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ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 5  |  Page : 419-423  

Epidemiological and clinical features of scrub typhus in Odisha, Eastern India


1 Department of Pediatrics, KIMS, KIIT Deemed University, Bhubaneswar, Odisha, India
2 Department of Health, KISS University, Bhubaneswar, Odisha, India
3 Department of Public Health, KSPH, KIIT Deemed University, Bhubaneswar, Odisha, India

Date of Submission21-Nov-2018
Date of Acceptance27-Feb-2019
Date of Web Publication19-Sep-2019

Correspondence Address:
Nirmal Kumar Mohakud
Department of Pediatrics, KIMS, KIIT Deemed University, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_236_18

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  Abstract 


Introduction: Scrub typhus is a mite-borne bacterial infection of humans caused by Orientia tsutsugamushi that presents with prolonged fever unless suspected early. The aim of this study was to characterize the epidemiological factors and clinical clues in this region for early diagnosis. Materials and Methods: This study was a retrospective, observational study conducted in all diagnosed scrub typhus cases admitted to the pediatric ward of a tertiary care hospital in-between January 1, 2015 and December 31, 2016. One hundred and one patients admitted with IgM positive for scrub typhus over 2-year period were analyzed for the epidemiological factors and clinical features. Results: Male:female ratio is 1.4:1. The mean age of the patients in our cohort was 4.83 years, ranging from 0.25 to 14 years. Majority (79.2%) was from the rural area. Fever was present in all cases and about 81.19% of children presented with fever for >7 days. Other findings were hepatosplenomegaly (55.45%), respiratory problems (47.54%), abdominal symptoms (40.59%), eschar (26.74%), rashes (15.84%), altered behavior (9.9%) and lymphadenopathy (2.97%) of cases studied. Thrombocytopenia, elevated liver enzymes, and raised C-reactive protein (CRP) were found characteristically. Defervescence after starting doxycycline was within 3.26 ± 2.26 days. Conclusions: Scrub typhus can present in various ways but mostly with prolonged fever. Hepatosplenomegaly, eschar, third spacing, raised CRP, and thrombocytopenia are important clues for early clinical diagnosis. Increased awareness and heightened suspicion, especially in the light of increasing number of patients are required for timely treatment and prevention of complications.

Keywords: C reactive protein, eschar, Odisha, scrub typhus, third spacing, thrombocytopenia


How to cite this article:
Das P, Singh D, Das M, Nayak RK, Mohakud NK. Epidemiological and clinical features of scrub typhus in Odisha, Eastern India. Med J DY Patil Vidyapeeth 2019;12:419-23

How to cite this URL:
Das P, Singh D, Das M, Nayak RK, Mohakud NK. Epidemiological and clinical features of scrub typhus in Odisha, Eastern India. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2020 Dec 5];12:419-23. Available from: https://www.mjdrdypv.org/text.asp?2019/12/5/419/267085




  Introduction Top


Scrub typhus is caused by Orientia tsutsugamushi (OT) and transmitted by bite of infected larva of leptotrombiculid mite species.[1] Peak transmission is following rainy season and risk factors are living close to bushes and wood piles, working on farms, and raising domestic animals.[2],[3] Worldwide incidence is more than 1 million infections every year and 1 billion are at risk.[4] Over the last 5 years, few studies have indicated the emergence of scrub typhus in southern and northeastern parts of India.[5],[6],[7] Since scrub typhus resembles many other conditions leading to pyrexia of unknown origin (PUO), WHO has given a standard definition to diagnose scrub typhus clinically which is helpful, especially in empirically starting treatment and in places where diagnostic facility are not available.[8]

Clinical suspicion may be delayed or absent in this area due to lack of knowledge and diagnostic facilities. Better understanding of the epidemiology of scrub typhus will help to prevent and control the disease. Suspecting the diagnosis and initiating prompt antimicrobial drug therapy are important to prevent morbidity and mortality.

Aims and objectives

To analyze the epidemiological pattern, clinical presentation, and biochemical parameters of diagnosed scrub typhus cases and to find the response of proven cases of scrub typhus to doxycycline treatment.

Inclusion and exclusion criteria

All serologically confirmed cases of scrub typhus ≤14 years admitted to the hospital were included in the study.

