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CASE REPORT
Year : 2020  |  Volume : 23  |  Issue : 6  |  Page : 808-811
 

Neurological manifestations of scrub typhus: A case series from Tertiary Care Hospital in Southern East Rajasthan


Department of Neurology, Government Medical College, Kota, Rajasthan, India

Date of Submission20-Feb-2019
Date of Acceptance26-Mar-2019
Date of Web Publication23-May-2019

Correspondence Address:
Dr. Prashant Shringi
Department of Neurology, Government Medical College, Kota, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_97_19

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   Abstract 

Scrub typhus is an acute febrile infectious illness caused by rickettsia species Orientia tsutsugamushi. In recent years, scrub typhus has reemerged as a life-threatening disease in India Scrub typhus has diverse clinical manifestations ranging from a nonspecific febrile illness to severe multiorgan dysfunction, and neurological complications are also common. Spectrum of neurological complications varies from common complications such as aseptic meningitis, meningoencephalitis and cerebellitis to rare complications such as myelitis, cerebral hemorrhage, acute disseminated encephalomyelitis (ADEM), and cerebral infarction. Scrub typhus is not a common cause of acute febrile illness in state like Rajasthan, but has emerged as a life-threatening disease in recent years along with dreaded neurological complications. This case series highlights various neurological manifestations of scrub typhus as early diagnosis and treatment of neurological complications have good prognosis.


Keywords: Acute febrile illness, cerebellar signs, neurological manifestations, scrub typhus


How to cite this article:
Sardana V, Shringi P. Neurological manifestations of scrub typhus: A case series from Tertiary Care Hospital in Southern East Rajasthan. Ann Indian Acad Neurol 2020;23:808-11

How to cite this URL:
Sardana V, Shringi P. Neurological manifestations of scrub typhus: A case series from Tertiary Care Hospital in Southern East Rajasthan. Ann Indian Acad Neurol [serial online] 2020 [cited 2021 Jan 21];23:808-11. Available from: https://www.annalsofian.org/text.asp?2020/23/6/808/258975



   Introduction Top


Scrub typhus is a rickettsial infection caused by Orientia tsutsugamushi, which is a Gram-negative obligate intracellular coccobacillus that is transmitted to the humans by the bite of larval stage (chigger) of trombiculid mite. The bites of these chiggers leave the characteristic “eschar,” which is pathognomonic of scrub typhus.[1],[2] The characteristic eschar is seen in 40%–50% of patients and may be inconspicuous as it is often present in areas like groin, gluteal folds, breast folds, and external genitalia and may go unnoticed in dark-skinned people.[3]

The disease has been reported from all over the world, but it is endemic in terrains of the tsutsugamushi triangle, a geographical region comprising South and East Asia and the Southwest Pacific.[4]

In India, studies have shown the endemic nature of scrub typhus in many states and union territories. The first reported cases were from Himachal Pradesh.[3] Scrub typhus is an important cause of acute febrile illness in India.[4] Case fatality rate may be as high as 30% if left untreated.[5] Scrub typhus is grossly underdiagnosed in India due to its nonspecific clinical presentation, limited awareness, and low index of suspicion among clinicians and lack of diagnostic facilities.[6] Infection manifests clinically as a nonspecific febrile illness often accompanied by headache, myalgia, nausea, vomiting, diarrhea, and breathlessness and ranges to severe multiorgan dysfunction.[6]

Central nervous system (CNS) involvement is a known complication of scrub typhus which ranges from aseptic meningitis to frank meningoencephalitis.[7]

Various neurological manifestations include meningoencephalitis, meningitis, encephalitis, encephalopathy, seizure, myelitis, ADEM, cranial neuropathies like sixth, seventh, mononeuritis multiplex, brachial plexopathy, Guillain–Barre syndrome, and rarely stroke. The most common reported manifestation is meningoencephalitis.[1],[8],[9]

Here, we report a case series of five cases of scrub typhus presenting in the neurology department with various neurological manifestations [Table 1].
Table 1: Clinical profile of scrub typhus patients with neurological manifestations

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Figure 1: FLAIR MRI images shows (a) bilateral frontotemporoparietal cortical white matter hyperintensity; (b) acute thrombus in superior saggital sinus; (c) hyperintensity in medulla and pontomedullary junction

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   Discussion Top


Scrub typhus was endemic in India in the past decade especially in Himachal, UP, and some states of south India, but since the past few years scrub typhus is emerging as a life-threatening illness in other parts of India. Scrub typus is uncommon in Rajasthan, but in our region due to abundant paddy fields in rural area, scrub typhus is emerging as an important cause of acute febrile illness in recent years. This disease is common in farmers and villagers of our region. Previous studies that were published reported cases of scrub typhus and their outcome from states like Himachal Pradesh, Uttar Pradesh, and Pondicherry; this is the first case series reported from western state Rajasthan with extensive work up and showing importance of early diagnosis and treatment. All casesof scrub typhus included in this case series had four fold rise in antibody titer on ELISA IgM test. Malaria and dengue are also a common cause of acute febrile illness in our region so both these two and other causes of infectious and noninfectious ruled out by various laboratory test.

