Scrub Typhus is an acute febrile illness caused by Orientia tsutsugamushi, an obligate intracellular Gram negative bacterium. The disease is endemic in Southeast Asia and Pacific Islands, and is prevalent in the Shivalik ranges from Kashmir to Assam, the Eastern and Western Ghats and the Vindhyachal and Satpura ranges in Central India [1]. The usual clinical features include fever, myalgia, headache, an eschar, regional or generalized lymphadenopathy and hepatosplenomegaly [1].

A five-year-old boy, from North 24 Parganas district of West Bengal, was referred with high grade fever for eleven days and severe headache and myalgia. On examination, he was haemodynamically stable and had generalized lymphadeno-pathy and hepatosplenomegaly. Other system examinations were normal. He was given supportive management with antipyretics.

A few hours after admission, he developed nasal intonation of voice with nasal regurgitation of food. Deviation of the uvula to the left and weakness of right palatal muscles was noted on examination, signifying palsy of right sided glossopharyngeal nerve and pharyngeal branch of vagus nerve. The possibility of involvement of other vagal branches was ruled out in the absence of dysphonia. Other cranial nerves and rest of the neurological examination were normal.

Complete blood counts showed a high (90%) neutrophilic differential leukocyte count. Acute inflammatory markers were raised but liver and renal function tests were normal. Work-up for etiology of fever was positive for scrub typhus IgM antibody (ELISA) which showed a five-fold rise subsequently. Cerebrospinal fluid revealed mononuclear pleocytosis with elevated protein but negative cultures. MRI brain was normal. He was started on oral azithromycin prescribed at 10 mg/kg once a day for 7 days. Child was afebrile within 30 hrs of the first dose. Physiotherapy of pharyngeal muscles was demonstrated and he was discharged with the advice to continue the same. There was no residual nerve palsy on follow-up after 4 weeks.

Glossopharyngeal and vagus nerve palsy have been associated with Varicella Zoster, Enterovirus and other pathogens [2]. However, palsy of these nerves due to O. tsutsugamushi has not been described earlier in the paediatric age group.

1The disease process is initiated by the bite of the mite. The pathogen multiplies at the bite site, forming an eschar, followed by proliferation of the organism in the endothelial cells of small vessels with perivascular infiltration of lymphocytes causing focal or disseminated vasculitis. The eschar is considered pathognomic but may be found in 7% to 80% of the patients [3]. Central nervous system involvement commonly manifests with altered sensorium due to aseptic meningitis or acute encephalomyelitis. Occasionally, seizures, intracerebral haemorrhage, cerebellitis, and rarely acute transverse myelitis, neuroleptic malignant syndrome, Gullain Barre syndrome or nerve palsy may be noted [4].

Cranial nerve involvement in scrub typhus may result from direct invasion of central nervous system by the bacteria leading to acute vasculitis or secondary immune reaction leading to vasculitis of vasa vasorum of nerve. There have been four earlier reported cases of abducens nerve palsy in scrub typhus, causing diplopia [3-5]. Multiple cranial nerve involvement, viz. 3rd, 7th, 9th, 10th and 12th have been earlier described in a case of scrub typhus meningitis and cerebellitis [6]. There were no residual deficits in any of the above cases.

The index case developed glossopharyngeal and vagus nerve (pharyngeal branch) palsy at the summit of symptoms. Although doxycycline is the recommended drug for treatment, he was treated with azithromycin, as use of doxycycline below 8 years of age is controversial. In an endemic country like India, scrub typhus should be kept as a differential in fever for more than 7 days with neurological deficits. Timely diagnosis and intervention can have complete resolution of neurological deficits.

1. Chakraborty S, Sarma N. Scrub typhus: An emerging threat. Indian J Dermatol. 2017;62:478-85.

2. Gunbey HP, Kutlar G, Aslan K, Sayit AT, Incesu L. Magnetic resonance imaging evidence of varicella zoster virus polyneuropathy: involvement of the glossopharyn-geal and vagus nerves associated with Ramsay Hunt syndrome. J Craniofac Surg. 2016;27:721-3.

3. Bhardwaj B, Panda P, Revannasiddaiah S, Bhardwaj H. Abducens nerve palsy in a patient with scrub typhus: a case report. Trop Biomed. 2013;30:706-9.

4. Rana A, Mahajan SK, Sharma A, Sharma S, Verma BS, Sharma A. Neurological manifestations of scrub typhus in adults. Trop Doct. 2017;47:22-5.

5. Ete T, Mishra J, Barman B, Mondal S, Sivam RK. Scrub typhus presenting with bilateral lateral rectus palsy in a female. J Clin Diagn Res. 2016;10:OD16-7.

6. Himral P, Sharma KN, Kudial S, Himral S. Scrub meningitis complicated by multiple cranial nerve palsies and cerebellitis. J Assoc Physicians India. 2019;67:88-9.