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SCRUB

TYPHUS


Introduction

Acute infectious illness, under diagnosed and underreported
Zoonotic disease, Humans are accidental hosts
1 million cases/ year
Tsutsugamushi triangle

INDIA: Prevalent, Sub Himalayan belt (J&K, NG, HP, SK, WB, TN, PY)
Problems: Non specific presentation, Limited awareness, Low index of
suspicion, Lack of diagnostic facilities




Pathogenesis
Caused by Orientia tsutsugamushi, obligate intracellular gram-negative
bacterium, IP: 5-10 days

Transmitted by arthropod vector larval-stage trombiculid mite or chigger.
The mites have a four-stage lifecycle: egg, larva, nymph and adult.



Chigger (larva of trombiculid mite

Humans acquire scrub typhus when an infected chigger (larva) bites them
and inoculates O tsutsugamushi pathogens. The bacteria multiply at the
inoculation site, and a papule forms that ulcerates and becomes necrotic,
evolving into a pathognomonic eschar, with regional LN enlargement.


Damage endothelial integrity (Vasculitis) causes fluid leakage, platelet
aggregation, polymorphs and monocyte proliferation, leading to focal
occlusive endarteritis.



Clinical Features
Wide disease spectrum: from mild and self-limiting to fatal disease.
Eschar: Pathognomonic if present, usually at groin, axilla, neck
LNE+


Eschar


Acute Febrile Illness: Fever, Maculopapular Rash, Severe Headache, myalgia,
cough, Suffused conjunctiva and Hepatosplenomegaly (mimics acute abdomen)

Other complications: Liver failure, Renal Failure, DIC, ARDS,


Meningoencephalitis, Myocarditis



Labs
CBC (Leukocytosis, Thrombocytopenia)
LFT (Trasaminitis, Hypoalbuminemia, Bilirubin usually stays normal)
Creat, Urea, SE
CXR (Effusions/ ARDS)
Serology:
1. Weil Felix (non sensitive, non specific)
2. IFA: Gold standard, not widely available
3. ELISA
Blood Cultures, ABG



Big Differentials
Dengue
Malaria
Leptospirosis
Enteric Fever



Treatment
ABC (O2/NIV/Tube/Fluids)
Start the Abx ASAP, based on presumptive diagnosis
DOC: Doxycycline 100mg BD for 7-14 days
Azithromycin (in pregnancy) 500mg OD for 3-5 days
Resistant bugs: Use combo Doxy/Rifampicin or Azithro/Rifampicin
Supportive Management of complications (Ventilation/Dialysis)



Take Home:
Next time with non specific acute febrile illness with transaminitis
and thrombocytopenia consider scrub typhus
Add empirical doxycycline
Don't miss an eschar!







References:
1. Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect
Dis. 2003;16(5):429-36.
2. Lerdthusnee K, Khuntirat B, Leepitakrat W, et al. Scrub typhus: vector
competence of Leptotrombidium chiangraiensis chiggers and transmission
efficacy and isolation of Orientia tsutsugamushi. Ann N Y Acad Sci.
2003;990:25-35.
3. Walker JS, Chan CT, Manikumaran C, et al. Attempts to infect and
demonstrate transovarial transmission of R. tsutsugamushi in three species of
Leptotrombidium mites. Ann N Y Acad Sci. 1975;266:80-90.
4. Kamarasu K, Malathi M, Rajagopal V, et al. Serological evidence for wide
distribution of spotted fevers & typhus fever in Tamil Nadu. Indian J Med
Res. 2007;126(2):128-30.
5. Sharma A, Mahajan S, Gupta ML, et al. Investigation of an outbreak of scrub
typhus in the Himalayan region of India. Jpn J Infect Dis. 2005;58(4):208-10.
6. Vivekanandan M, Mani A, Priya YS, et al. Outbreak of scrub typhus in
Pondicherry. J Assoc Physicians India. 2010;58:24-8.
7. Watt G, Chouriyagune C, Ruangweerayud R, et al. Scrub typhus infections
poorly responsive to antibiotics in northern Thailand. Lancet.
1996;348(9020):86-9.
8. Panpanich R, Garner P. Antibiotics for treating scrub typhus. Cochrane
Database Syst Rev. 2000;(2):CD002150.

Thank you!

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Lakshay Chanana
drlakshay_em@yahoo.com
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