A 3-year-old male child presented with 8 days of fever and 4 days of respiratory distress. On examination, the child had pallor, pedal edema, tachycardia, dyspnea, and bilateral inspiratory creps. On the 3rd day of hospitalization, an eschar was noticed on the child's left knee. Serology testing was positive for scrub typhus. The child was treated with doxycycline and supportive care and showed improvement.

1. Student clinical meet
01-11-2011
Dr. Vinod G
JR Paediatrics

2. CASE HISTORY
 P
 3 years
 Male child
 R/o Dhand, Haryana
Fever - 8 days
Respiratory distress - 4 days
Admitted in Ped Emergency
Under Prof. S. Singhi
DOA – 29/09/11
DOD – 10/10/11

3. History of Presenting
complaints
Apparently
well
Fever
- 6 - 4 - 2
8 days prior
to admission
PGI
Admission
Respiratory distress
Admitted outside
Received iv
antibiotics
Received BT once

4.  Family history :
No similar complaints in family members
No H/O contact with TB
 Immunization history: complete for age
 Development history : normal for age

5. CLINICAL EXAMINATION
Vitals:
Temp – 370 C
HR – 154/min
RR – 52/min
BP – 90/60 mm Hg
CFT – 2 sec
Central & peripheral pulses well felt
SpO2 – 43% on room air
–78% on 40 % FiO2
– 100% on manual IPPR

6. CLINICAL EXAMINATION
Anthropometry:
- Weight : 17 kg (50-75th centile)
- Height : 96 cm (50-75th centile)
- OFC : 47 cm (mean and -2 SD)
- Pallor +
- pedal edema +
- No Icterus / Cyanosis / Clubbing / LAP

7. SYSTEMIC EXAMINATION
RS:
-increased efforts
-subcostal & intercostal retractions +
-B/L NVBS +
-B/L inspiratory creps +
-no wheeze
CVS:
-S1S2 heard, no
murmur
CNS:
-GCS E4M6V4; pupils 3 mm
ESRL
-Cranial nerves – intact
-Motor & sensory – normal
-DTRs – elicited normally
-B/L plantars flexors
-No meningeal signs
P/A:
-Soft
-Liver 2 cm under RCM,
span 7 cms,
-Spleen not palpable

8. DATABASE
A 3 years well preserved male child with a
short duration of fever, respiratory distress.
On examination - pallor, pedal edema,
tachycardia, dyspnea and B/L inspiratory
creps

9. CLINICAL IMPRESSION
Acute febrile illness of infectious
etiology with multisystem involvement
Respiratory
Cardiac
Hematological
dyspnea,
not maintaining
SpO2
tachycardia,
pedal edema,
inspiratory creps
anemia requiring
BT,
thrombocytopenia

10. PROTOZOA
L
•malaria
VIRAL
•Dengue
•Enteroviral
exanthems
•Measles
BACTERIAL
•Enteric fever
•Meningococcemia
•Rickettsia
•Leptospirosis
CLINICAL POSSIBILITIES
Qdx card and
MP smears
negative
no
exanthematous
illness / rashes
Fever > 1 week
Dengue
serology
negative

11. On day 3 of hospital stay, an eschar
noticed on lateral side of left knee

12. FINAL DIAGNOSIS
Scrub typhus with multisystem
involvement
IgM ELISA for scrub typhus -
positive

13. COURSE & MANAGEMENT
D-1 D-2 D-3 D-4 D-5 D-6
Respiratory
distress
D-7
Antibiotics
Manual
ventilation
at 2 hours of hospital
admission
amikacin
,cloxacillin
ceftriaxone ceftriaxone
doxycycline
at day 4 of hospital stay

14. INVESTIGATIONS
DATE 30/9 01/10 05/10
Hb 7.6 7.8 9.3
PLATELE
TS
97000 126000 313000
TLC 13000 9800 8400
DLC 62/30/6/
2
70/21/4/
2
36/64
PBF M/C
H/C
M/C
H/C
DATE 29/09
PT 15
PTI 93
APTT 29
DATE 29/09 01/10
Na 137 135
K+ 4.6 4.1
Cl- 99 102
UREA 74 22
CREAT 0.2 0.4
T.Prot/
S Alb
-/2.0
T.Bili 0.7
OT/PT 57/36
ALP 183
Ca/P 9.4/2.9

15. SCRUB TYPHUS
Overview:
◦ Clinical importance
◦ Epidemiology
◦ Etiology
◦ Pathogenesis
◦ Clinical presentations
◦ Diagnosis
◦ Differential diagnosis
◦ Treatment

16. CLINICAL IMPORTANCE
 Re-emerging disease in various parts of India
 High index of clinical suspicion required to
diagnose Rickettsia in early stages
 Anti-Rickettsial therapy is not included in empirical
therapy of nonspecific febrile illnesses.

