Do not miss scrub typhus as a cause of multiorgan dysfunction in primary care practice.

Sir,

Scrub typhus is an important, often overlooked and potentially lethal disease entity responsible for multi organ dysfunction syndrome (MODS). Here we describe a patient of this disease who was diagnosed late, even though she had the classical clinical features. A 32-year-old female was referred to our unit from a district hospital for the complaints of fever, myalgia and dyspnea for 5 days, where she was being treated for complicated malaria with intravenous Artesunate for 3 days, but because of worsening parameters she was referred to a higher center. On clinical examination, she had pallor, icterus and blood pressure of 90/60 mmHg, respiratory rate of 30/min, tender muscles in all four limbs and gangrene of the left foot extending up to the mid foot. On examination, she had a saturation of 92% on room air; arterial blood gas analysis revealed a PO2 of 62 mmHg, PCO2 of 29 mmHg, pH of 7.49. Hemoglobin was 5.2 g/dl, total leukocyte count was 5400/mm3 with normal differentials and platelet counts of 78000/mm3. Liver function tests revealed serum Bilirubin of 6.4 mg/dl (predominantly indirect fraction), aspartate aminotransferase - 325 IU/L, alanine aminotransferase - 402 IU/L, alkaline phosphatase 202 IU/L. Serum creatinine was 2.8 mg/dl and serum urea was 154 mg/dl. Coagulation profile was normal. There was no visible eschar or rash. Dorsalis pedis pulse was not palpable in the left lower limb and the foot was cold to touch [Figure 1]. Malarial parasite was not detected in the smear or on antigen examination. Dengue serology was negative. As the clinical picture was suggestive and the patient had not responded to adequate antimalarial therapy, she was investigated for leptospira and rickettsial diseases. She tested positive for anti-scrub typhus immunoglobulin m antibodies (Weil-Felix test) with titers of >1:160. A diagnosis of scrub typhus with MODS was made and she was treated with supplemental oxygen, packed red cell transfusions and oral doxycycline, which was started at a dose of 100 mg twice daily for 7 days after a loading dose of 200 mg. Oxygen requirement decreased and the liver and renal functions became normal over the next 7 days. The patient was discharged after 8 days and is following up with the vascular surgeon for the treatment of the left foot gangrene, which is being managed conservatively at present.

Figure 1

Left foot of the patient showing gangrene- added in the text

Scrub typhus, is caused by Orientia tsutsugamushi. The disease is contracted by the bite of trombiculid mite larvae and humans are accidental hosts.[1] The disease is easily confirmed by serological tests. Doxycycline is the drug of choice; azithromycin and rifampicin are the other alternatives. The disease is increasingly being recognized as a cause of MODS and respiratory distress from intensive care units all over North India.[2] The disease closely mimics the more rampant malaria and dengue fevers and is therefore, very often overlooked and not treated. Even, the classical eschar may be present in only up to 50% patients[3] and should not lead to its exclusion from the list of differential diagnosis. A delay in appropriate therapy is associated with unfavorable outcomes such as gangrene in our patient and calls for early diagnosis and treatment. The primary care physician should include scrub typhus as differential diagnosis in the appropriate patient.