J Postgrad Med. 2016 Oct-Dec; 62(4): 235–238.

PMCID: PMC5105208
doi: 10.4103/0022-3859.184662: 10.4103/0022-3859.184662 PMID: 27763480

Chest radiographic manifestations of scrub typhus

KPP Abhilash, PR Mannam,1 K Rajendran, RA John,1 and P Ramasami2

Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
1
Department of Radio-Diagnosis, Christian Medical College, Vellore, Tamil Nadu, India
2
Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
Address for correspondence: Dr. Kundavaram Paul Prabhakar Abhilash, E-mail: kppabhilash@gmail.com

Received 2016 Apr 12; Revised 2016 May 26; Accepted 2016 May 28.

Copyright : © 2016 Journal of Postgraduate Medicine

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Abstract

Background and Rationale:

Respiratory system involvement in scrub typhus is seen in 20–72% of patients. In endemic ar‐
eas, good understanding and familiarity with the various radiologic findings of scrub typhus
are essential in identifying pulmonary complications.

Materials and Methods:

Patients admitted to a tertiary care center with scrub typhus between October 2012 and
September 2013 and had a chest X ray done were included in the analysis. Details and radio‐
graphic findings were noted and factors associated with abnormal X-rays were analyzed.

Results:

The study cohort contained 398 patients. Common presenting complaints included fever
(100%), generalized myalgia (83%), headache (65%), dyspnea (54%), cough (24.3%), and al‐
tered sensorium (14%). Almost half of the patients (49.4%) had normal chest radiographs.
Common radiological pulmonary abnormalities included pleural effusion (14.6%), acute respi‐
ratory distress syndrome (14%), airspace opacity (10.5%), reticulonodular opacities (10.3%),
peribronchial thickening (5.8%), and pulmonary edema (2%). Cardiomegaly was noted in 3.5%
of patients. Breathlessness, presence of an eschar, platelet counts of <20,000 cells/cumm, and
total serum bilirubin >2 mg/dL had the highest odds of having an abnormal chest radiograph.
Patients with an abnormal chest X-ray had a higher requirement of noninvasive ventilation
(odds ratio [OR]: 13.98; 95% confidence interval CI: 5.89–33.16), invasive ventilation (OR:
18.07; 95% CI: 6.42–50.88), inotropes (OR: 8.76; 95% CI: 4.35–17.62), higher involvement of
other organ systems, longer duration of hospital stay (3.18 ± 3 vs. 7.27 ± 5.58 days; P < 0.001),
and higher mortality (OR: 4.63; 95% CI: 1.54–13.85).

Conclusion:

Almost half of the patients with scrub typhus have abnormal chest radiographs. Chest radiog‐
raphy should be included as part of basic evaluation at presentation in patients with scrub ty‐
phus, especially in those with breathlessness, eschar, jaundice, and severe thrombocytopenia.

KEY WORDS: Chest X-ray, pulmonary involvement, radiological findings, scrub typhus

Background and Rationale

Scrub typhus is an acute bacterial febrile illness caused by Orientia tsutsugamushi.[1,2] It has
now reached endemic proportions and is the predominant pathogen causing acute undifferen‐
tiated febrile illness in many parts of India.[1,2,3] The basic pathogenesis is vasculitis and
perivasculitis of the small blood vessels, resulting in multiple organ involvements.[4,5]
Respiratory system (RS) involvement is quite common and may vary in severity from mild
bronchitis to severe acute respiratory distress syndrome (ARDS) warranting mechanical venti‐
lation. Abnormal chest radiography has been described in 42–72% of patients.[3,6,7] Common
radiological abnormalities include parenchymal fine to coarse reticular infiltrates, nodular infil‐
trates, consolidation, pulmonary edema, and rarely pleural effusion. However, literature on
chest radiographs seen in scrub typhus is scant and described in small cohorts. Familiarity with
the various radiologic findings of scrub typhus is important in identifying and initiating prompt
treatment, thus helping to reduce morbidity. The aim of this study is to describe the various
findings of plain chest radiograph in a large cohort of patients with scrub typhus and to corre‐
late them with clinical features and outcome. To our knowledge, this is the largest cohort of ra‐
diological description of pulmonary involvement due to scrub typhus.

