Scrub typhus presenting as an acute abdomen.

Scrub typhus is a mite-borne infectious disease caused by Orientia tsutsugamushi, which presents as an acute febrile illness with headache, myalgia, breathlessness, and an eschar, a pathognomonic sign, in a varying proportion of patients. However, this illness can present unusually with fever and severe abdominal pain mimicking acute abdomen. A careful search for an eschar in all patients with an acute febrile illness would provide a valuable diagnostic clue and avoid unnecessary investigations and surgical exploration.

INTRODUCTION

Scrub typhus is a mite-borne infectious disease caused by Orientia tsutsugamushi, which presents as an acute febrile illness, which causes significant morbidity and mortality in the Asia-Pacific region. The severity of infection can range from a self-limiting febrile illness to a fulminant sepsis syndrome with multi-organ failure and death. The usual presentation is that of a short duration fever, headache, myalgia, rash, and lymphadenopathy. Jaundice, renal failure, pneumonitis, acute respiratory distress syndrome, septic shock, myocarditis, and meningo-encephalitis are the known complications of this illness. We present a case of a patient who presented with fever and an acute abdomen underwent surgical exploration and subsequently confirmed to have scrub typhus.

CASE REPORT

A 54 years lady presented with history of fever and severe abdominal pain since 5 days. She underwent a laparotomy and cholecystectomy in another hospital for suspected acute abdomen. She was referred to this hospital since the laparotomy did not reveal any surgical cause for the abdominal pain and patient had progressive breathlessness. Clinical examination revealed an eschar over the abdomen and had features of Systemic Inflammatory Response Syndrome (SIRS) with significant hypoxia. Blood counts revealed hemoglobin of 9.8 g%, total White Blood Cell (WBC) count-21,500 with 62% neutrophils and platelet count of 1,42,000/cu.mm. Biochemical tests showed a creatinine of 1.5 mg%, total bilirubin-1.5 mg%, direct bilirubin-0.2 mg%, protein-5.4 g %, albumin-1.7 g%, Serum Glutamic Oxaloacetic Transaminase (SGOT)-108, Serum Glutamic Pyruvate Transaminase (SGPT)-27, Alkaline phosphatase of 211. Based on the presence of an eschar and evidence of multi-organ failure requiring invasive ventilation, she was diagnosed to have scrub typhus and started on oral doxycycline and intravenous azithromycin with which she showed significant improvement. She became afebrile in 48 h and weaned off the ventilator in 3 days. The diagnosis of Scrub typhus was confirmed by a positive IgM Enzyme Linked Immunosorbent Assay (ELISA). She was discharged after 1 week and was afebrile and doing well on a 2 week follow-up.

DISCUSSION

Scrub typhus is a very common cause of fever comprising 48% of in-patient admissions with acute febrile illness in our hospital.[1] This is associated with significant morbidity and mortality and needs to be identified quickly to initiate appropriate antibiotic therapy. Unusual presentations of this febrile illness need to be kept in mind and a thorough search for an eschar is of paramount importance in anybody who presents with fever. There were 2 other case reports in the literature of scrub typhus presenting as an acute abdomen who then had surgical exploration under initial impression of acute cholecystitis and acute appendicitis respectively.[23] Another patient presented with features of acute pancreatitis with a pancreatic abscess and then found to have scrub typhus.[4]

Our patient presented with fever and abdominal pain with multi-organ involvement and was confirmed to have scrub typhus. The patient had a prompt response to doxycycline and intravenous azithromycin and was normal at subsequent follow-up.

In conclusion, the possibility of scrub typhus presenting with fever and acute abdomen should be kept in mind and a careful search for an eschar should be part of routine examination in any patient who presents with an acute febrile illness.