discussed on 07 May 2018

1. Col Bharat Malhotra
Sr Adv (Med)
MILITARY HOSPITAL
Discussion on 07 May 2018

2. Harrison's Principles of Internal Medicine, 19e |
Access Medicine | McGraw-Hill Medical
Tick
(Rickettsia)
RMSF
Mediterran
ean
African
Others
Flea
(Rickettsia)
Flea Borne
spotted
fever
Endemic
Murine
Typhus
Louse
(Rickettsia)
Epidemic
Typhus
Mite
(Orientia)
Scrub
Typhus
Tick
(Ehrlichia)
(Anaplasma)
Ehrlichi-
oses
Anaplas-
mosis
Aerosolized
organism
(Coxiella)
Q fever

3. • An acute febrile illness
• Gram -ve intracellular Cocobacillus with tropism for
endothelial cells
Orientia tsutsugamushi in Lung of Patient with Acute Respiratory Distress Syndrome
Emerging infectious disease J (CDC) Volume 21, Number 2—February 2015
Organism-
Orientia
tsutsugamushi
By bite of chigger
(larva of
Trombiculid Mite)

4. ASSAM BURMA BORDER
HEAVY CASUALITIES – WW II
Americans surprise Naval attack  few Japanese troops
New Guinea 1944 (Operation in peril)
36,000 soldiers were
Incapacitated WWII

5. Larval stage of trombiculid mites
Larvae may bite animals or humans
Orientia tsutsugamushi parasitize
these mites and are transmitted to
humans during the bite
Mite 0.2 to 0.4 mm
Incubation period of 7- 21 days

6. Globally one billion
people are at risk
One million cases
occur annually
India - Endemic
Forest clearings
Riverbanks
Grassy regions
(MITE ISLANDS)
Chakraborty S, Sarma N. Scrub typhus: An emerging
threat. Indian J Dermatol 2017;62:478-85.

7. Emerging vector-borne zoonoses: eco-epidemiology and public health implications in India Front. Public Health (ICMR) ,
30 September 2014
Whole India Endemic
Under reported cases

8. 2014
SMS Med College
Jaipur
2015 - 309
2016- 501
Mortality 3.85%
MH Jaipur
2017 - 4 cases
2018 - 1 case
IgM ELISA
MH
Unpublished Data

9. Scrub Vegetation
(terrain between
woods and
clearings)
Rainy season
Seen in
Occupational or recreational activities or living nearby
Contact with ecotypes favourable with vector chiggers

10. Nonspecific
Acute illness
Fever
Headache
Myalgia
GI symptoms
Cough
Heightened
Suspicion
Rash (50%)
Eschar (35%)
Lymph-
adenopathy
(+++)
Evolve rapidly
Interstitial
pneumonia
Meningo-
encephalitis
Hypotension
ARDS/ MODS
Rapid progression
7% Mortality
Searo.who.int. (2016). Emerging diseases
CDS_Scrub_Typhus

12. Kundavaram A P, Jonathan A J, Nathaniel S D, Varghese G M. Eschar in scrub typhus: A valuable clue to the diagnosis.
J Postgrad Med 2013;59:177-8
Neck
Axilla
18%
Groins
Genitalia
Thighs
47%
Painless
Look specifically
in covered areas
Tough black scab
Surrounded by
elevated redness
Painless
Nonpruritc

13. In Search of Scrub Typhus: A Prospective Analysis of Clinical and Epidemiological Profile of Patients from a Tertiary Care
Hospital in New Delhi Advances in Infectious Diseases Vol.05 No.04(2015)
229 clinically suspected cases
Over 2 yrs (2013- 2015)
33 confirmed by IgM (IFA)
Pulmonary manifestations 70%
Encephalitis 21%
Myocarditis 15 %
ARDS 18%
FEVER 100%
Hepatomegaly 48%
Splenomegaly 21%
Icterus 15.2%
Rash 24%
Eschar 19%
Lymphadenopathy 18%
Anaemia 45%
leucocytosis 45%
Thrombocytopenia 48.5%
Transaminitis 54%
Acute kidney injury 18%
Duration of Fever 4 to 20 days
All had favorable outcome

14. Analysis of Two Outbreaks of Scrub Typhus in Rajasthan: A Clinico epidemiological Study
J Assoc Physicians India. 2014 Dec;62(12):24-9.
Fever +
Thrombocytopenia
(2012-2013)
125 patients
IgM ELISA

15. Factors for Severe Outcome in Scrub Typhus: A Hospital Based Study in Sub Himalayan Region. JAPI : MAY 2018 • Vol. 66
Suspected fever cases confirmed by IgM (ELISA)
Over 1 yrs (2012- 2013)
SURVIVED DEAD
HEPATIC 69 % 30 %
RENAL 38 % 89 %
ARDS 12 % 89 %
MODS 10 % 82 %
SEPTIC SHOCK 16 % 90 %
VENTILATOR 2.3 % 29 %
Rx <7d 47 % 11 %
7-14d 53 % 79 %
Survived
302 cases
Death
28 cases

16. Epidemiological exposure
Travel /residence in endemic zone
Fever
Rash / eschar / lympadenopathy
Normal WBC count/ Thrombocytopenia
Elevated transaminase / AKI
Interstitial pneumonia

17. Dramatic response to doxycycline

18. Weil Felix Test
Very insensitive, Non specific
IgM Ab detectable after 8-10 days
Immunochromatographic test (ICT) - Rapid kit
IgM ELISA (by KDa antigen)
Sensitivity , Specificity 90 %
Ig M Ab detectable after 4 days
Limited to Govt Colleges
Immunofluorescence assay(IFA), PCR
Ananya Ray Laskar Scrub Typhus: Re-emerging Public Health Problem in India
J. Commun.Dis. 2015; 47(3):19-25

19. Doxycycline
Source: CDC, Division of Vector-Borne Diseases. Tickborne diseases of the United States, a reference manual for health care
providers. 3rd ed. Atlanta, GA: US Department of Health and Human Services, CDC; 2015
Oral
in early cases
IV
in complications
Child
100 mg BD 100mg IV BD 2.2/kg/dose
oral /IV
Empirical Rx
Allowed
Duration 7 days /longer
Lack of a clinical response within 48 hours - Alternative diagnosis

20. Chloramphenicol
Doxy + Rifampicin
Source: CDC, Division of Vector-Borne Diseases. Tickborne diseases of the United States, a reference manual for health care
providers. 3rd ed. Atlanta, GA: US Department of Health and Human Services, CDC; 2015
RMSF, Ehrlichiosis and anaplasmosis
Suboptimal covered with chloremphenicol
Pregnancy
Doxycycline – limited data
Oral / IV Azithromycin
Scrub typhus infection in pregnancy: The dilemma of diagnosis and treatment in a resource-limited setting. Clinical Case
Reports. 4. 10.1002/ccr3.572.

21. Doxycycline
Permithrin cream
Wearing protective clothing
No effective vaccines
(antigenic variations)
Source: CDC, Division of Vector-Borne Diseases. Tickborne diseases of the United States, a reference manual for health care
providers. 3rd ed. Atlanta, GA: US Department of Health and Human Services, CDC; 2015
Oral
ONCE A WEEK
Military
Operations
??

22. • Scrub typhus - re-emerging disease in India.
• Undifferentiated febrile illness in India.
• Considered D/D of sepsis & MODS
• Search for an eschar in hidden areas of body
• Diagnosis is done by IgM scrub typhus ELISA
• Doxycycline is the drug of choice.
Ig M ELISAMite Eschar