Materials and Methods

The study is an analysis of a large, prospective observational study conducted in the emer‐
gency department (ED) and the Department of Radio-diagnosis at Christian Medical College,
Vellore, which is a 2700-bedded tertiary care teaching hospital in South India. All consecutive
adult patients (age >16 years) who presented to the ED and the outpatient department of gen‐
eral medicine between October 2012 and September 2013 and confirmed to have scrub typhus
were screened. All patients who had chest X-ray done were included in the study. Diagnosis of
ST was confirmed by IgM ELISA positivity (InBios International, Inc., Seattle, USA) and/or pres‐
ence of a pathognomonic eschar. Chest X rays of these patients were obtained from the com‐
puterized hospital information processing system (CHIPS). All chest radiographs were inter‐
preted and reported by two radiologists who were unaware of the final diagnosis. They re‐
viewed the chest radiographs independently and reached a decision on the final interpretation
by consensus. The abnormal chest radiographs were reviewed for the presence of radio‐
graphic findings such as reticulonodular opacities, airspace opacity, peribronchial thickening,
pleural effusion, pulmonary edema, ARDS, and cardiomegaly. Among those who required inten‐
sive care or mechanical ventilation, only the abnormalities on X-rays done in the first 48 h of
admission were considered as directly caused by scrub typhus. The patients were divided into
two groups based on the chest radiographs: A normal chest radiographic group and an abnor‐
mal chest radiographic group. These groups were compared for factors associated with abnor‐
mal X-rays and the clinical outcome.

The data were analyzed using Statistical Package for Social Sciences software for Windows
(SPSS Inc., Released 2007, version 16.0, Chicago, USA). For comparison between the groups,
the continuous variables are presented as mean (standard deviation [SD]) or as median
(range) depending upon the distribution of the data. Categorical and nominal variables are
presented as percentages. Chi-square test or Fisher exact test was used to compare dichoto‐
mous variables, and t-test or Mann–Whitney test was used for continuous variables as appro‐
priate. The differences between the two groups were analyzed by univariate analysis and multi‐
variate logistic regression analysis, and their 95% confidence intervals (CI) were calculated. For
all tests, a two-sided P < 0.05 was considered statistically significant.

This study was approved by the Institutional Review Board and Ethics Committee of Christian
Medical College, Vellore (IRB Min. No. 8007 dated 19/09/2012), and patient confidentiality was
maintained using unique identifiers.

Results

During the study period, 452 patients were confirmed to have scrub typhus. Chest X-ray was
not done in 54 patients as they did not have any respiratory symptom and were treated on an
outpatient basis. The study cohort contained 398 cases of scrub typhus who had chest radio‐
graphs done in the first 48 h of presentation.

The mean age of the patients was 43 ± 14.9 years, and there was a slight female predominance
(57%). The mean duration of fever prior to presentation was 8.20 ± 3.2 days. A pathognomonic
eschar was present in 58.8% (234/398) with common sites being the groin, genitalia, axilla,
neck, and breast folds. Common presenting complaints included fever (100%), generalized
myalgia (83%), headache (65%), breathlessness (54%), cough (24.3%), and altered sensorium
(14%).

Almost half of the patients (49.4%) had normal chest radiographs. Common radiological pul‐
monary abnormalities included pleural effusion (14.6%), features of ARDS (14%), airspace
opacity (10.5%), reticulonodular opacities (10.3%), peribronchial thickening (5.8%), and pul‐
monary edema (2%) [Table 1].

Comparisons of related clinical and laboratory data between chest radiographic examinations
with normal and abnormal findings are shown in Table 2. We found the symptom of breath‐
lessness, presence of an eschar, platelet counts of <20,000 cells/cumm, total serum bilirubin >2
mg/dL to have the highest odds of having an abnormal chest X-ray. Multiple logistic regression
analysis showed breathlessness (odds ratio [OR]: 3.02; 95% CI: 1.71–5.31; P < 0.001) and a se‐
quential organ failure assessment score >6 (OR: 3.66; 95% CI: 1.87–7.18; P < 0.001) to be inde‐
pendent predictors of an abnormal chest X-ray.
The comparison of clinical course and outcome between normal and abnormal chest radio‐
graphic groups is shown in Table 3. Patients with an abnormal chest X-ray had a higher re‐
quirement of oxygen therapy, noninvasive ventilation, invasive ventilation, inotropes, and
higher involvement of other organ systems and had a longer duration of hospital stay.

