Scrub Typhus

Ashirwad Sharma Bhattarai

2015 Batch
Intern
Classification of rickettsial disease
• Spotted fever group
• Rocky mountain spotted fever
• Other tick borne typhus fever
• Typhus group
• Epidemic typhus (louse borne typhus)
• Endemic typhus (flee borne typhus)
• Scrub typhus (mite borne)
Background

• Scrub typhus A/K/A (Bush typhus )is a largely ignored tropical disease
and a leading cause of undifferentiated febrile illness caused by
Orientia tsutsugamushi.
• It is frequently diagnosed in South Asian countries.
• After the 2015 earthquake in Nepal, a sudden upsurge in scrub
typhus cases were reported.
• It is often underdiagnosed and misdiagnosed due to non-specific
clinical presentation coupled with limited microbiological facilities,
leading to adverse clinical outcomes
• From 2015 to 2017, 1239 scrub typhus cases were confirmed with the
largest outbreak occurring in 2016 with 831 (67.1%) cases.
• A nationwide outbreak of scrub typhus was declared as the cases
were detected in 52 out of the 75 districts of Nepal.
Introduction
• Rickettsial infection caused by orientia tsutsugamushi, a gram
negative obligate intracellular coccobacillus of Rickketsiaceae family.
Tsutsuga= small and dangerous ; mushi= mite
• Multiply in capillary endothelial cells
• It usually affects cardiovascular and respiratory system.
• First described from japan in 1899
• Commonest occurring rickettsial infection in Nepal
• More during winter and rainy seasons.
• Generally seen in people whose occupational or recreational activities
bring into contact with vector chiggers.
• Occurs in areas where scrubs vegetations are found
• Bushes
• Bank of river
• Rice fields
• Poorly maintained kitchen gardens
Epidemiology
• Causative organism is Orientia tsutsugamushi
• Human acquire disease from the bite of infected mite larva (chigger).
• Human are accidental and dead end host.
• Larva is the only stage that can transmit the disease to the humans.
• Mites are both reservoir and vector of disease.
Life cycle
Clinical features
• Incubation period: 5-20 days after the initial bite
• Clinical spectrum may be self limiting disease to multi organ
dysfunction resulting to death.
• If untreated it has HFR:30-45%
• Chigger bite: painless, noticed by transient localized itch
• First sign of disease is vesicular lesion at the site of bite then scab-like
(A/K/A) eschar
• Bites are found on groin, axillae, genitalia, perianal area or neck
• Fever with chills and rigor
• Headache
• Vomitting
• Abdominal pain
• Myalgia
• Malaise
• Infection of conjunctiva
• Spotted rash
• Lymphadenopathy

Fig: Pathognomonic eschar

Complications
• Develops after 1 week of illness
• Atypical pneumonia
• Renal failure
• Encephalopathy
• Myocarditis
• DIC
• MODS
• Septic shock
Diagonosis
• Specific investigation
• Weil felix test
• Agglutination of the somatic antigens of non-motile proteus species by the patient’s
serum.
• IgM and IgG ELISA (Most sensitive)
• IgM Antibody titre observed at the end of 1st week and IgG appear at the end of 2nd week
• Immunofluorescence assay (Gold standard)
• Fourfold rise in antibody titre is considered as diagonistic of scrub typhus
• PCR
• Supportive investigations
• TLC: > 11,000/ microliter
• Mild thrombocytopenia
• Albuminuria
• Deranged LFT
• Chest X-ray : B/L infiltrates
Treatment
• Scrub typhus should be treated with the antibiotic Doxycycline.
• it can be used in person of any age.
• Pediatric dose : (4.5mg/kg/day) in two divided doses up to maximum of 100
mg twice daily for 7-14 days.
• Adult dose : 200mg daily for 7 days
• Alternatives: Chloramphenicol,Azithromycin
• Children and pregnant women : Azithromycin 500mg OD
• As tetracyclines causes depression of skeletal growth in childrens so
should avoided in children under 8 yrs of age.
Prevention and control measures
• No vaccine is available to prevent scrub typhus.
• Persons who cannot avoid infested terrain should wear protective
clothing, and impregnate their clothing and bedding with miticide.
• Wash themselves and their clothes after every potential exposure.
• Insect repellents like dimethyl phthalate and benzyl benzoate can be
applied to skin and clothing to prevent chigger bites.
• Do not sit or lie on bare ground or grass, use a suitable ground sheet
or covers.
• In a baby or child:
• Dress your child in clothing that covers arms and legs, or cover crib, stroller,
and baby carrier with mosquito netting.
• Do not apply insect repellent onto a child’s hands, eyes, or mouth or on cuts
or irritated skin.
• Spray insect repellent onto your hands and then apply to child’s face.
Refrences
• https://www.stidh.gov.np/
• Davidson's Principles and Practice of Medicine,-24th Edition
• Park's Textbook Of Preventive And Social Medicine,-20th Edition
• Nelson Essentials of Pediatrics, -7th Edition
THANK YOU

Have a great day

ahead !!