Indian Pediatr 2012;49: 322-324
Pediatric Scrub Typhus in South Sikkim
Mittal , *B Gurung,
From the Zoonosis Division, National Centre
for Disease Control, 22, Sham Nath Marg, Delhi-110054; and
*District hospital Namchi, South Sikkim, India.
Correspondence to: Dr Naveen Gupta, Deputy
Director, Zoonosis Division,National Centre for Disease Control,
22, Sham Nath Marg, Delhi110 054, India. firstname.lastname@example.org
Received: February 28, 2011; Initial review:
March 01, 2011; Accepted: July 08, 2011.
We present five cases of paediatric Scrub typhus from Community Health
Centre, Namchi, South Sikkim emphasize timely diagnosis of scrub typhus
for appropriate management. Response to doxycycline was good, with fever
subsiding within 48-72 hrs of starting the treatment. Four out of five
cases completely recovered once appropriate medication was given.
Key words: Child, India, Scrub typhus, Sikkim.
Scrub typhus is endemic in
regions of eastern Asia and the South Western Pacific (Korea to
Australia) and from Japan to India and Pakistan [1-6]. Scrub typhus
is prevalent in many parts of India but specific data are not
available . There have been outbreaks in areas located in the
Sub-Himalayan belt, from Jammu to Nagaland. There were reports of
Scrub typhus outbreaks in Himachal Pradesh, Sikkim and Darjeeling
(West Bengal) during 2003-2004 and 2007. Outbreaks of Scrub typhus
are reported in Southern India during cooler months of year .
Non-specific presentation and lack of
characteristic eschar leads to misdiagnosis and under reporting of
scrub typhus. Further, non-availability of diagnostic facilities in
native areas makes it even more difficult for the physicians to
correctly diagnose and treat. We present five cases of pediatric
scrub typhus from Community Health Center, Namchi, South Sikkim.
Details of all five cases of pediatric scrub
typhus are presented in Table I. Suspicion of
rickettsial disease was kept in mind after malaria and typhoid were
ruled out. All cases were discussed with NCDC, Delhi and samples
were drawn and sent immediately before starting doxycycline.
Response to doxycycline was good, with fever subsiding within 48-72
h of starting the treatment. In all five cases significant titer of
antibodies more than 160 in OX K antigen in Weil Felix test were
found, and were also positive for IgM antibodies to Orientia
tsutsugamushi by Scrub typhus detect IgM ELISA kit (Inbios ,
USA). Other additional important clinical findings included
thrombocytopenia, anemia and low serum albumin.
Table I Clinical Profile of Pediatric Scrub Typhus Patients in South Sikkim, India.
Clinical and laboratory features
|Age (y) Sex
||Fever & cough ×
5 days Conjunctival congestion, Erythematous rash on face & upper chest
||Fever × 6 days Cough × 4 days Diarhoea × 2 days Swelling of feet
× 1 day
||Fever & abdominal
behaviour × 2-3
||Fever & headache
×10 days Puffiness of face & swelling of face × 3 days
||Fever, Chest pain
& Headache × 10
breathing × 2 days. Altered Sensorium × 1 day
||Both feet & eyelids
|Skin ulcer/ eschar
||5cm BCM*, Soft &
||6cm BCM*, Soft &
||5cm BCM*, Soft
||Bilateral rales +
||Delirium, Babinski sign +
||Moderate hepatospleno-megaly with minimal free
fluid in pelvis
|Treatment and Outcome
||Ceftriaxzone + DoxycyclineAfebrile
5 days, discharged on
Afebrile on day 3 Discharged on day 6
||Doxycycline Afebrile on day 4,
Edema receded, lung signs imporved, Discharged on day 12
||Doxycycline Afebrile on day 3,
Edema and renal parameters recovered,
*BCM: Below costal margin; NAD: No abnormality detected.
Scrub typhus usually presents with fever, rash
and complications involving respiratory, cardiac or central nervous
system. Inoculation of O. tsutsugamushi through the bite of
chigger is often painless and unnoticed . Scrub typhus is common
in rural areas. Out of five cases presented, 4 lived in Kuccha house
and went for open field defecation which predisposes them to chigger
bite. Appropriate history, and finding of eschar are often
pathognomonic but can be missed by inexperienced observers. Lack of
knowledge among physicians can lead to under diagnosis and improper
treatment. Routine laboratory tests are normal; elevated
transaminases and hypoalbuminemia can be used as pointer to
investigate for rickettsial diseases. In resource poor countries,
initial Weil felix test followed by ELISA based test for O.
tsutsugamushi and Rickettsia conorii can make proper
diagnosis. Although Indirect immunoflourescence assay (IFA) or
Indirect Immuno-peroxidase test (IIP) and polymerase chain reaction
(PCR) based tests are considered gold standard in confirmation of
rickettsial diseases, they can only be performed in sophisticated
laboratories, which was not possible in our case. We made the
diagnosis based on clinical symptomatology along with two different
tests (weil felix and IgM ELISA) and prompt response and recovery in
response to doxycycline. Further studies are required to estimate
the exact magnitude of disease in Sikkim.
Contributors: All authors contributed to all
aspects of the manuscript preparation.
Funding: None; Competing interests:
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