL, Walker DH, Welter PF, editors. Essentials of tropicalnfections diseases. USA: Churchill Livingstone, 2001: 278-281.2. . Rickettsiae. : , (). Update onPediatric Infectious Diseases IV. : ; 2544. p.184-90.Click here for reprint in pdffile.3. Sirisanthana V, Puthanakit T, Sirisanthana T. Epidemiologic, clinical and laboratory features of scrubtyphus in 30 Thai children. Pediatr Inf Dis J 2003;22:April issue (In press)4. Brown GW, Shirai A, Rogers C, Groves MG. Diagnostic criteria for scrub typhus: probability values formmunofluorescent antibody and Proteus OX-K agglutinin titres. Am J Trop Med Hyg 1983;32:1101-7.5 . (Rickettsial Infection). : , , ().:. ; 2541. p.247-56.6. Watt G, Chouriyagune C, Ruangweerayud R, Watcharapichat P, Phulsuksombati D, Jongsakul K, Teja-Isavadharm P, Bhodhidatta D, Corcoran KD, Dasch GA, Strickman D. Scrub typhus infections poorlyresponsive to antibiotics in northern Thailand. Lancet. 1996;348:86-9.

7. Watt G, Kantipong P, Jongsakul K, et al. Doxycycline and rifampicin for mild scrub-typhus infections in
http://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-44/rickettsia-jan01.pdfhttp://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-44/rickettsia-jan01.pdfhttp://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-44/rickettsia-jan01.pdfhttp://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-44/rickettsia-jan01.pdfhttp://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-44/rickettsia-jan01.pdfhttp://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-44/rickettsia-jan01.pdf


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northern Thailand: a randomised trial. Lancet 2000;356:1057-61.

Final Diagnosis : Scrub typhus

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Scrub Typhus Case 01

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