A suspected surgical case of acute abdomen: A case report of scrub typhus.

INTRODUCTION: Scrub typhus presents with diverse clinical manifestations which range from sub-clinical disease to organ failure and fatal disease. CASE
PRESENTATION: The patient presented with fever followed by acute abdominal pain and later developed septic shock with multi-organ failure. Radiological evaluations were normal, however, on thorough physical examination, an eschar was found in her right inguinal region. CLINICAL DISCUSSION: Aside from classical clinical symptoms, it can also involve various organs, most commonly of respiratory, cardiovascular and hepatic systems. Additionally, suspected patients should be thoroughly examined for the presence of an eschar, especially over the covered areas such as the groin, genitalia, infra-mammary area and axilla.
CONCLUSION: Scrub typhus should be considered in all patients from an endemic area presenting as acute undifferentiated febrile illness associated with organ involvement. Positive finding of an eschar and high index of suspicion for the various presentations of scrub typhus can avoid unnecessary surgical exploration and aid in prompt diagnosis and treatment.

Introduction

Scrub typhus is a mite-borne rickettsial zoonosis caused by Orientia tsutsugamushi [1]. It is endemic in the “tsutsugamushi triangle”, which is framed by Japan, Taiwan, China, and South Korea to the north, India and Nepal to the west, and Australia and Indonesia to the south [2]. It is one of the emerging infectious diseases in Nepal [3,4].

Classical clinical features of scrub typhus include high fever, malaise, headache, cough, generalized lymphadenopathy and maculopapular rash [5]. The bite from an infected chigger (larva of trombiculid mite) commonly results in a localized cutaneous necrosis producing a painless papule called eschar [6]. The possible complications are jaundice, splenomegaly, renal failure, pneumonia, Acute Respiratory Distress Syndrome (ARDS), septic shock, myocarditis, meningo-encephalitis and multiorgan failure [5,7].

Here we present a case of scrub typhus presenting as acute abdomen with thrombocytopenia, septic shock and multi-organ failure.

Method

We report this case in line with the updated consensus-based surgical case report (SCARE) guidelines [8].

Case presentation

A 37-year-old female presented to the emergency department with the complaint of severe abdominal pain for 2 days. She was referred from Nepalgunj for a suspected surgical cause of acute pain abdomen and further management. The pain was acute in onset, diffuse all over the abdomen and was associated with few episodes of vomiting and nausea followed by reduced appetite. She did not have jaundice or hematemesis. Three days prior to pain abdomen, the patient had a history of fever for which she had been taking over-the-counter (OTC) drugs from her local pharmacy. The patient had a past history of a laparoscopic cholecystectomy, one year ago, for symptomatic gallstone disease and her postoperative period was uneventful.

On her clinical examination, she was afebrile and in acute distress due to pain with tachycardia and tachypnea. Her vitals were suggestive of septic shock with blood pressure of 80/40 mmHg on presentation. However, after fluid resuscitation, her vitals were stabilized. The abdomen was distended and diffusely tender. On rectal examination, normal tone, finger stained with stool and no palpable mass were noted. She had features of Systemic Inflammatory Response Syndrome (SIRS) with significant hypoxia. A thorough physical examination revealed an eschar over the right inguinal region (Fig. 1).

Fig. 1

Eschar in the right inguinal region on the anterior abdominal wall.

Laboratory investigation revealed an elevated white blood cell count of 19.9 × 10 3 cells/μL with 62% neutrophils and platelet count of 84 × 103 cells/μL (thrombocytopenia). Biochemical tests showed creatinine: 1.5 mg%, total bilirubin: 1.5 mg%, direct bilirubin: 0.2 mg%, protein: 5.4 g%, albumin: 2.6 g%, Serum Glutamic Oxaloacetic Transaminase (SGOT): 108 IU/L, Serum Glutamic Pyruvic Transaminase (SGPT): 27 IU/L, Alkaline phosphatase: 167 IU/L.

On radiological examination, X-ray abdomen erect/supine and Ultrasound abdomen/pelvis were unremarkable. Contrast Enhanced Computed Tomography (CECT) abdomen was normal with minimal fluid collection in the pelvis while CECT chest showed minimal bilateral pleural effusion. Based on the presence of an eschar and evidence of multi-organ failure requiring invasive ventilation and resuscitation, she was diagnosed to have scrub typhus. Then, she was referred to the department of internal medicine and started on oral Doxycycline and intravenous Azithromycin. She showed significant improvement and was weaned off the ventilator in two days. The diagnosis of scrub typhus was confirmed by a positive IgM Enzyme Linked Immunosorbent Assay (ELISA). She was discharged after one week and was afebrile and doing well on a two-week follow-up. The timeline of events and interventions is given below (Fig. 2).