Patients were excluded if they were immunocompromised (HIV positive, on immunosuppressant, or had hematological or autoimmune diseases) or had any other diagnosis or seronegative for scrub typhus.


  Materials and Methods Top


This was a retrospective, observational study conducted in all children admitted and diagnosed as scrub typhus cases in the Pediatrics ward of a tertiary care hospital, Odisha and Eastern India that showed up in-between January 1, 2015 and December 31, 2016. The study was approved by the institutional ethical committee of the hospital (Ref No: KIMS/KIIT/IEC/33/2017). In serologically positive scrub typhus cases, calculations were performed using Stata/IC 14.0 for Mac (Stata Corp., College Station, TX, USA). The Scrub Typhus Detect™ IgM ELISA was used for detection of OT (formerly Rickettsia) which is an ELISA system for the detection of IgM antibodies in human serum to OT-derived recombinant antigen. Cutoff value of >0.14 is taken to define case positivity which had a sensitivity of 77.3% and specificity of 71.4%.[9] Additional tests taken for analyses were complete blood count, C-reactive protein (CRP), liver function tests (LFT), serum urea and creatinine, and electrolytes. Clinical and laboratory parameters were compared to assess the factors closely associated with the disease and contributing to their diagnosis.


  Results Top


One hundred and one patients admitted over 2-year period with positive IgM were analyzed. The male:female ratio was found to be 1.4:1. The mean age of the patients in our cohort was 4.83 years, with the maximum age being 14 years and the minimum being 0.25 years.

A total of 21 (19.8%) children were from the urban area and 80 (79.2%) were from the rural area.

In our study, most of the cases were detected after rainy season and cooler months [Figure 1].
Figure 1: Seasonal distribution of scrub typhus cases over 2-year period. Cases are mostly distributed on end of rainy season and beginning of winter season

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Fever was present in all cases and about 81.19% of children presented with fever for >7 days' duration. Other common symptoms were hepatosplenomegaly (55.45%), respiratory problems (47.54%), abdominal symptoms (40.59%), eschar (26.74%), rashes (15.84%), altered behavior (9.9%), and lymphadenopathy (2.97%) [Table 1].
Table 1: Clinical characteristics profile of children with scrub typhus with age (n=101)

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Anemia (hemoglobin % <9 mg/dl) was detected in 27.08% of cases. Leukocytosis was found in 47.87% of cases which is higher than that reported by other studies from the same place which report leukocytosis in 35% cases [10] and was similar to another study from southern India which showed 42.7% cases had leukocytosis.[8] Thrombocytopenia (platelet count <150,000/mm 3) was elevated in 47.36% and liver enzymes transaminases AST, ALT were elevated in 95.31% and 73.43%, respectively. CRP was elevated (>6 mg/l) in 88.09% of cases [Table 2]. Raised CRP levels were found to be present in most of the cases with scrub typhus and can be an important clue in diagnosing scrub typhus.
Table 2: Laboratory findings in pediatric scrub typhus patients

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On comparison of two groups of children presenting with fever for <7 days and ≥7 days, no significant difference was found in clinical and biochemical parameters except leukocytosis which was higher in the prolonged fever group (P < 0.02) [Table 3].
Table 3: Association of biochemical parameters with prolonged fever in scrub typhus

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  Discussion Top


There have been many reports of outbreaks of scrub typhus in different regions of India. However, data for the prevalence of this disease in Odisha are still not sufficient to reflect reality. There has been increasing incidence of scrub typhus being diagnosed in Odisha every year and yet many remain by far ignorant about suspecting and early treatment. A seasonal predilection for cases to come after the monsoon season and in cold season lasting from July to December was seen. Scrub typhus still remains an underdiagnosed disease in India and many children present late and end up with complications.[4] In this study, we intended to retrospectively assess the presentation of cases admitted over the last 2 years by gathering data of KIMS pediatric patients diagnosed serologically as scrub typhus IgM positive. There has been few studies from Odisha over the last few years; however, they were limited by number of cases.[11],[12] We have studied one hundred and one cases with scrub typhus diagnosed on the basis of IgM serology which is more sensitive compared to Weil–Felix test which has been used in some studies.[8] The serological test that we have used to confirm scrub typhus ELISA is considered 77.3% sensitive and 71.4% specific.[9] In the present study, we found male preponderance. Similar type of sex distribution was observed in the study done at Uttarakhand.[13]