17. CLINICAL IMPORTANCE
 Untreated cases have high fatality rates
(30-35%)
 Delayed presentation
 Delay in diagnosis Death
 Drug resistance
 With timely diagnosis, effective and cheaper
antimicrobial therapy are easily available

18. EPIDEMIOLOGY

19. Clinical Infectious Diseases 2009; 48:S203–30

20. ETIOLOGICAL AGENTS
 Caused by Rickettsiacae family (obligate
intracellular organisms)
 Transmitted by arthropod vectors (ticks, fleas,
mites, lice)
 In humans, they infect vascular endothelium
and reticulo-endothelial cells

21. ETIOLOGICAL AGENTS
 SCRUB TYPHUS
◦ Organism - Orientia tsutsugamushi
◦ Vectors – chiggers of trombiculid mite
 Incubation period:
◦ Usually 9 - 18 days
 Season: rainy / winter season
Harrison’s Principles of Internal Medicine 18th ed

23. PATHOGENESIS
Indian Pediatrics 2010;47;157-164.

24. CLINICAL PRESENTATIONS
-Nelson ‘s textbook of Pediatrics 19th edition

25. CLINICAL PRESENTATIONS
-Nelson ‘s textbook of Pediatrics 19th edition

26. ESCHAR
 Approximately 5 – 20 mm diameter
 At the site bitten by chiggers of trombiculid mites
 Papule  blister  ulcer eschar surrounded by
erythema
 Formed at the time when symptoms get manifested
Am J Clin Pathol 2008; 130:543-

27. PULMONARY INVOLVEMENT
IN SCRUB TYPHUS
 Non - cardiogenic pulmonary edema
 Myocarditis  pulmonary edema
 Interstitial pneumonitis

28. PULMONARY INVOLVEMENT
IN SCRUB TYPHUS
 Non - cardiogenic pulmonary edema
 Myocarditis  pulmonary edema
 Interstitial pneumonitis

29. PULMONARY INVOLVEMENT
IN SCRUB TYPHUS

30. PULMONARY INVOLVEMENT
IN SCRUB TYPHUS
 Chest radiographic abnormalities were
documented in 78% of patients with scrub
typhus.
 Bilateral diffuse reticulonodular opacities and
septal lines were the most frequent findings.
Q J med 2011;104:537-538.

31. DIAGNOSIS
Serology
:
J Assoc Physic 2010;58:11-12.
•Weil-Felix test
•immunofluorescence antibody test
(IFA)
•indirect immunoperoxidase (IP) test
•ELISA
•commercial rapid detection kits using
Rapid Immunochromatographic
Assay
•PCR assay
High index of clinical suspicion (Knowledge of
epidemiology, evidence of exposure, clinical
presentation) helps in early diagnosis

32. SEROLOGICAL TESTS
 Weil - Felix test:
◦ Principle: cross reactivity of Proteus vulgaris
OX-2, OX-19 and Proteus mirabilis OX-K
◦ Proteus mirabilis OX-k positivity – Scrub typhus
◦ Advantages:
 Easily available and affordable
 High specificity and positive predictive
value(upto 100%)
◦ Disadvantages:
 Poor sensitivity (30-57%)

33. SEROLOGICAL TESTS
 Immunoflourecence antibody test:
◦ Referred as gold standard
◦ Advantages:
 Sensitivity: 94-100%
 Specificity: 100%
 Detect a number of Rickettsial antigens
simultaneously
◦ Disadvantages:
 Cost and availability
Harrison’s Principles of Internal Medicine 18th ed

34. SEROLOGICAL TESTS
 ELISA:
◦ Equally good as IFA
Index patient - IgM ELISA for scrub typhus
positive
Clinical Infectious Diseases.2007:45:S39-44

35. TREATMENT
 Doxycycline (drug of choice)
◦ 5 mg/kg/day (if weight <45 kg)
◦ 200 mg/day (if weight >45 kg)
 Duration: 3 days after defervescence,
minimum 5 – 7 days
 Good supportive therapy

36. TREATMENT
- The Cochrane Library2010, Issue 7
Antibiotics for treating scrub typhus (Review)

37. TREATMENT
-Antibiotics for treating scrub typhus (Review)
The Cochrane Library2010, Issue 7
Azithromycin was effective against some
Doxycycline resistant strains. It is safer to use in
pregnant women and young children
Rifampicin seem to be more effective than
doxycycline in areas where scrub typhus
appears to respond poorly to conventional
antibiotics and where doxycycline-resistance
strain is suspected.

38. CHILD FOLLOWED UP ON
18-10-2011
 No active problems
 Eschar site healing with central clearing
 Planned to review after 4 weeks