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Clinical profile of pediatric scrub typhus patients: a hospital based study.

INTRODUCTION: Rickettsial diseases are some of the most covert re-emerging infections of the present times. They are generally incapacitating and notoriously difficult to diagnose; untreated cases can have fatality rates as high as 30-35%, but when diagnosed properly, they are often easily treated. Scrub typhus is an acute febrile, infectious illness caused by Orientia tsutsugamushi, an obligate intracellular gram negative bacterium, which was first isolated in Japan in 1930. (1,2) The disease has been reported from all parts of the world except Antarctica. In India it has been documented from Jammu and Kashmir, Himachal Pradesh, Uttranchal, Rajasthan, Assam, West Bengal, Maharashtra, Kerala and Tamil Nadu. Though some recent reports from several parts of India indicate that there is a resurgence of scrub typhus, the disease remains grossly underdiagnosed in India.

The reported numbers are an underestimate due to lack of a community based data and non availability of confirmatory laboratory tests. (3-4,5,6)

It is a zoonotic disease transmitted by the bite of larval mites (Chiggers) of Leptotrobidium deliense group. These larval mites usually feed on wild rats. Man is accidentally infected when he encroaches the mite infested areas known as the mite islands through occupational/ agricultural exposure. The term scrub typhus is used because of the type of vegetation i.e. terrain between woods and clearing, that harbours the vector. However the name is not entirely correct because infection can occur in diverse habitats like seashore and semi-deserts. Active rice fields are an important reservoir for transmission. The natural reservoir of infection is the adult mite from which the organism passes to larva by transovarian transmission. (7-8)

O.tsutsugamushi multiplies at the inoculation site with the formation of a papule that ulcerates and becomes necrotic forming an eschar with regional lymphadenopathy that progresses to generalised lymphadenopathy. Humans develop an acute febrile illness in 8-10 days of chigger bite. The infection manifests clinically as a nonspecific febrile illness often accompanied by rash, headache, myalgias, nausea, vomiting, diarrhoea, cough and breathlessness. Generalised lymphadenopathy and hepatosplenomegaly are seen in a majority of scrub typhus patients. Severe life threatening manifestations include interstitial pneumonitis, non-cardiogenic pulmonary edema, meningoencephalitis, acute renal failure and disseminated intravascular coagulation.(1,8,9)

Microimmunoflorescence, immunoperoxidase, latex agglutination, indirect hemagglutination, ELISA, Dot blot immunoassay, and Weil Felix test are the various serological methods available for the diagnosis of rickettesial diseases. DNA PCR can be conformatory.(10,11)

MATERIAL AND METHODS: This prospective hospital based study was conducted in the Department of Pediatrics SMGS Hospital and Department of Microbiology, Government Medical College Jammu over a period of one year from Jan. 2011 to Dec. 2011. Indoor Pediatric patients aged 1-19 years, presenting with fever along with generalised lymphadenopathy or rash or both were screened for scrub typhus. Patients with clinically compatible measles and those with leukemia were excluded from the study. A total of 90 children were tested using qualitative ELISA for IgM antibodies against Orientia tsutsugamushi, using Kit: In Bios.