Most of the cases of scrub typhus presented with prolonged fever or PUO. In our study, all cases presented with fever and in 81.19% of children, it was for >7 days.[14] Rash was present in 15.84% of patients, which is similar to the findings of other studies.[13] A higher incidence of rash (23%–100%) has been reported by others.[15],[16]

In our patients, we found third spacing in the form of pedal edema, facial puffiness, and ascites or free fluid in peritoneal cavity in a significant proportion of children (39.6% of all cases) presumably due to underlying vasculitis which can cause rashes, tissue edema, and organ dysfunction.[10] Similar to other case series, we also found the presence of organomegaly in the form of hepatomegaly and splenomegaly in 55.45% of cases.[11]

The bacteria multiply at the inoculation site from a papule that ulcerates to become necrotic and form an eschar with regional and sometimes generalized lymphadenopathy. Lymphadenopathy was seen in 2.97% of the cases which was less as compared to other studies.[17]

Eschar was detected in 26.74% of the cases which is consistent with others.[14] The conventional features of eschar were present in fewer patients in our study. This is similar to the findings of recent studies from northern [18] and southern India.[19],[20] It is likely that patients are unaware or ignore the presence of an eschar, and a detailed physical examination is rarely done specifically looking for it.[21] There is a wide variation in finding of eschar ranging from 25 to 90%.[22]

Tsutsugamushi induces vasculitis which leads to symptoms of systemic organ invasion including meningitis and meningoencephalitis.[23],[24] Central nervous system manifestation in the form of meningeal irritation and altered behavior was noted in 9.9% of cases similar to other study.[17]

Thrombocytopenia (platelet count <150,000/mm 3) was found in 47.36% of cases, along with raised CRP in 88.09% of cases, which is characteristic of scrub typhus in contrast to dengue, where thrombocytopenia is not always associated with raised CRP.[25],[26],[27],[28] Elevated liver enzymes, aspartate aminotransferase (AST) in 95.31% and alanine aminotransferase (ALT) in 73.43% of children, were seen.[27],[28] Hypoalbuminemia (albumin <3.5 g/dl) was found in 85% of cases in whom LFT was done.

All the patients in this study responded well to doxycycline at the dose of 4 mg/kg given at divided doses for at least 5 days or 3 days after the child had become afebrile. None of the patients required any other antibiotic and we did not find microbial resistance to doxycycline.[29] Defervescence after starting doxycycline (3.26 ± 2.26 days) as compared to defervescence after hospitalization (4.77 ± 2.24 days) is a very significant finding (P < 0.001). All cases that were started empirically on doxycycline based on clinical case definition and investigations had earlier defervescence of fever compared to those cases where doxycycline was started after confirming diagnosis on the basis of serology. The difference in time to be afebrile was almost 24 h between the two groups. Average hospital stay of scrub typhus cases was 7.62 ± 4.46 days like other studies.[30]

Limitations

The present study has some limitations. First, the study was performed at a tertiary referral hospital; therefore, it does not reflect the actual burden of the disease in the community, which may be higher. An additional limitation of this study was that not all the patients had the laboratory values for CRP, AST, ALT, albumin levels, and white blood cell counts. This lack of data may bias the percentage of abnormal laboratory findings in these patients. In spite of these limitations, we believe this study provides a better understanding of the clinical manifestations and outcomes of scrub typhus in children.


  Conclusions Top


Scrub typhus can present in innumerable ways but mostly with prolonged fever. Hepatosplenomegaly, elevated liver enzymes, third spacing, raised CRP, hyponatremia, and thrombocytopenia are important clues for early clinical diagnosis. Having a suspicion in case of prolonged fever, in the light of increasing number of patients, is required for early treatment with doxycycline to prevent complications.

Acknowledgments

The authors are grateful to all the patients and their parents for their kind cooperation. We are obliged to Dr. Bhaskar Thakur, biostatistician for analyzing the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]


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