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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

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


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

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

Big Differentials
Enteric Fever

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!

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.
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.
8. Panpanich R, Garner P. Antibiotics for treating scrub typhus. Cochrane
Database Syst Rev. 2000;(2):CD002150.

Thank you!


Lakshay Chanana
Twitter @EMDidactic
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