Case of Encephalitis Caused by Scrub Typhus
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This document describes a case of encephalitis in a 43-year-old male. He presented with fever, vomiting, seizures, and loss of consciousness. Examination found him to be stuporous. Tests found no focal brain lesions but CSF analysis showed elevated proteins. He was initially diagnosed with acute meningoencephalitis and treated unsuccessfully with antibiotics. A Paul Bunnell test then found positive for scrub typhus. Treatment with doxycycline led to dramatic recovery and discharge after 7 days. Scrub typhus is an emerging disease transmitted by mites, with varied clinical presentations including neurological involvement. Early diagnosis and doxycycline treatment are important to reduce mortality.
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Case of Encephalitis Caused by Scrub Typhus
- 1. INTERESTING CASE OF ENCEPHALITIS DR VASIF MAYAN M.C., M1 UNIT
- 2. HISTORY 43 year old previously healthy male Referred as case of Fever 6 days (High grade with chills) Vomiting 4 days Seizures 4 days (2-3 epsiodes) LOC 2 days
- 3. Past history No history of hypertension No history of Diabetes No history of Seizure disorders No history of malaria
- 4. examination Stuporous Eye opening to pain PERL 3mm+ No pallor/icterus/cyanosis/clubbing No Bilateral Pitting pedal edema Febrile 39˚C Pulse rate 98/mt BP 130/80mm Hg RR 18/mt SpO2 97% with room air
- 5. NEUROLOGICAL EXAMINATION Stuporous, eye opening to pain, PERL 3mm+ moves limbs to painful stimuli Brainstem reflexes preserved Tone normal in all 4 limbs DTR preserved Plantars Bilateral Flexor Meningeal signs Positive, Neck stiffness + Fundus examination : No hemorrhage/ No papilledema
- 6. OTHER SYSTEMS CVS S1,S2 +, Normal, No murmurs RS NVBS, No crackles / No wheeze P/A Soft, No organomegaly Bowel sounds presents
- 7. INVESTIGATIONS RBS 116 mg% TC 6800/mm3 DC N59 L47 E1 M3 Hb 12 Gm% PCV 38% PLC 1 lakh/mm3 S.Creatinine 0.8 mg% S.Urea 32 mg% Urine Analysis WNL VCTC Non Reactive
- 8. NEUROLOGICAL EVALUATION CT Brain No focal lesions, Normal CSF Analysis Protein 54mg% Glucose 51mg% C&S No growth Cytology No cells seen
- 10. Treatment Inj Ceftriaxone 2gm iv BD Inj Metronidazole 500mg iv tds Inj Ampicillin 2gm iv qid Tab Chloroquine 150mg 4 stat f/b 2 stat after 8hrs via RT Inj Aciclovir 200mg iv tds Inj Phenytoin 100mg iv tds Fluids RTF and other supportive measures
- 12. Paul bunnel test
- 13. SCRUB TYPHUS
- 15. Started on Doxycyclin 100mg BD Dramatic recovery Discharged in 7days
- 16. “Tsutsugamushi triangle”, one billion people are at risk for scrub typhus (India) one million cases occur annually (India) Mortality rates in untreated patients range from 0-30% Re-emerging disease
- 17. Agent It is an obligate intracellular gram-ve bacterium that has a large number of serotypes. Does not have a vacuolar membrane; thus, it grows freely in the cytoplasm of infected cells. O. tsutsugamushi has a different cellwall structure and genetic composition than that of the rickettsiae.
- 18. Disease transmission Transmitted to humans and rodents by the bite of infected larvae of the trombiculid mite Leptotrombidium deliense (“chiggers”), which feeds on lymph and tissue fluid rather than blood.