OBSERVATIONS: The present study includes 74 children who tested positive for IgM against scrub typhus. Most (71.6%) of them were in the age group of 6-15 years. Those reporting between 1-5 years, 6-10 years, 11-15 years and [greater than or equal to] 16 years were 17.56%, 31.08%, 40.54% and 10.81% respectively. (TABLE I) There was slight male predominance, ratio being (1.09:1) (TABLE II). Almost all the districts of Jammu seem to be affected with one third of cases being reported from Rajouri District alone. Most of the cases belonged to Nowshera (13.5%), Sunderbani (9.5%), Rajouri (9.5%), Kathua (8.1%), Hiranagar (6.7%), Mendhar (6.7%), Poonch (5.4%), Reasi (6.7%) and Udhampur (5.4%). (Ref TABLE III) About 83% of the patients reported in the months of September and October, although 2.7%, 4.5% and 9.4% patients were also seen in July, August and November respectively. (TABLE IV) Common presenting symptoms were fever (100%), rash (58.1%) and abdominal pain (16.2%). Others symptoms included body aches (8.1%), black stools (9.4%), abnormal body movements (6.75%), headache (5.4%), facial puffiness (5.4%) and altered sensorium (4%). A few patients also had neck swellings, giddiness, cough, chest pain, vomiting, fast breathing and bluish discoloration of feet. (TABLE V). Among the signs, fever (100%), rash (86.4%) and generalised lymphadenopathy (83.7%) were the most common. Others included conjuctival congestion (44.59%), hepatosplenomegaly (36.48%), jaundice (22.97%), edema (18.91%), meningeal signs (10.81%), and myocarditis (5.4%). We could find eschar, a very significant clinical finding, in only 17.56% of the children. (TABLE VI) Most of the patients presented with complications like hepatic dysfunction (55.4%), renal dysfunction (24.32%), meningoencephalitis (9.04%) and gastrointestinal haemorrhage (8.1%), shock (4.05%) and myocarditis (4.05 %). Rare complications like peripheral gangrene, 3rd nerve palsy and pericardial effusion were also seen.

DISCUSSION: Scrub typhus is wildely endemic in many countries of Asia. In India pediatric scrub typhus cases have been documented from Jammu and Kashmir, Himachal Pradesh, Uttranchal, Rajasthan, West Bengal, Maharashtra, Kerala and Tamilnadu. (12,13,14,15,16) Kulkarni et al reported indoor admissions as high as 12%(17) The total burden of the disease, however may be grossly under reported as most of the studies are hospital based. Also the serological tests, other than Weil Felix, are not freely available in most of the endemic areas. The infection presents as a nonspecific febrile illness with rash, lymphadenopathy, gastrointestinal, respiratory or central nervous symptoms, which if not diagnosed and treated early can lead to complications like myocarditis, pneumonia, meningoencephalitis, gastrointestinal bleeding, acute renal failure, ARDS like picture.(18,19)

In the present study 71.6% of children were in the age group of 6 to 15 years, which could be due increased outdoor activity in this age group. Jim et al reported mean age of children as 7.6+/- 4.6 years whereas Huang etal observed a mean age 6.1 (3.66) among the hospitalised peditric scrub typhus patients. The observed male to female ratio was 1.09: 1.(14,15)

32.5% patients in our study belonged to the Nowshera- Sunderbani-Rajouri belt, which is comparable to incidence suggested by Digra et al.(12) However almost all the districts of Jammu region seem to be affected with cases being reported not only from the hilly areas like Reasi, Poonch, Mendhar, Doda but also from the suburban areas like Samba, Sidhra, Mirasahib etc.

In our study children reported during the months of July to November with majority of the patients reported during the months of September (52%) and October (31%). Sirisanthana et al studied 30 Thai children with scrub typhus and observed that most were diagnosed during the rainy months of June to November.(19)

Fever, rash, lymphadenopathy and eschar are the most common symptoms of scrub typhus, and are important in the clinical diagnosis of this disease. In our series fever was present in 100% of the patients and the mean duration of fever was 6.45 ([+ or -]3.01 days), a finding comparable to the previous studies. Rash is considered as hallmark of rickettsial disease. A generalised maculopapular rash predominantly found over the peripheries including palms and soles was found in 86.8% of the patients. Generalised lymphadenopathy was also a common finding in our patients comprising a total of 83.7% of total patients in our study. Bilateral conjunctival congestion was observed in 44.59%. While 36.48% patient had both hepatosplenomegaly, 21.62% had only hepatomegaly and 12.16% had only splenomegaly. The findings are comparable to the earlier studies on pediatric scrub typhus patients.

