Child and Chest Health Care Delhi NCR

Satyam is a 5 years old male child,visited our OPD with parents ,who complained of their son is suffering from fever for last 9 days ,before which he was completely normal.He is not interested in eating anything even of his choice for last 5 days and not taking interest in any outdoor or indoor play for last 2 days.He has taken treatment form local doctor for the same with no relief.

On examination,he is febrile with axillary temperature of 102degreeF,Pulse rate 120/minute,regular with fair volume. Anthropometry was within normal limit.Respiratory rate 42/minute,regular and no chest retraction.There was no pallor,no icterus.Bilateral tender lymphadenopathy was there and there was bipedal edema with swelling in hands. There was maculopaular rashes over body.Throat was congested with bilateral conjuntival injections. Tongue was normal in colour with no coating.On systemic examination,chest was clear on auscultation,haert sounds were normal with no adventitious sound ,CNS examination was normal.Abdominal examination revealed non tender hepatosplenomegaly.

Following possibilities werw kept in mind

=ENTERIC FEVER

=MALARIA

=INFECTIOUS MONONUCLEOSIS

KAWASAKI DISEASES

and child was investigated accordingly.

TLC was 5000/cmm with neutrophilic predomonance.Hemoglobin was 11gm/dl,ESR was 38mm in onehour,Platelets 1.6 lacs/cmm

Serum widal and typhidot was negative,P.S .for MP and malaria antigen was negative and blood culture was sterile.

Serum anti EBV IgM was negative

LFT and KFT : liver enzymes were  within normal range,Serum electrolytes,blood urea and serum creatinine were normal.

BLOOD SUGAR:normal

Chest Xray shows mild right sided pleural effusion,USG abdomen shows mild ascites with mesenteric lymphadenopathy.

Echocardiography did not show any dilatation of coronary artery and its branches.

Then, upon reviewing the literature, it was suspected that it may be a case of SCRUB TYPHUS and investigated for that.

Weil Felix test was negative.

Serum IgM antibody against 56 kDa protein by ELISA was positive.Then we leveled the case as scrub typhus and the child responded well to azithromycin.

On retrospective history taking,there was no history of visit to hilly or forest regions in recent past but the child had visited a village in western U.P.India, in recent past.

SCRUB TYPHUS

It is an  infectious  disease(type of Rickettsiosis), caused by bites by mites which are common in Forest areas.

It is a vector born disease commonly seen in hills and forests but may be seen anywhere.

The organism responsible for the disease is known as Orientia tsutsugamushi which is transmitted to human from rodents by the bite of a mite,  when it is in larval stage(chigger).

The average incubation period is 10 days which varies from 5 to 20 days.

The bite is painless and so goes unnoticed, in most of the cases.

The site of bite becomes erythmatous which enlarges peripherally and there becomes central necrosis with peripheral erythmma which is known as Eschar and it is pathongnomonic of scrub typhus.

concurrent infection may inhibit the replication of HIV.

It causes vasculitis(endothelial inflammation0).

CLINICAL FEATURES:

symptoms

Fever is a universal feature which is usually of high grade 104 degree-105degree F(40-40.5 degree C).

Fever may be associated with chills and rigor.

There may be dry cough,malaise,loose motion or .vomiting, pain abdomen.The child may complaint of headache.

signs

There may be regional or generalised lymphadenopathy,which may be tender.

Eschar may be noticed in some cases at the site of mite bite.

There may be conjunctival injections.Edema may be present in lower limbs and there may be swelling of hands.

On systemic examination ,one can find hepatosplenomealy,hepatomegaly,or only splenomegaly

There may be signs of third spacing of fluids in the form of pleural effusion or ascites.

LABORATORY FINDING:Alongwith clinical features ,one can find following labratory abnormalities.

Anemia,lymphopenia followed by lymphocytosis(leukocytosis),thrombocytopenia,raised ESR,raised CRP.Increased level of liver trasaminases,hypoalbuminemia and hyponatremia.

DIAGNOSIS:The clinical triad of scrub typhus is fever,eschar and rash.

Weil Felix test which is widely available for the diagnosis of Rickettsial diseases, but it is less sensitive and less specific to diagnose this condition.The gold standard test to diagnose is, Indirect immunoflouresence test, which is available at selected centres of the world.In this test, patients serum is mixed with scrub typhus antigen ,which is then reacted to florescent bound anti human antibody.

TREATMENT:Apart from symptomatic treatment,specific therapy includes macrolides like azithromycin,roxithromycin,and telethromycin.Tetracycline and Doxycycline, chloramphenicol.Quinolones have been less used.

Rfampicin is given in multidrug resistant cases.

COMPLICATIONS:If not recognised and treated early ,it may be complicated by pneumonitis,meningoencephlitis acute renal failure and DIC ,that may be fatal.

MY OPINION: In any geographical location,when the child presents with fever with chills and rigor,with hepatosplenomegaly,one should investigate for typhus fever after ruling out malaria,enteric fever,leptospirisis and Dengue fever.

REFERENCES:

• Silpapojakul K, Chupuppakam S, Yuthasompob S, et al.: Scrub and murinetyphus in children with obscure fever in the tropics. Pediatr Infect Dis J.10:200–203 1991 2041666

• Silpapojakul K, Varachit B, Silpapojakul K: Paediatric scrub typhus in Thailand: a study of 73 confirmed cases. Trans R Soc Trop Med Hyg.98:354–359 2004 15099991

• Sirisanthana V, Puthanakit T, Sirisanthana T: Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J. 22:341–345 2003 12690274

• Watt G, Kantipong P, de Souza M, et al.: HIV-1 suppression during acutescrub–typhus infection. Lancet. 356:475–479 2000 10981892

• Koh GSKW,Maude RJ,Paris DH,NeutonPN,Blacksell SD.Diagnosis of scrub typhus.Am J Trop Med Hyg.2010;82:368-70.

• Panpanich R, Garner P: Antibiotics for treating scrub typhus, Cochrane Database Syst Rev (3):CD002150, 2002.
• Lee KY, Lee HS, Hong JH, et al.: Roxithromycin treatment of scrub typhus(tsutsugamushi disease) in children. Pediatr Infect Dis J. 22:130–133 200312586976

  Watt G, Kantipong P, Jongsakul K, et al.: Doxycycline and rifampicin for mildscrub–typhus infections innorthern Thailand: A randomised trial. Lancet.356:1057–1061 2000 11009140