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Case Report

Indian Pediatr 2012;49: 322-324

Pediatric Scrub Typhus in South Sikkim


Naveen Gupta
, Veena Mittal , *B Gurung, *U Sherpa

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. nicdnaveen@gmail.com

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 [7]. 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 [8].

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.

Case Report

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 Case 1 Case 2 Case 3 Case 4 Case 5
Age (y) Sex 5/F 5/M 9/F 10/M 12/F
Presenting  complaints 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 distension    8-10 days, Abnormal behaviour 2-3 days Fever & headache 10 days Puffiness of face & swelling of face 3 days Fever, Chest pain & Headache 10 days. Fast breathing 2 days. Altered Sensorium 1 day
History of insect bite + -
Irritability + Delirious
Pallor + + + + +
Edema Both feet Both feet & eyelids Anasarca On Both feet
Skin ulcer/ eschar Scrotum
Hepatomegaly 5cm BCM*, Soft & tender 6cm BCM*, Soft & tender 5cm BCM*, Soft & tender
Splenomegaly 4 cm 7cm Just palpable
Respiratory symptoms Bilateral rales +
CNS symptoms Delirium, Babinski sign +
Hemoglobin (g/dL) 8.6 8.9 8.6 10.2 10
Chest X-Ray NAD Bilateral mild pleural & pericardial effusion Bilateral extensive fluffy shadows NAD Bilateral extensive fluffy shadows
Ultrasonography Moderate hepatospleno-megaly with minimal free fluid in pelvis NAD Moderate hepato-splenomegaly NAD Moderate  hepatos-plenomegaly
Treatment and Outcome Ceftriaxzone + DoxycyclineAfebrile 5 days, discharged on day 7 Doxycycline 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, Discharged on day 6 Ceftrianzone + Doxycycline
 *BCM: Below costal margin; NAD: No abnormality detected.

Discussion

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 [9]. 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: None stated.

References

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10. Cemino DJ, Dieudone S. Pediatric scrub typhus. Updated Jan 2010 version Available from URL: http://emedicine.medscape.com/article/971797. Accessed on June 5, 2011.

 

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