Case Series and Case Reports
Pure cerebellitis due
to scrub typhus: a unique
case report
Suman S Karanth MD MBBS*
Anurag Gupta MCh†
Mukhyaprana Prabhu MD*
*Department of Medicine, Kasturba Medical College,
Manipal, India; †Department of Neurosurgery, Adarsha
Hospital, Udupi, India
Correspondence to: Dr Anurag Gupta, Department of
Neurosurgery, Adarsha Hospital, Udupi-576104, India
Email: docanurag@gmail.com
TROPICAL DOCTOR 2013; 43: 41– 42
DOI: 10.1177/0049475513480775
SUMMARY We report the case of a 24-year old Indian
man who presented with: high fever; drowsiness; an
eschar and gross cerebellar dysfunction with horizontal
gaze nystagmus; ataxic speech; and truncal ataxia. Scrub
typhus was diagnosed by serological tests.This is the first
case of a pure cerebellar involvement as the only manifes-
tation of scrub typhus in the published literature.
Introduction
Scrub typhus is a rickettsial disease caused by Orientia tsut-
sugamushi. The disease is typically characterized by: fever;
myalgia; sore throat; rash; eschar formation; abdominal
pain; and headache.1 Serious complications include: intersti-
tial pneumonia; gastrointestinal bleeding; acute renal failure;
and multiple organ failures.1 Neurological involvement has
been commonly reported in rickettsial diseases in the form
of meningitis and encephalitis.1 However, an isolated cer-
ebellar involvement in scrub typhus has not yet been reported
in the published literature. We describe a rare case of young
man with pure cerebellitis as a presenting feature of scrub
typhus.
Case history
A 24 year old Indian man, a farmer by occupation, was
brought to the emergency department with drowsiness of
2 days duration. He had history of fever, headache along
with difficulty in walking and truncal ataxia 12 days prior.
He was admitted to a peripheral hospital for a few days
prior to admission to our hospital. On admission, the
patient was febrile (1018F), conscious but drowsy. Kernig’s
and Brudzinski signs were negative. He had a horizontal
gaze nystagmus, ataxic speech and gross truncal ataxia.
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Features of bilateral cerebellar hemispherical dysfunction
such as past pointing and dysdiadokokinesia were present.
No obvious cranial nerve palsy or motor or sensory deficit
was found. A fundus examination was normal. A local exam-
ination revealed an eschar on the right thigh. The rest of the
physical examination was unremarkable.
A routine haematological analysis was normal except for
an elevated total leucocyte count (14  109 cells/L) with
neutrophilia (56%) and thrombocytopenia (93  109 cells/L).
His levels of serum glutamic oxalo-acetic transaminase
(299 IU/L), serum glutamic pyruvic transaminase (153 IU/L)
and creatine kinase (1081 IU/L) were elevated. Magnetic
resonance imaging of the brain was normal. A lumbar punc-
ture performed showed clear cerebrospinal fluid (CSF) with
an opening pressure of 200 mmHg, mild lymphocytic pleo-
cytosis (white blood cells: 25/mm3) and marginally elevated
protein levels (60 mg/dL). A CSF fluid analysis for herpes
simplex virus, India ink and Gram stains was negative.
Cultures for both bacteria and fungus were negative.
At this juncture, the possibility of both scrub typhus and
leptospirosis prompted us to start intravenous ceftriaxone
and oral doxycycline. Serological tests for leptospirosis,
hepatitis A, B or C and human immunodeficiency virus
were negative. The Weil-Felix test was strongly positive
(OXK ¼ 1:640 titres). The serum immunoglobulin M (IgM)
and G (IgG) antibody titres against O. tsutsugamushi,
measured by an immunofluorescent antibody assay, were
1:5120 and 1:10240, respectively. A CSF analysis for
O. tsutsugamushi could not be performed as it was not avail-
able in our hospital. We continued doxycycline after the
microbiological confirmation of the diagnosis.
Following therapy, the fever subsided within 3 days with
rapid and marked neurological improvement. By the 6th
day he was able to ambulate independently with subsequent
resolution of residual cerebellar dysfunction over the next
few days. Antibiotics were continued for a total of 14 days.
On discharge, he had no residual neurological deficits.
Discussion
Scrub typhus is an acute febrile disease caused by
O. tsutsugamushi which is transmitted by the bite of larval
stage (chiggers) of the thrombiculoid mite. With 1 million
new cases per year, it is emerging as an important public
health problem in Asia.2 Those engaged in agricultural or
recreational activities along south-east Asia and the Pacific
Rim are especially susceptible.3 The presentation can be mild
with a self-limiting clinical course with recovery in a few
days or, rarely, severe disease with a protracted and fatal
course.1 Eschar is pathognomic and is present in 40% –50%
of cases. It is usually located at sites such as the axilla, groin,
waist and neck where clothes bind or skin folds.2 Scrub
typhus must be considered alongside leptospirosis, rickettsial
pox and dengue in patients with a history of exposure from
an endemic geographical area.4 A Weil-Felix agglutination
41
Case Series and Case Reports
test or indirect immunofluorescence which detects an increase
in serum antibody titre can be used to confirm diagnosis.
Using indirect immunofluorescence, either an antibody
titre of 1:400 or a fourfold increase in titre to 1:200 or greater
is considered a positive result. A titre of 1:320 or greater
or a fourfold rise in titre from 1:50 determines a positive
Weil-Felix test.5
Amongst the rickettsial diseases, the highest degree
of CNS involvement occurs with epidemic typhus and
Rocky Mountain spotted fever followed by scrub typhus.
Meningitis and meningoencephalitis are the most common
presentations.1 Focal CNS involvement has rarely been
reported in the published literature. One case of acute dis-
seminated encephalomyelitis (ADEM),6 ADEM with bilat-
eral facial nerve palsy and quadriparesis7 and cerebral
haemorrhage,8 have been reported. Cerebellar involvement
in scrub typhus, however, has rarely been reported. In a
series by Silpapojakul K et al., only one of 72 cases had cer-
ebellitis.9 In another series, 1 of 29 patients had cerebellar
signs.10 However, there have been no reports of scrub
typhus presenting purely as cerebellitis, as in our patient. A
predilection to the CNS is thought to be due to
O. tsutsugamushi being an obligate intracellular parasite in
the phagocytes that invade the CNS as a part of systemic
infection. It causes a disseminated vasculitic process with
perivasculitis by invading the endothelial cells. This pro-
duces an acute generalized inflammation of the vascular
lining6 resulting in the various CNS manifestations.
Conventional treatment for scrub typhus includes tetra-
cycline and chloramphenicol. In areas where response
to the above is poor, either rifampicin or doxycycline may
be used but rifampicin is more affective in doxycycline
resistance cases.11
Conclusion
We present the first documented case of pure cerebellitis
in scrub typhus in India. With appropriate antibiotics, our
patient made a complete neurological recovery without
residual deficits. We emphasize the need for the early recog-
nition of unusual presentations of common diseases with
42
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prompt therapy in order to prevent further morbidity and
mortality.
Conflict of interest: None of the authors have any potential
conflicts of interest.
Source of funding: There was no source of funding.
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