|Year : 2020 | Volume
| Issue : 2 | Page : 164-166
Successful management of acute respiratory distress syndrome in scrub typhus: A rare entity
Nishith Govil1, Kumar Parag2, Hariom Khandelwal2, Bharat Bhushan Bhardwaj3
1 Department of Anesthesiology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Cardiac Anaesthesia, SGRRIM and HS, Dehradun, Uttarakhand, India
3 Department of Emergency Medicine, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||27-Jan-2020|
|Date of Decision||27-Jun-2020|
|Date of Acceptance||22-Jul-2020|
|Date of Web Publication||19-Aug-2020|
Department of Anesthesiology, AIIMS, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Scrub typhus or tsutsugamushi disease is characterized by nonspecific signs and symptoms. Disease manifestation are acute fever, eschar formation at the site of chigger bite and serious respiratory complication. We report the case of a 22-year-old girl admitted in our intensive care unit (ICU) with the chief complaints of fever with chills, rigor, and severe headache diagnosed as scrub typhus. She was treated well for 7 days, cured, and discharged from the ICU. For a physician, awareness of regional prevalence and a history of travel to endemic areas or outdoor activities such as mountaineering and expedition should raise the suspicion for scrub typhus. Early diagnosis and treatment will prevent death and reduce morbidity.
Keywords: Acute respiratory distress syndrome, rifampicin, scrub typhus disease
|How to cite this article:|
Govil N, Parag K, Khandelwal H, Bhardwaj BB. Successful management of acute respiratory distress syndrome in scrub typhus: A rare entity. Saudi J Health Sci 2020;9:164-6
|How to cite this URL:|
Govil N, Parag K, Khandelwal H, Bhardwaj BB. Successful management of acute respiratory distress syndrome in scrub typhus: A rare entity. Saudi J Health Sci [serial online] 2020 [cited 2020 Oct 26];9:164-6. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/2/164/292647
| Introduction|| |
Scrub typhus or tsutsugamushi disease is caused by the bite of a mite. It is characterized by nonspecific signs and symptoms. Disease manifestation are acute fever, eschar formation at the site of chigger bite and serious respiratory complication. Skin manifestation is characterized by an erythematous, maculopapular rash. The symptoms of scrub typhus are mild and nonspecific, and a spontaneous recovery is seen in a majority of cases. Serious complications such as septic shock, pneumonitis, myocarditis, meningitis, acute renal failure, and acute respiratory distress syndrome (ARDS) may occur and could be fatal if diagnosis is delayed. After taking consent of the patient for possible publication of her case in medical literature and concealing all the details that could reveal her identity, we would like to report one such rare presentation of this entity.
| Case Report|| |
A 22-year-old female was admitted to our intensive care unit (ICU) with the chief complaints of fever with chills, rigor, and severe headache for 7 days. She also had a history of watery stool and vomiting (several episodes in a day) for 2 days. All these followed after the appearance of a maculopapular rash 2 weeks ago in the right axilla, which developed into blister, dried, and left a black scar.
The patient gave a history of being bitten by a mite 2 weeks ago when she went into a jungle with her sister and two friends to collect wild chestnuts (Castanea dentata). One friend already died on the same day in the evening, her sister died 2 days back, and another friend was reportedly very ill. The patient noticed an itchy area in her right axilla, which was painful and finally developed into a black scar.
On admission, the patient was conscious and oriented to time and place, with oxygen saturation (SpO2) of 76% on room air. The SpO2 increased to 92% with administration of 4 L/min oxygen via a facemask. She had a heart rate (HR) of 120–140/min, blood pressure (BP) of 90/60 mmHg, and a respiratory rate (RR) of 36–40/min. Physical examination revealed bilateral basal crepitation and a soft palpable liver.
Investigation revealed hemoglobin of 9.1 g%, total leukocyte count (TLC) of 19,800/mm3, serum creatinine of 0.6 mg/dL, urea of 22 mg/L, erythrocyte sedimentation rate of 65 mm/h, and platelets of 140,000/mm3. Arterial blood gas analysis (ABG) showed pH of 7.4, PaO2 of 36 mmHg, PaCO2 of 49 mmHg, and a PaO2/FiO2 of 100. Chest X-ray was suggestive of ARDS with bilateral infiltration of the lung fields. Weil–Felix test showed OXK+ at a dilution of 1:160. Coagulation profile and liver function tests were within normal limits. The peripheral blood smear, urine culture, and blood culture reports were negative.
Treatment was initiated with injection ciprofloxacin 500 mg intravenous (IV) 12 hourly, injection chloramphenicol 500 mg IV 6 hourly, and injection metronidazole 400 mg IV 8 hourly. The patient remained conscious, was oriented, was maintaining an SpO2>90% with oxygen by facemask at a rate of 4 L/min, and was hemodynamically stable with no metabolic derangements.