All the patients were treated with oral doxycycline (100 mg twice daily for 7 days) with or with‐
out intravenous azithromycin (500 mg once daily for 5 days). Seventy-four percent of patients
required admission with 20.3% (81/398) requiring intensive care monitoring. The overall mor‐
tality rate was 5.1% (21/398) with patients with an abnormal X ray having a higher mortality
(OR: 4.63; 95 % CI: 1.54-13.85).

Discussion

Scrub typhus results in significant morbidity and mortality in the Asia-Pacific region where it
even accounts for up to 50% of undifferentiated febrile illness in some areas.[3] The mean du‐
ration of fever of 8.1 (SD: 3.2) days is comparable to the usual mean duration of presentation
in most studies.[3,8,9] Our rate of finding an eschar in 58.8% of patients is similar to that re‐
ported from other studies that have been performed close to this geographic area.[10]
However, the eschar pick-up rate is very varied and ranges from 9.5% to 90%.[8,11] In our in‐
stitution, the pick-up rate for an eschar has improved from 45.5% in 2008 to 58.8% in our
study.[3] This shows greater awareness and increases vigilance in searching for probably the
most important diagnostic clue in patients with scrub typhus.[12]

As seen in our study, RS dysfunction due to scrub typhus is seen in a significant number of pa‐
tients (46.4%). Varghese et al. described pulmonary dysfunction as the most common compli‐
cation with majority of the patients eventually requiring invasive or noninvasive ventilatory
support.[9] Respiratory symptoms have been reported to range from 20% to 72% among pa‐
tients with scrub typhus.[3,7,13] The common respiratory symptoms in our study were dysp‐
nea (54%) and cough (22.6%). ARDS, which is probably the most serious pulmonary complica‐
tion, has been reported in 8–34% of patients with severe scrub typhus.[3,8,9,14]

In our study, almost half of the patients (49.4%) had normal chest radiographs. This is compa‐
rable with reports from Taiwan where 45.2% of the chest radiographs were normal.[15]
Common radiological pulmonary abnormalities in our study included pleural effusion, ARDS,
airspace opacity, reticulonodular opacities, peribronchial thickening, and pulmonary edema.
Previous studies showed reticulonodular opacities, septal lines, pleural effusion, and hilar en‐
largement to be frequent chest radiographic abnormalities.[8,12,16] In a study by Choi et al.
(sample size: 75), the most frequent pulmonary abnormality was bilateral reticulonodular
opacities (40%) while Wu et al. (sample size: 136) described pleural effusion as the most fre‐
quent abnormality in patients with scrub typhus. We found pleural effusion to be associated in
14.6% of our patients, a rate consistent with other studies (10.8–23.4%).[7,15] Chest radio‐
graphic features suggestive of ARDS were seen in 14% of our patients. In other studies, fea‐
tures of ARDS on chest radiography ranged from 6% to 25%.[3,15] Only 3.5% of our patients
had cardiomegaly although it was reported in up to 28.5% of patients in some studies. Our
study had a much larger sample size (452) and included both inpatients and outpatients
whereas the other studies included only inpatients.[7,16]
A limitation of our study was that it was conducted at a single medical center, and hence, the
patient population may be biased by patient selection and referral pattern. Nonetheless, the
study provides relatively rare information about chest radiographic findings of adult scrub ty‐
phus patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Figures and Tables

Table 1

Chest radiographic findings in scrub typhus (n=398)

Finding Number Percentage

Normal 197 49.4

Pleural effusion 58 14.6

Acute respiratory distress syndrome* 56 14

Airspace opacity 42 10.5

Reticulonodular opacity 41 10.3

Peribronchial thickening 23 5.8

Cardiomegaly 14 3.5

Pulmonary edema 8 2

Others 8 2

Others: Postinflammatory changes, granulomas, fibrosis, emphysema. *Bilateral near symmetric pulmonary infiltrates
involving one-third or more of each lung field
Table 2

Univariate analysis of the variables among normal and abnormal chest X-ray findings

Variables n, SD OR (95% CI) P

Patients with normal CXR Patients with abnormal

(n=189) CXR (n=210)

Mean age (years) 40.35 (14.98) 46.43 (14.37) 1.03 (1.01- <0.001
1.04)

Age >60 years 21 (11.11) 37 (17.62) 1.71 (0.96- 0.068

3.04)