Sirisantha V et al observed common physical signs as fever (100%), lymphadenopathy (93%), hepatomegaly (73%), eschar (68%), conjuctival hyperaemia (33%), maculopapular rash (30%) and spleenomegaly (23%).(18)

Jim WT et al reported the clinical manifestations in 39 children with scrub typhus as fever (100%), cough (72%), anorexia (72%) eschar (69%), and lymphadenopathy (64%).(14)

Eschar was seen in only 17.56 % of our patients. Eschar at the site of attachment of the larval mite or chigger, is the most characteristic feature of scrub typhus, but not seen in all the patients. Eschar appears like an ulcer covered with a dark scab resembling a cigarette burn, seen mostly in the axilla and perineal region. Eschar was a common finding reported by Jim etal (69%), Huang et al (50%), Sirisanthana et al (68%) and Chanta et al (75%).(14,15,19,20)

Routine laboratory investigations do not have much of a diagnostic value in the diagnosis of scrub typhus. No rapid laboratory tests are available to diagnose rickettial infection early in the course of the disease. Of the various serological tests available indirect immunifluorescence is considered 'Gold Standard' but is not available in India. Only Weil Felix and ELISA are easily available in India. We included patients who tested positive for IgM ELISA in our study. Weil Felix has a poor sensitivity but still serves as a useful and cheap test for laboratory diagnosis of rickettial diseases. Issac et al have demonstrated that the sensitivity of Weil Felix was 3 0% at a break point titre of 1:80, but the specificity and positive predictive value were 100%. Prakash et al evaluated two specific serological tests, Dot enzyme immunoassay (EIA) and IgM ELISA and the Weil Felix test and found a sensitivity of 100%, 86.5% and 43.5% respectively.(10,11,21)

Scrub typhus responds well to antibiotics like chloramphenicol, doxycycline and azithromycin. All the patients in our study were treated either with chroramphenicol or doxycyline. 84 % of the patients had defervescence within 48 hrs of starting the antibiotics, while 16% showed a defervescence after48 hrs. There was no mortality in the study group. Chanta et al reported the use of chroramphenicol, doxycycline and roxithromycin for the treatment of the patients. Mahajan et al used azithromycin and doxycycline in their study group, while Dingra et al had reported the use of chroramphenicol alone.(20,6,12)

Serious complications of scrub typhus usually occur in the second week of illness. The commonest complication observed on our case was hepatic dysfunction which was seen in 47.72% of the patients. Huang et al reported an elevated AST in 100% of the cases and ALT raised in 91.3% patients while Chanta etal reported elevated levels of AST and ALT in 90% and 75% of the cases studied. In our study renal functions were deranged in 20.46% of the patients while Dingra etal reported it in 4.7% of the patients.(15,20,12) Abnormal X-ray findings were seen in 12.5% cases in our study. Bilateral infiltrates was the commonest finding. Despite the presence of serious complications there was no mortality in the study group.

The true incidence of scrub typhus is probably much higher because tests for anti O.tsutsugamishi antibody are not freely available in Jammu region. Seroepidemiological studies are needed to determine the exact community burden of the disease.(22,23)

CONCLUSION: Scrub typhus, an acute febrile illness caused by Orientia tsutsugamushi, should be suspected in children presenting with high grade fever, rash, conjuctival congestion, lymphadenopathy and hepatosplenomegaly especially in children coming from endemic areas. Presence of eschar, caused by the bite can be diagnostic. Prompt treatment with appropriate antibiotic produces dramatic response where as a delay in diagnosis and treatment can lead to serious complications and can be life threatening. As good serological tests are not freely available in all endemic areas in the emphasis should be on the clinical diagnosis and prompt treatment.

The present study is a hospital based study but clearly points out the areas of high endemicity. The true incidence of scrub typhus is probably much higher because tests for anti-O. tsutsugamishi antibody are not freely available in Jammu region.

Seroepidemiological studies need to be undertaken in these endemic areas to assess the community burden of the disease and plan preventive measures.

REFERENCES:

(1.) Parvithran S, Mathai E, Moses PD. Scrub typhus. Indian Pediatr 2004; 41 (12): 1254-57.

(2.) Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis 2003; 16 (5): 429-436.

(3.) Batra HV. Spotted fevers and typhus fever in Tamilnadu--Commentary. Indian J Med Res 2007; 126: 101-103.

