Post-CPR scrub typhus patient with ARDS: A case report.

Sir,

Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi confined to East Asia and the Western Pacific islands.[1] The case description includes a primary papular lesion, which enlarges, undergoes central necrosis, and crusts to form a flat black eschar. This is associated with regional and later generalised lymphadenopathy (enlarged and tender nodes). Despite antibiotic treatment, scrub typhus with severe complications rarely progresses to a fatal disease including sepsis and myocarditis. In the case of fulminant scrub typhus myocarditis, its complications can lead to cardiogenic shock and cardiac arrest. But it has rarely been reported. Here, we report a patient who was taken after hypoxic cardiac arrest and treated with open lung ventilation and was subsequently discharged.

A 34-year-old female presented to our institution with symptoms of high-grade fever, chills, headache for 8 days followed by pedal oedema with shortness of breath. The patient was diagnosed with scrub typhus (eschar right side inguinal region) and acute respiratory distress syndrome (ARDS). On examination, peripheral capillary oxygen saturation (SPO2) and heart rate (HR) were not recordable; Glasgow coma scale showed E1V1M1, bilaterally chest crepts were present. The patient had deranged laboratory investigations [Figure 1]. Later, X-ray chest was done, bilateral chest infiltrates were present, and in serological test, IgM antibodies for scrub typhus were found.

Figure 1

Change in laboratory investigations from day-1 to day-9

The patient was intubated and cardiopulmonary resuscitation (CPR) started, inj. adrenaline was given; the patient revived and shifted to the intensive care unit (ICU) with noradrenaline infusion for further management. All standard monitoring was attached (opening vitals HR- 150/min, blood pressure- 74/44 mmHg, SPO268%, pupil dilated reactive to light). Infusions of dopamine and dobutamine were started and the patient was put on assisted-control mode-volume controlled ventilation (Acmv-Vcv) mode with the setting of tidal volume-300, respiratory rate- 24, positive end expiratory pressure (PEEP)-12 cm H2O, and the fraction of inspired oxygen-1 [Table 1]. Further PEEP was increased to 20 cm H2O with close monitoring of vitals. Lung protective strategies involve the use of higher respiratory rate, lower tidal volume (48 mL/kg predicted body weight) to achieve the minute ventilation and for improvement of oxygenation; we require higher PEEP with targeted plateau pressure <30 cm H2O to meet pH goal of 7.30 to 7.45 and to prevent barotrauma.[23] The patient was sedated with midazolam infusion to prevent dyssynchrony.

Table 1

Ventilation parameters during the course of hospital stay

	ACMV-VCV	ACMV-PCV	ACMV-PCV	ACMV-PCV	ACMV-PCV	ACMV-PCV	ACMV-PCV	SIMV-PCV	SPONT
TV	300	-	-	-	-	-	-	-	-
RR	24	22	22	18	16	16	14	12	-
PEEP	20	18	18	12	10	10	10	8	5
PSV	-	-	-	-	-	-	-	14	10
FiO2	1	1	0.7	0.45	0.5	0.5	0.5	0.4	0.3
	Day-1	Day-2	Day-3	Day-4	Day-5	Day-6	Day-7	Day-8	Day-9
PH	7.337	7.331	7.333	7.372	7.49	7.361	7.496	7.504	7.451
pco2	32.6	44.6	63	60.7	46.4	61.5	33.1	33.6	35.5
PaO2	45.6	58	65	69.2	70	68.4	126.4	94.6	161
HCO3	17	22	33.3	35.3	35.4	34.8	25.6	26.5	25
Lactate	6.18	1.21	0.78	0.69	0.66	0.86	0.94	0.69	0.72
PaO2/FiO2	45.6	58	90	173	140	137	252	235	536

ACMV-VCV=Assisted-control mode ventilation-volume-control ventilation, PCV=Pressure-control ventilation, SIMV=Synchronised intermittent mandatory ventilation, TV=Tidal volume, RR=Respiratory rate, PEEP=Positive end expiratory pressure, PSV=Pressure support ventilation, FiO2=Fraction of inspired oxygen, pH=Potential of hydrogen, pCO2=Partial pressure of carbon dioxide, PaO2=Partial pressure of oxygen, HCO3=Bicarbonate

The patient was started on tablet doxycycline 100 mg bd, inj. azithromycin 500 mg od, tab. rifampicin 600 mg od, inj. pantoprazole 40 mg od, inj. ondansetron 4 mg tid, inj. hydrocortisone 100 mg tid, and inj. paracetamol 1 gm tid.

The condition of the patient improved day by day and the patient was extubated on 26/10/2017 and discharged from ICU on 28/10/2017.

Severity varies from subclinical illness to severe illness with multiple organ system involvements, which can be serious enough to be fatal unless diagnosed early and treated. Serious complications of scrub typhus are not uncommon and may be fatal; they include pneumonia, myocarditis, meningo-encephalitis, acute renal failure, and gastrointestinal bleeding. Patients with scrub typhus and presenting with multiorgan dysfunction syndrome may end in mortality.[4] Doxycycline 200 mg/day is the treatment of choice for scrub typhus.[56] Other antibiotics useful for the treatment of this infection are chloramphenicol, azithromycin and rifampicin. Rapid resolution of fever following doxycycline is so characteristic that it can be used as a therapeutic test.

In this case, the patient presented very late on 8th day of fever with ARDS and had a hypoxic cardiac arrest in the initial examination. We found the eschar in the patient and started the treatment. The patients with ARDS require mechanical ventilation support, and we were able to save the patient with the help of mechanical ventilation.

Early diagnosis and treatment with the support of mechanical ventilation is the key to survival.

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Conflicts of interest

There are no conflicts of interest.