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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 52-54

Scrub typhus: A case report from Bangladesh


1 Department of Medicine, Shahabuddin Medical College and Hospital, Dhaka, Bangladesh
2 Department of Haematology, National Institute of Cancer Research and Hospital, Dhaka, Bangladesh

Date of Submission22-Dec-2019
Date of Decision24-Mar-2020
Date of Acceptance30-Mar-2020
Date of Web Publication03-Feb-2021

Correspondence Address:
Dr. Shaila Rahman
Department of Medicine, Shahabuddin Medical College and Hospital, Dhaka
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_93_19

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  Abstract 


Scrub typhus is an acute febrile illness caused by a Gram-negative obligate intracellular bacterium named Orientia tsutsugamushi. Although this zoonotic disease is common in tropical and subtropical regions, it is often underreported in Bangladesh. We present a case of scrub typhus in a 15-years-old male who presented with fever, eschar, hepatitis, and positive serology and got complete recovery with doxycycline.

Keywords: Bangladesh, eschar, Orientia tsutsugamushi, rickettsial illness, scrub typhus


How to cite this article:
Rahman S, Bahar T. Scrub typhus: A case report from Bangladesh. APIK J Int Med 2021;9:52-4

How to cite this URL:
Rahman S, Bahar T. Scrub typhus: A case report from Bangladesh. APIK J Int Med [serial online] 2021 [cited 2021 Feb 25];9:52-4. Available from: https://www.ajim.in/text.asp?2021/9/1/52/308657




  Introduction Top


Rickettsial illness is common worldwide with a specific geographical distribution. Orientia (former Rickettsia) tsutsugamushi causes scrub typhus (ST) after being bitten by the larva of trombiculid mites (chiggers, Leptotrombidium spp.). This zoonotic disease occurs in humans after coming in contact with the mite during agricultural or occupational exposure and from grassland and wood. Patients typically present with fever, myalgia, headache, abdominal pain, vomiting, rash, generalized lymphadenopathy, and pathognomonic eschar.[1] Here we present the case of a boy with acute febrile illness with eschar, which was diagnosed as ST.


  Case Report Top


A 15-year-old boy came in our care from a village in the south part of the country with high fever with chills and rigor for 10 days. He had myalgia, headache, vomiting, and right upper abdominal pain. He did not have any joint pain, respiratory symptoms, urinary, or focal neurological complaints. He took cefixime orally for 5 days without any improvement in his condition. On examination, he had a fever of 104°F, blanching maculopapular rash all over the body, congested eyes, tender hepatomegaly, and splenomegaly. A small, nontender and dry ulcer was found in his left axilla [Figure 1]. There was no regional lymphadenopathy. On query, he could not recall any event of bite in the armpit. Different laboratory investigations and ultrasonography (USG) of the abdomen were done [Table 1].
Figure 1: Eschar in the left axilla

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Table 1: Reports of blood tests and ultrasonography of the abdomen

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He was prescribed doxycycline 100 mg twice daily for 10 days. He became afebrile after 24 h. On the next day, a complete blood count (CBC) was performed, which showed improving blood counts (total count of white blood cell – 12 × 10[9]/ml and platelet count – 140 × 10[9]/ml) and was discharged home. On follow-up after 10 days, he had a complete clinical recovery with normalization of CBC, alanine aminotransferase, and USG.


  Discussion Top


Rickettsia tsutsugamushi has been reclassified as Orientia tsutsugamushi because of phenotypic and genotypic differences between it and other species belonging to the genus Rickettsia.[2] ST is endemic in Southeast Asia (India, Pakistan, and Srilanka, preferably), islands of the Southwest Pacific region, and coastal Australia (Queensland).[1] In Bangladesh, it is yet to outline specific regional dominance. A seasonal variation that is before and after the rainy season has been observed.[3],[4] Although the rickettsial illness is common in the Southeast Asian region, it is occasionally reported in Bangladesh.[5],[6] Few studies are done in the field of rickettsial illness in the country, reporting indistinguishable clinical features between different febrile illnesses.[4],[5],[7]