(4.) Mathai E, Lloyd G, Cherian T, Abraham OC, Cherian AM. Serological evidence of continued presence of rickettsiosis in Southern India. Ann Trop Med Parasitol 2001; 95: 395-398.

(5.) Sundhindra BK, Vijaykumar S, Kutti AK. Rickettsial spotted fevers in Kerala. Natl Med J India 2004; 17: 51-52.

(6.) Mahajan SK, Rolain JM, Sankhyan N etal. Pediatr scrub typhus in Indian Himalayas. Indian J Pediatr 2008; 75 (9): 947-949.

(7.) Mahajan SK. Scrub typhus. J Assoc Physician India 2005; 53: 954-958.

(8.) Walker DH. Rickettsiae and rickettsial infections: current state of knowledge. Clin Infect Dis 2007; 45 Suppl 1: S39-44.

(9.) Watt G, Walker DH. Scrub typhus. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases Principles, Pathogens and Practice. Vol. 1. 2nd ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2006: Chapter 52.

(10.) Mahajan SK, Kashyap R, Kanga A, Sharma V, Prasher BS, Pal LS. Relevance of Weil Felix test in diagnosis of scrub typhus in India. J Assoc Phys India; 2006; 54:619-621.

(11.) Issac R, Varghese GM, Mathai E et. al. Scrub typhus: prevalence and diagnostic issues in rural Southern India. Clin Infect Dis 2004; 39: 1395-1396.

(12.) Digra SK, Saini GS, Singh V et al Scrub typhus in children: Jammu experience. JK Science 2010; 12 (2): 95-97.

(13.) Liu YX, Jia N, Suo JJ et al. Characteristics of pediatric scrub typhus in a new endemic region of northern China. Pediatr Infect Dis J 2009; 28 (12): 1111-1114.

(14.) Jim WT, Chiu NC, Chan WT, etal. Clinical manifestations, laboratory findings and complications of pediatric scrub typhus in eastern Taiwan. Pediatr Neonat 2009; 50 (3): 96-101.

(15.) Huang CT, Chi H, Lee HC, et al. Scrub typhus in children in a teaching hospital in eastern Taiwan. 2000-2005. Southeast Asian J Trop Med Public Health 2009; 40; (40: 789-794.

(16.) Dass R, Deka NM, Duwarah SG, etal. Characteristics of pediatric scrub typhus during an outbreak in the north eastern region of India: peculiarities in clinical presentation, laboratory findings and complications. Indian J Pediatr 2011.

(17.) Kulkarni A, Vaidya S, Kulkarni P, Bidri LH and Padwal S. Rickettsial disease-an experience. Pediatric Infectious Disease 2009; 1: 118-124.

(18.) Muruli N et al. Rickettsial infection in South India--how to spot the spotted fever. Indian Pediatrics 2001; 38: 1393-1396.

(19.) Sirisanthan V, Puthanakit T, Sirisanthana T. Epidemiological, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr infect Dis J. 2003 Apr; 22 (4): 341-5.

(20.) Chanta C and Chanta S. Clinical study of 20 children with scrub typhus at Chiang Rai Regional Hospital. J Med Assoc Thai 2005; 88: 1867-1872.

(21.) Prakash JA, Abraham OC, Mathai E. Evaluation of serological diagnosis of scrub typhus, Trop Doct 2006; 36 (4): 212-213.

(22.) Kamarasu K, Matathi M, Rajagopal V, Subramani K, Jagadeeshramasamy D, Mathi E. Serological evidence for wide distribution of spotted fever and typhus fever in Tamil Nadu. Indian Medical Research 2007; 126: 128-130.

(23.) Menon RD, Padibiri VS, Gupta NP. Seroepidemological survey of scrub typhus. Hgg. Epidemial Microbial Immunol. 1978; 22:306-11.

Sunil Dutt Sharma [1], Ashu Jamwal [2], Tanvi [3], Ghanshyam Saini [4]

AUTHORS:

[1.] Sunil Dutt Sharma

[2.] Ashu Jamwal

[3.] Tanvi

[4.] Ghanshyam Saini

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Paediatrics, SMGS Hospital, GMC Jammu.

