Track your Manuscript
Enter Correct Manuscript Reference Number:
Get Details
Why Us
Open Access
Peer-reviewed
Rapid publication
Lifetime hosting
Free indexing service
Free promotion service
More citations
Search engine friendly
Go Back       IAR Journal of Medical Case Reports | IAR J Med Cse Rep. 2(2) | Volume:2 Issue:2 ( March 30, 2021 ) : 13-15
114 Downloads240 Views

DOI : 10.47310/iarjmcr.2021.v02i02.009       Download PDF       HTML       XML

Hepatic and Neurological findings in Pediatric Scrub Typus patients of Hilly District of North India


Article History

Received: 08.03.2020 Revision: 14.03.2020 Accepted: 23. 03.2021 Published: 30.03.2021


Author Details

Dr. Raju1 & Dr. Vipin Roach2


Authors Affiliations

1Medical Officer (Specialist), Himachal Pradesh Health Services, (HPHS), Govt of Himachal Pradesh, India


2Assistant Professor, Department of Pediatrics, I.G.M.C., Shimla, Himachal Pradesh, India


Abstract: Background: Scrub typhus is one of the oldest recognized vector transmitted zoonosis, fraught with a history of military and wartime mortality. The aim of this study is to determine the Hepatic and Neurological manifestations among patients with Scrub typhus. Materials and Methods: This cross-sectional Sero-Epidemiological study was conducted in the department of Paediatrics, Indira Gandhi Medical College, and Shimla from 1st June 2017 to 30th Nov 2018. The study participants were newly diagnosed paediatric cases(n-102) of scrub typhus with a positive Scrub typhus IgM ELISA test.  Results: Raised level of Serum glutamic oxaloacetic transaminase (>40IU) was present in 72(70.6%) patients, raised level of serum glutamic pyruvic transaminase (>30IU) was present in 70 (68.6%) of patients, raised values of Serum Alkaline phosphatase (>250IU) was present in 38 (37.3%) of patients. Hypoproteinemia (serum protein <5.5g/dl) was found in 27(26.5%) of patients, Hypoalbuminemia (<3gdl) was found in 49 (48.1%) of patients. Hyperbilurubinemia was present in 29(28.4%) of patients. 17 (16.7%) patients had altered sensorium GCS score < 15, 1(0.9%) patients had cerebellar signs, 5(4.9%) had meningeal signs, 2(1.9%) had cranial nerves palsy (2st, 3rd 6th, 7th and 8th) and 1(10.9%) had generalized tonic clonic seizures. Conclusion: The general physicians should be sensitized regarding LFT and CNS Findings associated with Scrub typhus which are useful diagnostic clue.


Keywords: Hepatic and Neurological manifestations, scrub typhus, Shimla.


Introduction

The World Health Organization has reported scrub typhus one of the world’s most under diagnosed and under reported disease that often requires hospitalization. Better understanding of the vectors, its outbreaks and its pathogenesis is required to control human outbreaks within and beyond its recognized regions of endemicity (Luce-Fedrow, A. et al., 2018; & World Health Organization. 2018).


Himachal Pradesh is a mountainous state in northern India, situated at an altitude between 350-6816 meters above mean sea level. During the rainy seasons, areas of lower altitudes experience an average temperature between 20ºC to 35ºC which is suitable for the spread of arthropod vector. Maximum number of the cases are being reported between the months of July to November (Sharma, A. et al., 2005).


Scrub typhus is an acute febrile illness caused by O. tsutsugamushi (Kim, D. M. et al., 2007). Liver dysfunction is a well-documented complication of Scrub typhus. Abnormalities of liver function are common (elevated aspartate aminotransferase levels in 78–89%, elevated alanine aminotransferase levels in 64–92%, elevated alkaline phosphatase levels in 27–84%, elevated bilirubin levels in 16–38%). Notably, elevation of transaminases appears to be more common than raised bilirubin but liver failure is rarely reported (Rajapakse, S. et al., 2017).