Nervous system involvement is a common complication of scrub typhus infection. Orientia tsutsugamushi enters the CNS by invasion of endothelial cells in blood vessels. Cytokines released by acutely inflamed vascular endothelial cells secondary to invasion in blood vessels damage endothelial integrity causing fluid leakage. There is localized platelet aggregation, polymorphs, and monocyte proliferation, leading to angiitis.[1],[8] CNS involvement is a known complication of scrub typhus which ranges from aseptic meningitis to frank meningoencephalitis.[7] Many studies in India and in other countries found that meningoencephalitis is a most common neurological complication of scrub typhus. A study done by Rana et al. found that the most common neurological manifestation was meningoencephalitis (40%).[8] A cross-sectional study on 37 patients published by Mishra et al. found two-thirds of patients with scrub typhus had neurological involvement manifesting as meningoencephalitis, encephalitis, or encephalopathy,[1] but cerebrospinal fluid findings can mimic tuberculous meningitis and viral meningoencephalitis.[7] In a Korean study, 89 patients with severe complications and 119 without severe complications due to scrub typhus were evaluated. In the group with severe scrub typhus, 23 (11.3%) patients had meningoencephalitis.[10] Scrub typhus as a cause of ADEM is extremely rare, pathophysiology is obscure, but it has been postulated to result from an autoimmune response to myelin basic protein triggered by infection as in our cases it may be due to cross reactivity of IgM antibodies to myelin protein.[11]

Meningoencephalitis was the most common encountered symptom in our study along with rare complications such as ADEM and cerebral venous thrombosis. We started early and prompt treatment to prevent further complications and promote early recovery; despite that, one patient died due respiratory failure secondary to scrub typhus.


   Conclusion Top


This case series highlights that scrub typhus is emerging as a life-threatening disease in southeast Rajasthan. Neurological manifestations are very common in scrub typhus. Knowledge of these manifestations will enable clinicians to consider scrub typhus as one of the differential diagnoses of acute febrile illness with neurological involvement. The neurological complications in scrub typhus have good prognosis if diagnosed and treated early.

Acknowledgement

The authors thank the Department of Neurology, Government Medical College, Kota.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Misra UK, Kalita J, Mani VE. Neurological manifestations of scrub typhus. J Neurol Neurosurg Psychiatry 2014;0:1-6. doi: 10.1136/jnnp-2014-308722.  Back to cited text no. 1
    
2.
Saifudheen K, Kumar KG, Jose J, Veena V, Gafoor VA. First case of scrub typhus with meningoencephalitis from Kerala: An emerging infectious threat. Ann Indian Acad Neurol 2012;15.  Back to cited text no. 2
    
3.
Chunchanur SK. Scrub typhus in India – An impending threat. Ann Clin Immun Microbiol 2018;1;Article 1003.  Back to cited text no. 3
    
4.
Peter JV, Sudarsan TI, Prakash JA, Varghese GM. Severe scrub typhus infection: Clinical features, diagnostic challenges and management. World J Crit Care Med 2015;4:244-50.  Back to cited text no. 4
    
5.
Gurunathan PS, Ravichandran T, Stalin S, Prabu V, Anandan H. Clinical profile, Morbidity pattern and outcome of children with scrub typhus. Int J Sci Study 2016;4:247-50.  Back to cited text no. 5
    
6.
Vivekanandan M, Mani A, Priya YS, Singh AP, Jayakumar S, Purty S. Outbreak of scrub typhus in Pondicherry. J Assoc Physicians India 2010;58:24-8.  Back to cited text no. 6
    
7.
Drevets DA, Leenen PJ, Greenfield RA. Invasion of central nervous system by intracellular bacteria. Clin Microbiol Rev 2004;17:323-47.  Back to cited text no. 7
    
8.
Rana A, Mahajan SK, Sharma A, Sharma S, Verma BS, Sharma A. Neurological manifestations of scrub typhus in adults. Trop Doctor 1-4. doi: 10.1177/0049475516636543.  Back to cited text no. 8
    
9.
Gulati S, Maheshwari A. Neurological manifestations of scrub typhus. Ann Indian Acad Neurol 2013:16.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Kim DM, Kim SW, Choi SH, Yun NR. Clinical and laboratory findings associated with severe scrub typhus. BMC Infect Dis 2010;10:108.  Back to cited text no. 10
    
11.
Chen PH, Hung KH, Cheng SJ, Hsu KN. Scrub typhus-associated acute disseminated encephalomyelitis. Acta Neurologica Taiwanica 2006;15:251-4.  Back to cited text no. 11
    


    Figures

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    Tables

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