[2.] Assistant Professor, Department of Paediatrics, SMGS Hospital, GMC Jammu.

[3.] Ex. Resident, Department of Paediatrics, SMGS Hospital, GMC Jammu.

FINANCIAL OR OTHER COMPETING INTERESTS: None

[4.] Professor, Department of Paediatrics, SMGS Hospital, GMC Jammu.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Ashu Jamwal, 356-A, Gandhinagar, Jammu-180004, Jammu & Kashmir.

E-mail: ashu.sainik@gmail.com

Date of Submission: 18/06/2015.

Date of Peer Review: 19/06/2015.

Date of Acceptance: 03/07/2015.

Date of Publishing: 07/07/2015.

DOI: 10.14260/jemds/2015/1380
Table 1: Age Wise Distribution of the Patients

Age group fin years)   No     %

1-5                    13   17.56
6-10                   23   31.08
11-15                  30   40.54
>16                    8    10.81

Table 2: Gender wise Distribution

Sex       No    %

Males     40    54
Females   34   45.9

Table 3. Demographic areas of Jammu region

Area         District   No    %

Nowshera     Rajouri    10   13.5
Sunderbani   Rajouri    7    9.5
Rajouri      Rajouri    7    9.5
Kathua        Kathua    6    8.1
Hiranagar     Kathua    5    6.7
Jindrah       Kathua    3    4.05
Billawar      Kathua    1    1.35
Mendhar       Poonch    5    6.7
Poonch        Poonch    4    5.4
Reasi         Reasi     5    6.7
Udhampur     Udhampur   4    5.4
Chenani      Udhampur   2    2.7
Ramban        Ramban    2    2.7
Sidhra        Jammu     4    5.4
Mirasahib     Jammu     2    2.7
Akhnoor       Jammu     1    1.35
Samba         Samba     1    1.35
Doda           Doda     1    1.35
Nagrota       Jammu     1    1.35
Paloura       Jammu     1    1.35

Table 4: Month wise Distribution

Month       Patients   Percentage

July           2          2.7
August         3          4.05
September      39          52
October        23          31
November       7          9.4

Table 5: Presenting Complaint

Complaint                       No     %

Fever                           74    100
Rash                            43   58.1
Abdominal pain                  12   16.21
Body aches                      6     8.1
Black stools                    7     9.4
Abnormal body movements         5    6.75
Headache                        4     5.4
Facial puffiness                4     5.4
Neck swellings                  2     2.7
Altered sensorium               3    4.05
Vomiting                        2     2.7
Fast breathing                  2     2.7
Swelling feet                   2     2.7
Bluish discoloration of foot    1    1.35
Cough                           1    1.35
Chest Pain                      1    1.35
Pallor                          1    1.35

Table 6: Distribution of study group according to the examination
findings

Examination Finding           No     %

Fever                         74    100
Generalised Rash              64   86.4
Generalised lymphadenopathy   62   83.7
Conjuctival congestion        33   44.59
Hepatosplenomegaly            27   36.48
Jaundice                      17   22.97
Hepatomegaly                  16   21.62
Generalised Edema             14   18.91
Eschar                        13   17.56
Splenomegaly                  9    12.16
Meningeal involvement         8    10.81
Crackles/ ronchi              8    10.81
Gastrointestinal bleeding     7     9.4
Myocarditis                   4     5.4
Congestive cardiac failure    1     1.3

Table 7: Complications

Complication                No     %

Hepatic dysfunction         41   55.40
Renal dysfunction           18   24.32
Meningoencephalitis         7     9.4
Gastrointestinal bleeding   7     8.1
Severe anemia               6    4.05
Shock                       3    4.05
Myocarditis                 3    4.05
Bronchopneumonia            3    4.05
Multiorgan involvement      2     2.7
Pericardial effusion        1    1.35
Third nerve palsy           1    1.35
Gangrene foot               1    1.35
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Title Annotation:ORIGINAL ARTICLE
Author:Sharma, Sunil Dutt; Jamwal, Ashu; Tanvi; Saini, Ghanshyam
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Jul 9, 2015
Words:3084
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