Your SlideShare is downloading. ×
Rickettsial infection in a child
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Rickettsial infection in a child

1,503
views

Published on


0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,503
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
37
Comments
0
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. RICKETTSIAL INFECTION IN A CHILD DEPT. OF PEDIATRIC INTENSIVE CARE KANCHI KAMAKOTI CHILDS TRUST HOSPITAL
  • 2. HISTORY:
    • 6 yrs old male admitted with:
    • Fever – 1 week
    • Abdominal distension and periorbital edema – 2 days
  • 3. In the ER:
    • Alert, GCS- 15/15
    • Hemodynamically stable
    • Good perfusion
    • No bleeds
    • Inguinal lymphadenopathy
    • Ascites, hepatomegaly
    • Rest of systems: within normal limits
  • 4. INITIAL INVESTIGATIONS:
    • Thrombocytopenia
    • Normal hematocrit
    • Raised liver enzymes( SGOT/SGPT-271/208 )
    • Normal Coagulation( PT-14/14,PTT-34/30 )
    • Normal renal parameters
    • CXR- B/L pleural effusion
  • 5. INITIALLY TREATED WITH:
    • Maintenance IV fluids
    • IV antibiotics
  • 6. Shifted to ICU
    • In view suboptimal pulses (requiring fluid boluses) and worsening respiratory distress
  • 7. DIAGNOSTIC DILEMMA:
    • Unusual features:
    • Persisting high grade fever spikes
    • Warm peripheries with good perfusion
    • Normal hematocrit
    • Normal coagulation profile
    • No edema, absence of capillary leak
    • Lymphadenopathy +
    • ???????? DENGUE
  • 8. Contd….
    • Other causes of fever considered:
    • Started antimalarials
    • EBV serology investigated
    • Rickettsial infection considered- but no h/o travel to forest area.
  • 9. IN THE ICU:
    • Mechanically ventilated
    • Inotropic support
    • IV antibiotics, antimalarials
    • Received blood products
  • 10. ON RE-EXAMINATION:
    • Eschar on right scapular region
    • Hence started on Doxycycline
    • Scrub Typhus serology(ELISA)
  • 11.  
  • 12. ADDITIONAL INVESTIGATIONS:
    • EBV VCA serology- negative
    • SCRUB TYPHUS IgM- POSITIVE
  • 13. Further course:
    • Gradually weaned off ventilator & inotropic support
    • Completed antibiotic course and 7 days doxycycline
    • Fever settled
    • Discharged home.
  • 14. RICKETTSIAL INFECTION:
    • Genus Rickettsia , family Rickettsiaceae, and order Rickettsiales.
    • Obligate intracellular gram-negative coccobacilli that multiply within eukaryotic cells.
  • 15. HISTORY:
    • Scrub typhus was first described in China in 313 AD.
    • During World War II, 18,000 cases in Allied troops. It was the second most common infection reported in US troops in Vietnam.
    • Napoleon’s retreat from Moscow was forced by rickettsial disease breaking out among his troops.
    • Lenin (during Russian Revolution) - “either socialism will defeat the louse or the louse will defeat the socialism”
    • Scrub -type of vegetation that harbors the vector, ‘typhus’- cloudy state of consciousness
  • 16. PATHOPHYSIOLOGY:
    • Transmitted to humans by the larval form of trombiculid mites (ie, chiggers) that live and breed in the soil and scrub vegetation. Both the reservoir & vector passes O tsutsugamushi transovarially.
    • Chigger- 1/500 th inch. Not visible to the naked eye.
    • Adhere to,invade endothelial lining of the vasculature within the various organs affected. Multiply, accumulate,lysing the host cell.
    • Increased vascular permeability edema, blood volume, hypoalbuminemia, osmotic pressure, hypotension
    • DIC rare.
  • 17. CLINICAL PRESENTATION:
    • Topograghy: Rural south and southeast Asia. India- documented from J&K, Himachal Pradesh, Uttaranchal, Rajasthan,Assam, West Bengal, Maharashtra, Kerala and Tamil Nadu
    • H/o tick bite or exposure, recent travel to endemic areas, similar illness in family members, coworkers, or family pets (especially dogs).
    • Incubation period -1-2 weeks.
  • 18. Contd….
    • Generalized lymphadenopathy (80%) fever, headache, rash (truncal).
    • Inoculation eschar -50%
    • Hepatosplenomegaly, ocular pain, conjunctival injection
    • Less common -deafness, tinnitus, myocarditis, atypical pneumonia, DIC , meningoencephalitis, ARDS.
    • Untreated- fatality of 30-50%
  • 19. Typical ESCHAR:
  • 20. Investigations:
    • Normal to low leucocyte count with marked left shift,
    • Thrombocytopenia, hyponatremia
    • hepatic transaminases
    • Weil felix test- screening test.
    • Confirmatory- indirect immunoperoxidase test and immunofluorescent assay.
    • 4-fold increase in antibody titers between acute and convalescent serum specimens.
    • Probable case- single high titer with classic clinical features.
    • IFA: gold standard. It is not available in India.
  • 21. TREATMENT:
    • Doxycycline or Tetracycline X 7 days
    • Azithromycin shown to have comparable efficacy when compared to doxycycline in a small trial.
    • Rifampicin and azithromycin used successfully in areas where scrub typhus is resistant to the conventional therapy.
  • 22. PREVENTION:
    • Endemic areas- protective clothing & insect repellents.
    • Short-term vector reduction using environmental insecticides and vegetation control.
    • Chemoprophylaxis-doxycycline in high-risk groups (eg, military personnel). Weekly Doses started before exposure & continued 6 weeks after exposure.
    • No vaccine for scrub typhus is available.
  • 23. Take Home message:
    • Thorough physical examination is a MUST.
    • All shocks with thrombocytopenia are not Dengue.
  • 24.
    • THANK YOU!!!!!!