Fig. 2

Timeline of events and interventions (OTC: over-the-counter; MOF: Multi-organ failure; USG: ultrasonography; CECT: Contrast Enhanced Computed Tomography; ELISA: Enzyme Linked Immunosorbent Assay).

Discussion

Scrub typhus presents with diverse clinical manifestations which range from sub-clinical disease to organ failure and fatal disease. Scrub typhus should be an important differential diagnosis in patients presenting with acute undifferentiated febrile illness associated with organ involvement, most commonly respiratory, cardiovascular and hepatic dysfunction [5]. However, few cases of scrub typhus presenting as acute abdominal pain [9,10] have been reported. In such cases, surgical exploration under an initial impression of acute cholecystitis and acute appendicitis was done [10,11]. Another patient with features of acute pancreatitis with a pancreatic abscess was later found to have scrub typhus [12]. A case of scrub typhus with acute abdomen, septic shock and DIC in a child has also been reported [13].

Our case is a female from a rural residential area. She frequently works in the garden and fields near her home. All of these are risk factors significantly associated with acquiring a scrub typhus infection [14]. Furthermore, an analytical study by George et al. found scrub typhus cases were more likely to rest on grass/mud without a mat and to have rodents in their house. Cases were also less likely to have a toilet within the house and to change undergarments or clothes before sleeping [15].

A necrotic eschar at the inoculating site of the mite is a pathognomic sign. A retrospective analysis by Kundavaram et al. [16], examined the distribution of eschars in 418 positive scrub typhus patients. The eschar was located on the chest and abdomen among 42.3% of females and on the axilla, groin and genitalia in 55.8% of males. However, eschars are also found in unusual sites such as the cheek, earlobe, and dorsum of the foot [16]. As the bite from an infected chigger is painless, patients are usually unaware of the presence of an eschar. Therefore, in cases of acute febrile illness in endemic areas, a thorough examination for the eschar should be done, including covered areas such as the groin, genitalia, infra-mammary area, and axilla.

A total of 1271 cases of scrub typhus were reported to the Epidemiology and Disease Control Division (EDCD) of Nepal from July 17 to November 3 of 2019 alone [4]. A nationwide outbreak of scrub typhus was declared as the cases were detected in 63 out of the 77 districts of Nepal [4]. The case fatality rate was 5.7% in 2015, which declined to 1.1% in 2017 [3]. Seasonal trend was observed with a peak during August and September [3]. Over the past few years, scrub typhus has been an emerging public health problem in Nepal, with detection of O. tsutsugamushi in humans, animals, and chigger mites throughout the country with frequent outbreaks [3,4]. Therefore, a high degree of clinical suspicion of the various presentations of scrub typhus is required in Nepal and other endemic areas for timely diagnosis and treatment.

Conclusion

The presentation of scrub typhus can be non-specific or associated with pain abdomen or other organ dysfunction. Therefore, scrub typhus should be considered in all patients who live in or have traveled to an endemic area presenting as acute undifferentiated febrile illness associated with organ involvement. Additionally, such patients should be thoroughly examined for the presence of an eschar, especially over the covered areas such as the groin, genitalia, infra-mammary area and axilla. Positive finding of an eschar and high index of suspicion for the various presentations of scrub typhus can avoid unnecessary surgical exploration and aid in prompt diagnosis and treatment.

Ethical approval

Not required in our case.

Sources of funding

None.

Author contribution

Sunil Basukala (SB) = Conceptualization, Supervision.

Ayush Tamang (AT), Shriya Sharma (SS), Ujwal Bhusal (UB) = Writing- Original Draft.

SB, AT, SS, UB= Visualization, Writing-review and editing.

All the authors read and approved the final manuscript.

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Guarantor

Sunil Basukala (SB), MS, MD in Hospital Administration (MDHA), Department of Surgery, Shree Birendra hospital, Nepalese Army Institute of Health Sciences, 44600 Kathmandu, Nepal. Email: sunil.basukala@naihs.edu.np

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

No any conflict of interest.