Male sex 93 (49.21) 79 (37.62) 0.62 (0.42- 0.020

0.93)

Duration of fever 8.4 (3.4) 8.1 (3.1) 0.97 (0.91- 0.337

1.03)

Breathlessness 52 (27.51) 157 (74.76) 7.8 (5-12.19) <0.001

Cough 34 (17.99) 56 (26.67) 1.66 (1.02- 0.039

2.68)

Diabetes mellitus 27 (14.29) 34 (16.19) 1.16 (0.67- 0.598

2.01)

Respiratory rate (/min) 23.53 (6.20) 31.93 (8.80) 1.17 (1.13- <0.001
1.21)

SpO 2 <90% 16 (8.47) 80 (38.28) 6.71 (3.74- <0.001

12.01)

Eschar 92 (48.68) 143 (68.10) 2.25 (1.5-3.38) <0.001

SOFA score 3.01 (2.79) 7.59 (4.50) 1.45 (1.34- <0.001

1.58)

Total WBC count 9202.70 (4536.57) 11,066.19 (5265.81) 1.00 (1.00- <0.001
(cells/mL) 1.00)

Creatinine (mg/dL) 1.33 (1.14) 1.78 (1.43) 1.43 (1.15- 0.002

1.79)

Bilirubin >2 (mg/dL) 28 (14.81) 82 (39.61) 3.77 (2.31- <0.001

6.15)

Albumin (mg/dL) 3.29 (0.62) 2.66 (0.56) 0.17 (0.11- <0.001

0.26)

SGOT (U/L) 136.88 (157.14) 152.95 (126.74) 1.001 (0.999- 0.266

1.002)

SGPT (U/L) 88.68 (83.54) 80.43 (66.35) 0.999 (0.996- 0.278

1 001)
SOFA: Sequential organ failure assessment, SGOT: Serum glutamic oxaloacetic transaminase, SGPT: Serum glutamic
pyruvate transaminase, OR: Odds ratio, CI: Confidence interval, CXR: Chest X-ray, SD: Standard deviation
Table 3

Comparison of clinical course and outcome in scrub typhus patients between normal and abnormal chest radiographic
groups

Variables n, SD OR (95% CI) P

Patients with normal CXR Patients with abnormal CXR

(n=189) (n=210)

Noninvasive ventilation 6 (3.17) 66 (31.43) 13.98 (5.89- <0.001

33.16)

Invasive ventilation 4 (2.12) 59 (28.10) 18.07 (6.42- <0.001

50.88)

Oxygen requirement 30 (15.87) 144 (68.57) 11.56 (7.11- <0.001

18.82)

Inotropes requirement 10 (5.29) 69 (32.86) 8.76 (4.35- <0.001

17.62)

Duration of hospital 3.18 (3) 7.27 (5.58) 1.33 (1.23- <0.001

stay 1.43)

CVS involvement 16 (8.47) 94 (44.76) 8.76 (4.91- <0.001

15.65)

Hematological 110 (59.14) 176 (83.81) 3.58 (2.24- <0.001

involvement 5.72)

CNS involvement 24 (12.70) 66 (31.43) 3.15 (1.88- <0.001

5.29)

Hepatic involvement 90 (47.62) 161 (76.67) 3.61 (2.35- <0.001

5.55)

Renal involvement 46 (24.34) 86 (40.95) 2.16 (1.4-3.32) <0.001

Outcome (mortality) 3 (2.12) 18 (9.09) 4.63 (1.54- <0.001

13.85)

Hematological involvement: Thrombocytopenia (platelet count <100,000/cells cumm), leukopenia (WBC count
<2500/cells cumm), leukocytosis (WBC count >11,000/cells cumm) or evidence of coagulopathy, Renal involvement:
Serum creatinine >1.4 mg/dL or need for dialysis, CVS involvement: Hypotension or need for inotropic or vasopressor
support, CNS involvement: Alteration in the level of consciousness or aseptic meningitis, Hepatic involvement: Serum
bilirubin >2 mg/dl or three-fold elevation of SGOT/SGPT or elevated alkaline phosphatase. SGOT: Serum glutamic ox‐
aloacetic transaminase, SGPT: Serum glutamic pyruvate transaminase, OR: Odds ratio, CI: Confidence interval, CXR:
Chest X-ray, SD: Standard deviation, WBC: White blood count, CNS: Central nervous system, CVS: Cardiovascular system