Meningitis and meningoencephalitis are common nervous system manifestations of Scrub typhus and later in the more severe form, seen in a subset of patients, are characterized by altered sensorium and seizures (Rajapakse, S. et al., 2017). The CSF findings in Scrub typhus are non-specific and mimic those of TB meningitis (CSF lymphocytic pleocytosis with increased proteins). Neuro imaging demonstrates diffuse cerebral edema. The patients with neurological involvement invariably have multi-organ dysfunction syndrome and need intensive care (Rajapakse, S. et al., 2017; & Abhilash, K. P. P. et al., 2015).


Cranial nerve palsies like isolated abducens nerve palsy and bilateral asymmetrical facial nerve palsy are also being reported in Scrub typus with the involvement of CNS. Hearing loss is a well-documented complication and only manifestation which improves gradually with antibiotic treatment (Rajapakse, S. et al., 2017; & Mahajan, S. K., & Bakshi, D. 2007).


Scrub typhus is a well documented disease in the state of Himachal Pradesh, but there have been no studies on Hepatic and neurological manifestations which is associated with the exposure to Orientia tsutsugamushi in the paediatric age group population. Therefore, this study was done to determine the Hepatic and Neurological manifestations among patients with Scrub typhus. 


Aims and Objectives

  • To determine the Hepatic and Neurological manifestations among patients with Scrub typhus. 


Materials and Methods

This study was conducted in the department of Paediatrics, Indira Gandhi Medical College, Shimla, a tertiary care teaching institute in Himachal Pradesh.


Duration of study: From 1st June 2017 to 30th Nov 2018.


Study Design: Cross-sectional Study.


Ethical Clearance: Approval from the Institutional ethical committee of Indira Gandhi Medical College Shimla.


Study Population

The study participants consisted of all 102 newly diagnosed paediatric cases of scrub typhus, admitted in pediatric ward of IGMC Hospital Shimla based on positive IgM against scrub typhus during the study period.


Exclusion Criteria

1. The study subjects having concomitant HIV, Malaria, Tuberculosis, Hepatitis, Typhoid and Acinetobacter septicaemia.

2. Participants in the control group B and group C having febrile illness during the last three months.

3. Participants or their parents who are not willing to participate in the study.


Sampling Method

All the diagnosed cases of scrub typhus based on enrolment criteria at the time of admission in the paediatric ward were enrolled.

Statistical Analysis

Data from the case record files was recorded on a Microsoft excel spreadsheet. Statistical analysis was performed using Epi Info 7. All discrete variables were expressed as percentages.


Results

In the present study, among 102 newly diagnosed cases of Scrub Typus, 57 (55.9%) were males while 45 (44.1%) were females. 39 (38.2%) were in the age group of 1-10 years while 63 (61.8%) were in the age group of 11-18 years.


Table 1: Age and Gender distribution of the Study Population

Variables

n(%)

Gender

Male

57 (55.9%)

Female

45 (44.1%)

Age groups

1-10 years

39 (38.2%)

11-18 years

63 (61.8%)


Liver Function Tests:

Raised level of Serum glutamic oxaloacetic transaminase (>40IU) was present in 72(70.6%) patients with range of 15-6732 IU (mean of 173.90±388.48), raised level of serum glutamic pyruvic transaminase (>30IU) was present in 70 (68.6%) of patients with range of 11-4294 IU (mean of 127.57±258.37), raised values of Serum Alkaline phosphatase (>250IU) was present in 38 (37.3%) of patients with range of 42-2684 IU (mean of 302.46±34.81). Hypoproteinemia (serum protein <5.5g/dl) was found in 27(26.5%) of patients with range of 3-7 g (mean of 5.71±.86), Hypoalbuminemia (<3gdl) was found in 49 (48.1%) of patients with range of 2-5g (mean of 2.90±.60). Hyperbilurubinemia was present in 29(28.4%) of patients with range of 0.2-29 mg (mean of 2.26±3.38).


