interesting case discussion - cpa chennai typus.pdf · started on iv fluids after shock correction...
TRANSCRIPT
Scrub typhusISP, STANLEY MEDICAL COLLEGE
Dr Renjini (DCH)Dr Ekambaranath.MDDr Sujatha Sridaran.MDDr Karunakaran .MD
CASE SCENARIO 1
4 yr old female child
From Thirupati Andhra Pradesh
FEVER 10 DAYS
ABDOMINAL PAIN 5 DAYS
VOMITING 2 DAYS
FACIAL PUFFINESS 1 DAY
O/e child alert ,febrile
Pallor +
Peripheral pulses +++/+-
CFT >2 sec
Periorbital puffiness+
Eyes congested
VITALS PR : 100 /min RR:32/min
BP :92/ 60 mmof hg
TEMP :102 F
ESCHAR
- Ulcerative lesion with
erythematous rim
- Left inguinal region
No significant lymphadenopathy
SYSTEM EXAMINATIONLiver palpable 5 cm ↓RCM
Soft tender to touch
Spleen palpable 3 cm firm
INVESTIGATIONSHb: 8 gm
TC: 6100
DC: P45 L55
PCV: 24
PL :29000
URE : alb+
PS for MP : NEG
C XRAY : WNL
WIDAL: NEG
SGOT/PT : 121/96
Blood C/S : No growth
MALARIA
DENGUE FEVER
SCRUB TYPHUS
Started on iv fluids after shock correction
Chloroquine started
Azithromycin started on day 2
DISEASE COURSE Fever Continued
2nd Day Devoloped Upgaze Palsy , Tonic
Posturing With Altered Sensorium
Controlled With Inj Phenytoin
QBC Sent Next Day And Started On Artesunate
CT Brain NORMAL
QBC NEGATIVE
Over Next 48 Hrs Child Improved
Platelet Count Increased
DENGUE IgG IgM :NEG
IgM ELISA for SCRUB TYPHUS
POSITIVE
11 Yrs Old Female Child
From Chennai
Fever 10 Days
Vomiting 2 Days
Treated Outside For ENTERIC FEVER
Child Febrile , Alert
Peripheries Cool Below Knee
Pulses +++ /_ _ ; CFT > 2 SEC
HR: 120 ; RR: 32
BP: 60/30 Mm Of Hg
Purpuric Rashes Over Abdomen And Face
ESCHAR Ulcerative Lesion With
Central Necrotic Area
Rt Axilla
Started 4 Days Before
Fever As A Papule
No Significant Lymphadenopathy
System ExaminationLiver Palpable 6cm ↓RCM
Soft ; Tender To Touch
Spleen 2 Cm ↓ LCM Firm
INVESTIGATIONS
Hb : 8
TC :4100
DC : P 50 L 47 E03
ESR : 8/22
PL :72000
URE alb 1+
PS FOR MP : NEG
C XRAY: WNL
SGOT/PT : 68/48
DIFFERENTIAL DIAGNOSIS
DENGUE FEVER
MALARIA
ENTERIC FEVER
SCRUB TYPHUS
Shock Correction With RL And Colloids
Started On Ceftriaxone
Supportive Care
Chloroquine Started
DISEASE COURSE Fever Was Persisting
On 2nd day Platelet decreased to 32000Facial puffiness And Pedal Edema
Increased Tachypnea
Evidence Of Pleural Effusion And Ascites
On 6th Day Fever Still Persisting
C/O Diplopia
O/E : B/L LR Palsy Blurred Disc Margin
Clouding Of Consciousness
Neck Rigidity + + ; Plantar ↑↑
CT Brain NORMAL
LP Done
Started On ARTESUNATE and AZITHROMYCIN
Fever Spikes Decreased In 48 To 72 Hrs
Recovered From LR Palsy
Sensorium Improved.
Other InvestigationsWidal –Neg
Mx – Neg
MSAT- Neg
Dengue IgG IgM-Neg
Blood C&S - No growth
LP Protein:40
Sugar :54
Acellular
No Growth
Rpt Platelet -
1.2Lac
POSITIVE
SCRUB TYPHUS
Reemerging infectious disease
Agent – Orientia tsutsugamushi
Vector – Reservoir – Chiggers
- larva of trombiculid mite ;Leptotrombidium
Gram Neg Obligate Intracellular Bacteria
Lack Cellwall.
CHIGGER
reservoir
Larval stage
vector
Mode of Transmission
Mite
Rats & Mice
Humans
Mite
No direct person to person transmission
(Accidental host)
Man – accidental host
Vector to human transmission
bite while feeding
No person to person transmission
except – blood transfusion
- organ transplantation
EPIDEMIOLOGY
Himalayan regions
South India
Tamil Nadu
Kerala
Andhra Pradesh
Karnataka
PATHOGENESIS
Local multiplication
Invade vascular endothelium
& RE cells
Vasculitis
Skin rash,microvascular leak
Edema, Tissue hypoperfusion
Inflammaton & vascular leakage
Interstitial pneumonitisNon cardiogenic pulmonary edema
Cerebral edemaMeningoencephalitis
Inf. Of endothelial cells - procoagulant activity
DIC
Ip 5 To 12 Days ;Mean 10 – 20 D
Fever ; High Grade With Shaking Chills
Regional Or Generalised Lymphadenopathy---20 % To 90%
Hepatomegaly --- 2/3
Splenomegaly ---- 1/3
Clinical features
Eschar
Axilla , Inguinal Region,genitalia , Neck
7% To 68%
Gastrointestinal Symptoms ----40%
Thrombocytopenia ---1/4 To 1/3
Rashes < 30%
CLINICAL FEATURES
Headache – frontal
less in children
Myalgia – lumbar region,thigh,calf
Rash – 3 to 5 days
- maculopapular,petechial / hemorrhagic
- palpable purpura
- initially near ankles, lower limbs,wrist
- centripetally to whole body
DIFFERENTIAL DIAGNOSIS
Dengue
Malaria
Typhoid
Anthrax
Leptospirosis
Tularemia
COMPLICATIONS
Interstitial pneumonitis --20 TO 35%
Meningoencephalitis syndrome -- 10%
Myocarditis
Aseptic meningitis
Acute renal failure
DIC
INVESTIGATIONS• CBC – Early leucopenia with late lymphocytosis
- Thrombocytopenia- high ESR
• Hyponatremia• Hypoalbuminemia• Elevated transaminases• hyperbilirubinemia• proteinuria
I INVESTIGATON…..
Weil felix test
Complement fixation test
Gold standard IFA
PCR
Ig M ELISA widely used
Case Fatality In Untreated Case --- 30%
TREATMENT
Doxycycline –
5 to 7 days
5mg/kg/day in 2 div doses in < 45kg
200mg/ day in 2 div doses in > 45kg
Azithromycin, Rifampicin in children and in cases resistant to Doxycycline
Supportive care
KEY POINTS Ricketssial infections are prevalent in Various parts of
India
High index of suspicion is needed for early diagnosis Failure of which leads to significant increase in mortality ,morbidity and expensive PUO workup
References
Indian PediatricsVol 47 Feb 17,2010
CDC Ricketssial Disease at http://www.cdc.gov
Batra HV Spotted fever and typhus fever in TamilNaduIndian J Med Res 2007: 126:101-103
Principles and practices of Pediatric Infectious Diseases – Churchill Livingstone
FAQ on Scrub typhus SEARO WHO
THANK YOU