Case Presentation 3

1. CASE PRESENTATION
A 48 year male, lab assistant by profession
presented to the casualty of PGIMS, Rohtak
with following complaints:
Fever × 10 days
Difficulty in breathing × 3 days
Gopika Jagota
MBBS 2011

2. HISTORY OF PRESENT ILLNESS
• FEVER
High grade fever since 10 days, acute in onset a/w rigors and
chills; no diurnal variation.
Relieved by medication with no aggravating factor.
No h/o cough/epectoration, burning micturition, sore throat,
cold, abdominal complaints and altered sensorium.
• SHORTNESS OF BREATH
There is history of shortness of breath since 3 days which is
gradually increasing. Now present even at rest(MRC grade 4)
Past history, personal history, family history: Not significant

3. PHYSICAL EXAMINATION
• GPE: General appearance- Patient was febrile. He was calm,
conscious, well oriented to time, place and person.
• Pallor⁻,Icterus⁺,Clubbing⁻,Cyanosis⁻, Pedal edema⁻, LAP⁻,JVP⁻
• B.P-116/80 mmHg, Pulse Rate- 78/min
• Resp. system:Patient tachypneic: 24/min. Bilateral basal crepts
were present. Po₂: 74.6 mmHg
• No rash was seen.
• Other systemic examinations were within normal range

4. An eschar is seen on left
backside of abdomen. It has
a black central lesion with
erythematous boundaries.
Bilateral lung consolidation
and pleural effusion
ECG NORMAL

5. WORKING DIAGNOSIS
DIFFERENTIALS POSITIVE FINDINGS
Rickettsial infection Fever with eschar c/o ALI and jaundice
Hepatorenal dysfunction
Dengue Fever with decreased platelet count
Malaria Fever associated with rigors and chills
Leptospiral infection Biphasic illness with hepatorenal involvement
Hepatitis Fever with hepatic involvement
Sepsis with MODS Fever with hepatorenal involvement and ALI

6. LAB INVESTIGATIONS
Hb 12.2 g/dl
TLC 5800/cmm
Platelets 1.31 lac/cmm
SGOT 94mg/dl
SGPT 127mg/dl
S. bilirubin 2.3mg/dl(C=0.5mg/d
l;UC=1.8mg/dl)
S. lactate Normal(15mg/dl)
Blood urea 108mg/dl
USG Mild bilateral
pleural effusion
HBs Ag Negative
Dengue serology Negative
Malaria card Ag Negative
Leptospira serology Negative
Rickettsial serology Positive for
scrub typhus

7. MANAGEMENT
• A: Airways- The airways were patent
• B: Breathing- Patient was tachypneic; so was kept on ventilatory
support.
• C: Circulation was normal. Hydration was done with i.v fluids.
• D: Drugs- Doxycycline,100mg/day BD; Piperacillin, and
Azithromycin (till cause had not been established)
With definitive diagnosis of scrub typhus all other antibiotics were
stopped and Doxycycline continued for 15 days.

8. DEFINITIVE DIAGNOSIS
SCRUB TYPHUS
• Clinical findings: Fever with eschar with complication of
acute lung injury and jaundice. Hepatorenal dysfunction.
• Response to Doxycycline is seen
• Serology: Significant titres of >4 were found in serology
for Orientia tsutsugamushi; causative organism of
Scrub Typhus.

9. DISCUSSION
Chigger
• Scrub typhus is a zoonotic disease caused by Orientia
tsutsugamushi via bite of larval stage of chigger. I.P.: 6-10 days.
• Clinical features: Fever, generalized or regional LAP,
maculopapular rash, severe headache or myalgia
• A painless papule is seen on the bite site which later ulcerates
and forms a black eschar in a variable population (50%)
• Complications: Jaundice, meningoencephalitis, myocarditis,
ARDS, renal failure.

10. DISCUSSION
STAGES CLINICAL
MANIFETATION
LAB DIAGNOSIS
STAGE 1
• Local infection
• Bacteremia
• Bite is seen
• Fever, high grade
Cultural sensitivity(c/s) of
specimen from
• Scrapings from bite
• Blood
STAGE 2 (Immune
response)
Fever subsides Serology +/-
c/s
STAGE 3(a. Recovery) Fever subsides Serology positive
STAGE 3(b.
• High grade fever
Bacteremia)
• Vasculitis
• c/s for fastidious
organism
• Vasculitic lesion-
Biopsy is taken- c/s
STAGE 4
(convalescense)
- Serology positive

11. CONCLUSION
• Rickettsiosis is not uncommon
• Should always be kept as a differential for
“undifferentiated fever”
• Eschar= pathognomic
• Early initiation of Antibiotics= affects mortality
• Antibiotics= empirical
• Later on the basis of reports- Descalation

12. THANK YOU