- 20. Mode of Transmission Mite Rats & Mice Humans Mite No direct person to person transmission (Accidental host)
- 21. CLINICAL FEATURES Illness varies from mild, self-limiting to fatal Incubation period - 6-21 days fever, headache, myalgia, cough, gastrointestinal symptoms a primary papular lesion(where the chigger has fed) enlarges, undergoes central necrosis, and crusts to form a flat black eschar Associated regional and later generalized lymphadenopathy and a macular rash may appear on the trunk
- 22. Neurological - meningoencephalitis Pulmonary - interstitial pneumonia GI - superficial mucosal hemorrhage, multiple erosions, and ulcers Cardiac - Myocarditis with conduction blocks & CCF Septicemic shock with ARDS, DIC, with renal & hepatic dysfunction Mortality - 7-30% complications
- 23. Indian studies Author No of Cases Neurological features Outcome Vivekanandan et.al (2004) 50 Meningitis-14% Altered sensorium- 20% Mortality-2% Razak et.al(2004) 29 Meningoencephalitis-20% Cerebellar signs-3% All improved Mahajan et.al(2006) 27 Meningoencephalitis-14.8% Mortality-3.7% Mahajan et.al(2010) 21 Seiures-19% Altered sensorium-23.8% Mortality-14.2% Chrispal et.al(2010) 189 Altered sensorium-22.2% Seizures-6.3% Meningitis-20.6% Mortality-12.2%
- 24. Investigations Hemogram- Leukopenia, thrombocytopenia Coagulopathy Elevation of liver enzymes and bilirubin - indicating hepatocellular damage ↑ Creatinine, Proteinuria Chest X-rays- Reticulonodular infiltrates CSF examinations show a mild mononuclear pleocytosis with normal glucose levels
- 25. Diagnostic investigations Test Comments Weil Felix Detects cross-reacting antibodies to Proteus mirabilis OX-K 4-fold ↑ in titre to OXK single titre ≥ 1:160 also diagnostic Lacks sensitivity & but is specific ELISA Detects Ab against infectious agents by using pooled human sera Higher sensitivity & specificity Western Blot Presence of a 41-kD band Higher sensitivity & specificity Indirect Fluorescent Assay Conclusive diagnosis: 4-fold ↑ in IFAs in paired serum obtained 2 wks apart Currently considered gold standard PCR amplification most sensitive Limited availability, expensive Isolation Can be isolated & cultured by inoculating intraperitoneally into white mice not used routinely
- 26. treatment Recommended regimen- Doxycycline (2.2 mg/kg/dose bid PO or IV, maximum 200 mg/day for 7-15 days) Chloramphenicol (50-100 mg/kg/day divided every 6 h IV) 500 mg qid orally for 7-15 days for adults Azithromycin (500 mg orally for 3 days) Rifampicin (600 to 900 mg/day)
- 29. Take home messages Scrub typhus is a growing and emerging disease grossly under- diagnosed due to its non-specific clinical presentation, limited awareness, and low index of suspicion consider as a differential diagnosis in acute febrile illness with thrombocytopenia, renal impairment, LFT abnormalities, altered sensorium,encephalitis, pneumonitis, or ARDS WEIL FELIX test very Specific Early diagnosis and treatment are imperative to reduce the mortality and the complications associated with the disease
Notas do Editor
- Scrub typhus is endemic to a part of the world known as the tsutsugamushi triangle (after O. tsutsugamushi)[2]. This extends from northern Japan and far-eastern Russia in the north, to the territories around the Solomon Sea into northern Australia in the south, and to Pakistan and Afghanistan in the west Asia-Pacific or Asia Pacific (abbreviated as Asia-Pac, Asia Pac, AsPac, Aspac, Apac, APAC, APNIC, APJ, JAPA or JAPAC) is the part of the world in or near the Western Pacific Ocean. The region varies in size depending on context, but it typically includes at least much of East Asia, Southeast Asia, and Oceania. The term may also include Russia (on the North Pacific) and countries in the Americas which are on the coast of the Eastern Pacific Ocean; the Asia-Pacific Economic Cooperation, for example, includes Canada, Chile, Russia, Mexico, Peru, and the United States. Alternatively, the term sometimes comprises all of Asia and Australasia as well as small/medium/large Pacific island nations - for example when dividing the world into large regions for commercial purposes (e.g. into Americas, EMEA and Asia Pacific). Even though imprecise, the term has become popular since the late 1980s in commerce, finance and politics[citation needed] though the economies within the region are heterogeneous, they are mostly emerging markets experiencing rapid growth.
- Rather than biting or piercing the skin, mite larvae prefer to insert their mouthparts down hair follicles or pores. A large numbers of the Orientia tsutsugamushi are present in the salivary glands of the larvae and these are injected into its host when it feeds (23). Human infection takes place when man accidentally picks up an infective larval mite while walking, sitting, or lying on the infested ground. incubation period ranging from 6 to 21 days (usually 10 - 12 days), patients usually present with fever and headache. Other symptoms and signs include myalgia, chills, cough, adenopathy, and diarrhoea. The patient is often labeled as “fever of unknown origin” because of the non specific symptoms. In about half the patients, a skin ulcer may develop after the onset of fever at the site of the mite bite. The ulcer is approximately 1 cm in diameter and fills with fluid, eventually rupturing and forming a black eschar. A macular rash may appear on the body on 5th to 7th day and last for a few hours to a few days. Complications such as pneumonitis, myocarditis, encephalitis and peripheral circulatory failure may occur. Deaths usually occur as a result of late presentation or a delayed diagnosis Leptotrombidium deliense and Leptotrombidium akamushi.