Severe scrub typhus infection: Clinical features, diagnostic challenges and management

Abstract

Scrub typhus infection is an important cause of acute undifferentiated fever in South East Asia. The clinical picture is characterized by sudden onset fever with chills and non-specific symptoms that include headache, myalgia, sweating and vomiting. The presence of an eschar, in about half the patients with proven scrub typhus infection and usually seen in the axilla, groin or inguinal region, is characteristic of scrub typhus. Common laboratory findings are elevated liver transaminases, thrombocytopenia and leukocytosis. About a third of patients admitted to hospital with scrub typhus infection have evidence of organ dysfunction that may include respiratory failure, circulatory shock, mild renal or hepatic dysfunction, central nervous system involvement or hematological abnormalities. Since the symptoms and signs are non-specific and resemble other tropical infections like malaria, enteric fever, dengue or leptospirosis, appropriate laboratory tests are necessary to confirm diagnosis. Serological assays are the mainstay of diagnosis as they are easy to perform; the reference test is the indirect immunofluorescence assay (IFA) for the detection of IgM antibodies. However in clinical practice, the enzyme-linked immuno-sorbent assay is done due to the ease of performing this test and a good sensitivity and sensitivity when compared with the IFA. Paired samples, obtained at least two weeks apart, demonstrating a ≥ 4 fold rise in titre, is necessary for confirmation of serologic diagnosis. The mainstay of treatment is the tetracycline group of antibiotics or chloramphenicol although macrolides are used alternatively. In mild cases, recovery is complete. In severe cases with multi-organ failure, mortality may be as high as 24%.

Keywords: Rickettsia; Diagnosis; Management; Outcome; Multi-organ failure

Core tip: Scrub typhus is an important differential diagnosis in patients who present with acute undifferentiated fever in South East Asia. Since the presentation may be non-specific, with features of organ failure in those with severe infection, early diagnosis and appropriate management is crucial. The presence of an eschar suggests scrub typhus infection. The diagnosis may be confirmed on serological assays, the reference test being the indirect immunofluorescence test for the detection of IgM antibodies. In those with mild infection, fever defervescence occurs in about 2-d with Doxycycline therapy.