There was no significant improvement at 24 h. Keeping in mind that some cases of scrub typhus are caused by doxycycline- or chloramphenicol-resistant strains that are susceptible to rifampicin, 500-mg rifampicin (5 mL suspension) orally 12 hourly was added to try to ensure recovery. Titers continued to remain high till 48 h of admission to the ICU while the temperature was 101°F –102°F and SpO2 was 94%–96% with oxygen supplementation by the facemask while the PaO2/FiO2 ratio had increased to 197. The urine output was maintained above 0.5 mL/kg/h by injection frusemide 10 mg intermittently. The patient developed congestion in the right eye (which was subsequently diagnosed as subconjunctival hemorrhage), which was treated conservatively. At the end of the 2nd ICU day, her HR was 90–100 L/min, BP was 128/70 mmHg, and RR was 30–45/min. On the 3rd ICU day, the patient started showing significant clinical improvement (RR: 25–30, temperature: 100°F, SpO2: 97% with 2 L/min O2 via nasal prongs, and PaO2/FiO2 ratio: 238). The urine output was maintained >1 mL/min without frusemide, and HR was 80/min and BP was 110/70 mmHg. Chest X-ray showed a marked improvement as compared to the X-ray done on the date of admission to the ICU [Figure 1].
On the 4th ICU day, the patient's condition further improved. She was afebrile; her RR was 20/min, SpO2 was 98% on room air, and PaO2/FiO2 ratio was 342.6; and ABG was also normal. Chest X-rays show marked improvement from the day of admission [Figure 2]. The fever and rash subsided in the ICU after our treatment, and the patient was shifted to the medicine ward on the 5th ICU day and advised to continue chloramphenicol for a total of 14 days to prevent relapse.
|Figure 2: Lung X-ray depicting pulmonary changes on successive day after intensive care unit admission. Day 0 is day of admission|
Click here to view
| Discussion|| |
Scrub typhus is a zoonotic disease (mite transmitted), in which humans are the accidental host. It is also known as tsutsugamushi disease from “Tsutsuga” meaning dangerous disease and “mushi” meaning insect or mite. It has been commonly reported from regions of far-eastern Russia and northern Japan to northern Australia to India, Pakistan, and Afghanistan.
The disease usually presents with nonspecific signs and symptoms. The disease manifestation ranges from fever, conjunctivitis, to lymphadenopathy, with red rashes at the site of bite. The characteristic lesion of scrub typhus is a black scar over the ulcer. On the 5th to 7th days, red maculopapular rashes appear over the body. Patients may have nonspecific symptoms such as chills, myalgia, abdominal pain, and cough.
Septic shock, pneumonitis, myocarditis, meningitis, acute renal failure, and ARDS may occur as serious complications of scrub typhus and could be fatal if diagnosis is delayed. ARDS developed in these patients is very challenging to treat as the hypoxemia becomes refractory to treatment and unresponsive to conventional modes of ventilation.,
Wang et al. in a retrospective study of 72 patients with scrub typhus and ARDS examined the radiography abnormalities and found the mortality up to 25%. The significant predictors of mortality are increased TLC and total bilirubin and delayed start of antibiotics. The most frequent findings observed in patients with co-existing scrub typhus and ARDS (72%) are parenchymal abnormalities including bilateral reticulonodular opacities, ground-glass opacities, consolidation, septal lines, and hilar lymph node enlargement.
The serological test used to confirm the diagnosis is the Weil–Felix test. The principle behind the Weil–Felix test is that the antibodies formed as a body's defense reaction agglutinate with the strains of Proteus vulgaris. Other tests available to diagnose rickettsial disease include polymerase chain reaction which is more specific but costly.
| Conclusion|| |
Scrub typhus can be life-threatening if associated with systemic complications and delayed diagnosis and if timely antibiotic therapy is not initiated. For a physician, awareness of regional prevalence and a history of travel to endemic areas or outdoor activities such as mountaineering and expedition should raise the suspicion for scrub typhus. Early diagnosis and treatment will prevent death and reduce morbidity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pathania M, Amisha, Malik P, Rathaur VK. Scrub typhus: Overview of demographic variables, clinical profile, and diagnostic issues in the sub-Himalayan region of India and its comparison to other Indian and Asian studies. J Family Med Prim Care 2019;8:1189-95.
] [Full text]
Rose W, Ghosh U, Punnen A, Sarkar R, Prakash JJA, Verghese VP. Comparison of scrub typhus with and without meningitis. Indian J Pediatr 2017;84:833-7.
Chandelia S, Jain S. Severe pediatric acute respiratory distress syndrome due to scrub typhus: Successful ventilation with airway pressure release ventilation mode after becoming refractory to protective ventilation. Indian J Crit Care Med 2017;21:326-8.
] [Full text]
Choi WY, Lee SY, Kwon HY, Im JH, Durey A, Baek JH, et al
. A case of scrub typhus complicated by adult respiratory distress syndrome and successful management with extracorporeal membrane oxygenation. Am J Trop Med Hyg 2016;95:554-7.
Wang CC, Liu SF, Liu JW, Chung YH, Su MC, Lin MC. Acute respiratory distress syndrome in scrub typhus. Am J Trop Med Hyg 2007;76:1148-52.
Prakash JA, Kavitha ML, Mathai E. Nested polymerase chain reaction on blood clots for gene encoding 56 kDa antigen and serology for the diagnosis of scrub typhus. Indian J Med Microbiol 2011;29:47-50.
] [Full text]
[Figure 1], [Figure 2]