Acute respiratory failure in scrub typhus patients.

Sir,

We read the brief communication titled “Acute respiratory failure (ARF) in scrub typhus patients” by Sahoo et al. published in August 2016 issue of Indian Journal of Critical Care Medicine with great interest.[1] Delay in diagnosis of scrub typhus or late treatment with doxycycline can increase morbidity and mortality. Having suspicion about scrub typhus in patients with fever, thrombocytopenia, and polyserositis and early treatment is the key for successful outcome. We have few comments for the author on this article.

First and foremost, the time of starting treatment with doxycycline (day from onset of fever) in your patients has not been mentioned. The doxycycline treatment in your patient was started empirically or as a definitive treatment.

Second, the day of illness to admission in the Intensive Care Unit was 10.02 ± 4.75 days. The delay in starting doxycycline in your patient was due to delayed diagnosis or late presentation of patient to the hospital. It has been showed by Venkategowda et al.[2] that delay in treatment with doxycycline can lead to high incidence of acute respiratory distress syndrome. The card/kit test which is used for diagnosing dengue may have false positive result[3] for dengue in patients who actually had scrub typhus. In patients having fever with thrombocytopenia with multiple organ dysfunction syndrome should be evaluated for more than one tropical infection to avoid unnecessary false positive result. Finally, it has been mentioned in results that out of 55 patients in the prospective observational study, 29 patients required respiratory support for the neurological cause (Glasgow coma scale <8). However, the Table 1[1] highlights that 27 patients required respiratory support for ARF and two patients for nonrespiratory failure.

Clinical features related to respiratory system usually occur during 2nd week of untreated disease.[45] High suspicious of scrub typhus in patients with fever, thrombocytopenia, and polyserositis and early treatment with doxycycline can reduce morbidity and mortality.

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