Central Nervous System

17 (16.7%) patients had altered sensorium GCS score < 15, 1(0.9%) patients had cerebellar signs, 5(4.9%) had meningeal signs, 2(1.9%) had cranial nerves palsy (2st, 3rd 6th, 7th and 8th) and 1(10.9%) had generalized tonic clonic seizures.

Discussion

Scrub typhus is an underappreciated cause of acute febrile illness in many parts of India (Kamarasu, K. et al., 2017; & Mahajan, S. K. et al., 2006). It is caused by the rickettsial pathogen O. tsutsugamushi, which is transmitted by the bite of larval trombiculid mites inhabiting scrub vegetation. Often, it results in life-threatening complications such as acute respiratory distress syndrome, hepato-renal dysfunction, and meningoencephalitis (Chrispal, A. et al., 2010).


In the present study, raised level of Serum glutamic oxaloacetic transaminase (>40IU) was present in 72(70.6%) patients with range of 15-6732 IU (mean of 173.90±388.48), raised level of serum glutamic pyruvic transaminase (>30IU) was present in 70 (68.6%) of patients with range of 11-4294 IU (mean of 127.57±258.37), raised values of Serum Alkaline phosphatase (>250IU) was present in 38 (37.3%) of patients with range of 42-2684 IU (mean of 302.46±34.81). Hypoproteinemia (serum protein <5.5g/dl) was found in 27(26.5%) of patients with range of 3-7 g (mean of 5.71±.86), Hypoalbuminemia (<3gdl) was found in 49 (48.1%) of patients with range of 2-5g (mean of 2.90±.60). Hyperbilurubinemia was present in 29(28.4%) of patients with range of 0.2-29 mg (mean of 2.26±3.38).


Similar to our study Mahajan et al., (2006) had also observed raised transaminase levels in 66.67% of patients. Zhang et al., (2010) also reported similar finding in their study with increased AST levels in 81% and ALT 79% of patients. Chanta et al., (2007) also had reported increased in AST, ALT and total bilirubin levels in 96%, 81%, 7.2% of cases respectively.


In the present study, 17 (16.7%) patients had altered sensorium GCS score < 15, 1(0.9%) patients had cerebellar signs, 5(4.9%) had meningeal signs, 2(1.9%) had cranial nerves palsy (2st, 3rd 6th, 7th and 8th) and 1(10.9%) had generalized tonic clonic seizures. Similar findings were seen in Vivekanandan (2010) and Vikrant et al., (2013) studies. In a study conducted by George M. Varghese et al., (2013) at Christan Medical college Vellore has reported meningitis or meningoencephalitis in 19.2% similar to our study. Kim et al., (2000) had described 6th and 7th nerve palsy.


Conclusions

Scrub typhus is endemic and documented zoonosis in the state of Himachal Pradesh as the climatic and geographical conditions are conducive for spread of vector of the scrub typhus. The general physicians should be sensitized regarding LFT and CNS Findings associated with Scrub typhus which are useful diagnostic clue,


References

  1. Abhilash, K. P. P., Gunasekaran, K., Mitra, S., Patole, S., Sathyendra, S., Jasmine, S., & Varghese, G. M. (2015). Scrub typhus meningitis: An under-recognized cause of aseptic meningitis in India. Neurology India63(2), 209.

  2. Chanta, C., Triratanapa, K., Ratanasirichup, P., & Mahaprom, W. (2007). Hepatic dysfunction in pediatric scrub typhus: role of liver function test in diagnosis and marker of disease severity. Medical journal of the Medical Association of Thailand90(11), 2366.

  3. Chrispal, A., Boorugu, H., Gopinath, K. G., Prakash, J. A. J., Chandy, S., Abraham, O. C., ... & Thomas, K. (2010). Scrub typhus: an unrecognized threat in South India–clinical profile and predictors of mortality. Tropical doctor40(3), 129-133.