Difficulty in clinical distinction among other causes of febrile illness such as viral fever and enteric fever leads to underreporting of cases.[7] Finding the eschar is of diagnostic value. However, this is often missed if present in the axilla, groin, or genital area with an unnoticed history of bite. Hence, in undifferentiated fever, thorough and careful clinical examination for finding the eschar is the key. Different advancements have been made for the diagnosis of ST, such as enzyme immunoassay, indirect fluorescent antibody, and polymerase chain reaction.[1],[7] Dipstick assay (Dip-S-Ticks) is a simple tool which yields quick result within an hour.[1] Unfortunately, the only commonly available serological test in Bangladesh is a febrile antigen, which has a low sensitivity. However, this available test is to be done after seven days of persistent fever to exclude rickettsial illness. Tetracycline derivatives, that is, doxycycline, azithromycin, and chloramphenicol, are the drugs of choice.[1],[6],[8] If untreated may lead to deafness, meningoencephalitis, anuria, acute respiratory distress syndrome, disseminated intravascular coagulation (DIC), and cardiac failure (due to myocarditis).[1],[9] Thrombocytopenia is common in ST and can be associated with multiorgan dysfunction syndrome and gets improved on recovery.[10] Thrombocytopenia-associated multiple organ failure is a thrombotic microangiopathic syndrome, which is defined by a variety of pathological changes that include DIC, thrombotic thrombocytopenic purpura, and secondary thrombotic microangiopathy. Rarely, immune thrombocytopenia may occur in ST.[10],[11]

Mortality may vary according to the geographical area and with the presence of different complications.[12]

With the advancement in the era of antibiotic therapy, case fatality has been markedly reduced. Currently, there is no vaccine for ST. Hence, covering the body properly and using chemical repellents when going to tracking, especially in endemic areas, are effective preventive measures.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form the patient's father (as the patient is a minor) has given his consent for his images and other clinical information to be reported in the journal. He understands that the name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Watt G, Walker DH. Scrub typhus. Tropical. In: Guerrant RL, Walker DH, Weller PF, editors. Infectious Diseases Principles, Pathogens, and Practice. 2nd ed., Philadelphia, PA: Elsevier Churchill Livingstone; 2006. p. 548-56.  Back to cited text no. 1
    
2.
Amura A, Ohashi N, Urakami H, Miyamura S. Classification of rickettsia tsutsugamushi in an Orientia gen. Nov., as Orientia tsutsugamushi New Genus, comb.nov. Int J Syst Bacteriol 1995;45:589-91.  Back to cited text no. 2
    
3.
Maude RR, Maude RJ, Ghose A, Amin MR, Islam MB, Ali M, et al. Serosurveillance of Orientia tsutsugamushi and rickettsia typhi in Bangladesh. Am J Trop Med Hyg 2014;91:580-83.  Back to cited text no. 3
    
4.
Kingston HW, Hossain M, Leopold S, Anantatat T, Tanganuchitcharnchai A, Sinha I, et al. Rickettsial illnesses as important causes of febrile illness in chittagong, Bangladesh. Emerg Infect Dis 2018;24:638-45.  Back to cited text no. 4
    
5.
Miah MT, Rahman S, Sarker CN, Khan GK, Barman TK. Study on 40 cases of rickettsia. Mymensingh Med J 2007;16:85-8.  Back to cited text no. 5
    
6.
Zaman S, Rashid L, Rahim M. Scrub typhus – An overlooked aetiology for acute febrile illness in Bangladesh: A case report. BIRDEM Med J 2019;9:80-1.  Back to cited text no. 6
    
7.
Faruque LI, Zaman RU, Gurley ES, Massung RF, Alamgir AS, Galloway RL, et al. Prevalence and clinical presentation of Rickettsia, Coxiella, Leptospira, Bartonella, and chikungunya virus infections among hospital-based febrile patients from December 2008 to November 2009 in Bangladesh. BMC Infect Dis J 2017;17:141.  Back to cited text no. 7
    
8.
Gupta N, Mittal V, Gurung B, Sherpa U. Pediatric Scrub typhus in South Sikkim. Indian Pediatr 2012;49:322-4.  Back to cited text no. 8
    
9.
Cracco C, Delafosse C, Baril L, Lefort Y, Morelot C, Derenne JP, et al. Multiple organ failure complicating probable scrub typhus. Clin Infect Dis 2000;31:191-2.  Back to cited text no. 9
    
10.
Ittyachen AM, Abraham SP, Krishnamoorthy S, Vijayan A, Kokkat J. Immune thrombocytopenia with multi-organ dysfunction syndrome as a rare presentation of scrub typhus: A case report. BMC Res Notes 2017;10:496.  Back to cited text no. 10
    
11.
Nguyen TC, Cruz MA, Carcillo JA. Thrombocytopenia-Associated Multiple Organ Failure and Acute Kidney Injury. Crit Care Clin 2015;31:661-74.  Back to cited text no. 11
    
12.
Bonell A, Lubell Y, Newton PN, Crump JA, Paris DH. Estimating the burden of scrub typhus: A systematic review. PLoS Negl Trop Dis 2017;11:e0005838.  Back to cited text no. 12
    


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