CASE PRESENTATION ON SCRUB

TYPHUS

PREPARED BY
SABITA ACHARYA
DEMOGRAPHIC DATA
• Age/sex: 54Years/female
• IP No:56448
• Date of Admission:2021/07/14
• Date of Discharge:2021/07/17
CHIEF COMPLAINTS

• Fever and chills for 5 days

• Headache
• Loss of appetite
• Burning micturition
• Bodyache
• Shortness of breathe for 1 day.
(On admission her Spo2 was 92% in Venturi Mask 35%)
HISTORY OF PRESENT ILLNESS INCLUDING PREVIOUS
HOSPITAL ADMISSION

• She had develop fever with chills and rigor along with frontal
headache and generalized bodyache so visited Chitwan Medical
College Medicine OPD on 12/7/2021.
• Patient came to GIH Emergency department with fever for 5 days,
headache, burning micturition, Shortness of breathe and loss of
appetite.
SIGNIFICANT PAST HISTORY

• Hypertension under medication Losita H (1 tab)

• Hypothyroidism under medication Tab Thyronorm.
• Covid 19 on last Bhadra
• Hysterectomy 7yrs back
SIGNIFICANT FAMILY AND PERSONAL
HISTORY
• She had 6 member in her family. Her daughter in law and her son
were affected with covid- 19 alone with her last Bhadra.
• She is not allergic to any drug and food.
• She stop smoking 15 years back and she in non-alcoholic.
• She belong to middle class family.
INDICATION OF ISOLATION

• As per her sign and symptoms investigation were send, among which
it shows SCRUB TYPHUS POSITIVE.
• On 15/07/2021, Gene Xpert was sent and patient was kept in
AIRBORNE ISOLATION.
FINAL DIAGNOSIS

• Bilateral Pneumonia with scrub typhus positive.

• Co-morbidity were Hypertension and Hypothyroidism.
PHYSICAL EXAMINATION

• General Inspection: ill looking

• Blood Pressure: 110/70 mmhg
• Pulse:84bpm
• Respiratory Rate:20pm
• Saturation: 92% in vm 35%
• Chest: Bilateral basal crackles
SUMMARY OF THE PATIENT

A 54 years old gentlewoman was admitted in 8 th floor isolation

room with complaints of fever with chill and rigor along with
headche and generalized bodyache since 5 days with the
diagnosis of Bilateral Pneumonia with scrub typhus positive.
During her stay, her GCS was 15. She was treated with Inj.
Ceftriaxone, Doxycycline,Azithromycin, Paracetamol.
PROGRESS REPORT
• 13/07/2021
Blood Culture send
HRCT done
EEG,ECHO and USG done
Sodium level was 126 mmol/L
ESR was 94 mm/hr
C-Reactive protein was 80mg/L
Scrub Typhus POSITIVE
SARS COV-2 was NEGATIVE
Haemoglobin was 10.4g/dl
• 14/07/2021
 Patient is in Nasal Prong 1litre
Planned to send Gene Xpert so patient was kept in AIRBORNE
ISOLATION.
Tropical Panel was send
LDH was 381 U/L
Albumin was 2.7g/dl
Cont….
• 15/07/2021
• Sputum G/S and C/S send (shows normal upper respiratory tract flora)
• Gene Xpert send
• O2 requirement was 0.5 to 2 L
• Incentive Spirometry was started.
Cont…
• 16/07/2021:
• Continued Incentive Spirometry
• Oxygen requirement was SOS
• Discharge plan
DISEASE CONDITION
Background
• Scrub typhus was described by hasimoto in 1810.
• First described in china
• Organism was isolated in 1931 and named as ricketsia
tsutsugamushi, now reclassified as orientia
tsutsugamushi.
Cont’d….
Scrub typhus is confined to the "tsutsugamushi
triangle” extending from far eastern Russia in the
north, to northern Australia in the south, and to
Pakistan and Afghanistan in the west.
Cont’d..
• It threatens one billion people globally and
causes illness in one million people each
year.
• Causes fatality rate up to 70% without
appropriate treatment.
• Endemic in Asia and pacific islands, Asia,
Australia, New Guinea, pacific islands.
Introduction
 It is an acute febrile illness also known as
bush typhus and Japanese river fever.

Caused by a gram negative, rod shaped

(cocco- bacillus) bacterium, known as orientia
(rickettsia) tsutsugamushi.

• Transmitted to humans during feeding of

infected trombiculid mite larvae (chiggers).
Lifecycle of scrub typhus
Cont’d..
Causes
BOOK PICTURE PATIENT PICTURE
Bite by Chigger i.e. larval stage of scrub typhus Unknown (Patient do not have any bite mark nor she
remember anything related to mite)
Pathophysiology
Infected chigger bites

Inocculates orentia tsutsugamushi

Multiplication of organisms in the site

Formation of papules that ulcerates and becomes

necrotic, evolving into scar and generalized
lymphadenopathy
 Organisms reach to circulation, continue
proliferation an endothelium of small blood
vessels and releasing cytokines

Endothelial damage causing fluid leakage,

platelets aggregation, polymorph and
monocyte proliferation

Affects skeletal muscles, skin, lungs, kidneys,

brain and cardiac muscles
CLINICAL FEATURES
BOOK PICTURE PATIENT PICTURE
Fever and chills Fever and chills
Headache Headache
Cough -
Body ache and muscle pain Body ache
A dark , scab like region at the site of the chigger bite -
(also known as eschar)
Mental changes ranging from confusion to coma -
Enlarged lymph nodes -
Rash -
- Burning micturition, loss appetite, Shortness of
breathe
DIAGNOSIS

BOOK PICTURE PATIENT PICTURE

History Taking History Taking
Physical Examination Physical Examination
Immunofluorescence and Immunoperoxydase assays -
Rapid immunochromatographic flow assay(RFA) -
Dot blot immunoassay -
The weil-felix test -
ELISA -
PCR -
- Tropical panel
- HRCT , X-RAY
TREATMANT
BOOK PICTURE PATIENT PICTURE
Doxycycline 200mg/day in two divided doses for 7 Doxycycline 100g BD
days
Azithromycin 500mg in single dose for 5 days Azithromycin 500 mg OD
Paracetamol 1gm TDS and sos from 15th July
Ceftriaxone 1 gm BD
Losita-H 25mg HS
Thyronorm 37.5 mcg OD
Nursing management
Nursing diagnosis
1. Impaired body temprature, hyperthermia related to
inflammatory process.

2. knowledge deficit related to disease condition

3. Breathing difficulty related to disease condition

PREVENTION
• Vector Control
• Application of insecticides eg: lindane or chlordane to ground and
vegetation.
• Environmental control
• Avoid walking barefoot
• Health and public awareness