  4. Jiang, J., & Richards, A. (2018). Scrub typhus: no longer restricted to the Tsutsugamushi Triangle. Tropical medicine and infectious disease. 3(11), 1-7

  5. Kamarasu, K., Malathi, M., Rajagopal, V., Subramani, K., Jagadeeshramasamy, D., & Mathai, E. (2007). Serological evidence for wide distribution of spotted fevers & typhus fever in Tamil Nadu. Indian Journal of Medical Research126(2), 128.

  6. Kim, D. M., Won, K. J., Park, C. Y., Yu, K. D., Kim, H. S., Yang, T. Y., ... & Shin, H. (2007). Distribution of eschars on the body of scrub typhus patients: a prospective study. The American journal of tropical medicine and hygiene76(5), 806-809.

  7. Kim, D.E., Lie, S.N., & Park, K. (2000). Case report 22 years old women admitted with scrub typhus. Arch Neural. 57, 1770-72.

  8. Luce-Fedrow, A., Lehman, M. L., Kelly, D. J., Mullins, K., Maina, A. N., Stewart, R. L., ... & Richards, A. L. (2018).  A Review of Scrub Typhus (Orientia tsutsugamushi and Related Organisms): Then, Now, and Tomorrow. Trop Med Infect Dis. 3(8),1-30

  9. Mahajan, S. K., & Bakshi, D. (2007). Acute reversible hearing loss in scrub typhus. JAPI55, 512-514.

  10. Mahajan, S. K., Rolain, J. M., Kashyap, R., Bakshi, D., Sharma, V., Prasher, B. S., ... & Raoult, D. (2006). Scrub typhus in Himalayas. Emerging infectious diseases12(10), 1590.

  11. Rajapakse, S., Weeratunga, P., Sivayoganathan, S., & Fernando, S. D. (2017). Clinical manifestations of scrub typhus. Transactions of the Royal Society of Tropical Medicine and Hygiene111(2), 43-54.

  12. Sharma, A., Mahajan, S., Gupta, M. L., Kanga, A., & Sharma, V. (2005). Investigation of an outbreak of scrub typhus in the Himalayan region of India. Japanese journal of infectious diseases58(4), 208.

  13. Varghese, G. M., Mathew, A., Kumar, S., Abraham, O. C., Trowbridge, P., & Mathai, E. (2013). Differential diagnosis of scrub typhus meningitis from bacterial meningitis using clinical and laboratory features. Neurology India61(1), 17-20

  14. Vikrant, S., Thakur, S., Sharma, A., Gupta, D., Kaushal, S. S., Kanga, A., et al.,. (2013) Scrub typhus associated acute kidney injury-a study from a tertiary care hospital from Westeran Himalayan state of India. Informa Healthcare. 1-6.

  15. Vivekanandan, M., Mani, A., Priya, Y. S., Singh, A. P., Jayakumar, S., & Purty, S. (2010). Outbreak of scrub typhus in Pondicherry. J Assoc Physicians India58(1), 24-8.

  16. World Health Organization. (2018). WHO recommended surveillance standards. Geneva: World Health Organization; 1999. Available at: https://apps.who.int/iris/handle/10665/65517 (Assessed on 16 November 2018)

  17. Zhang, S., Song, H., Liu, Y., Li, Q., Wang, Y., Wu, J., ... & Yu, X. J. (2010). Scrub typhus in previously unrecognized areas of endemicity in China. Journal of clinical microbiology48(4), 1241-1244.

About IAR Journals
International Academic & Research Consortium is a Scientific Research Consortium under the banner of IARCON Knowledge Hub Private Limited, with the main aim to promote the development and strengthening of the interfaces between various ..
View More
Copyright © 2020 International Acedemic Research Journals. All Rights Reserved.
Designed & Developed by