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Go Back       IAR Journal of Medical Case Reports | IAR J Med Cse Rep. 2(2) | Volume:2 Issue:2 ( March 30, 2021 ) : 16-19
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DOI : 10.47310/iarjmcr.2021.v02i02.010       Download PDF       HTML       XML

Eschar in Pediatric Scrub Typhus 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 and Dr. Vipin Roach*2


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, H.P, India


Abstract: Background: Scrub typhus is endemic and documented zoonotic disease in the state of Himachal Pradesh as the climatic and geographical conditions are conducive for spread of vector of this disease. The most pathognomonic sign of scrub typhus is the presence of an eschar which is formed by the bite of chigger mite that inoculates the causative agent of Scrub typhus Orientia tsutsugamushi. The aim of this study is to determine the prevalence as well as the most common sites of eschars over the bodies of 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. We studied the distribution of eschars over the bodies of all 102 patients with Scrub typhus. Results: Eschar was present in 39(38.24%) patients. Among these 39 patients 21(53.8%) were males while 18 (46.2%) were females. There was a significant difference in the distribution of eschars between males and females with a preponderance of the chest and abdomen among females and the inguinal and axilla in males. Conclusion: The eschar is the most useful diagnostic clue in patients with acute febrile illness in areas endemic for Scrub typhus and therefore should be thoroughly examined for its presence especially over the covered areas such as the inguinal, chest, abdomen and axilla.


Keywords: Eschar, Orientia tsutsugamushi, scrub typhus, Shimla.


Introduction

Rickettsial diseases and particularly, scrub typhus is one of the oldest recognized vector transmitted zoonosis (Luce-Fedrow, A. et al., 2018). 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 (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). The most characteristic clinical feature of Scrub typhus is the presence of an eschar at the site of the bite of the mite which is confirmatory of Scrub. The eschar starts as a small papule, at the site of chigger feeding and then ulcerates and forms a black crust like a skin burn from a cigarette (Xu, G. et al., 2017). The prevalence of an eschar is highly variable, from 7 to 80% in various studies, and this variation maybe due to difficulties in identifying the eschar in dark skinned individuals, differences in the eschar inducing capacity of different strains of the organism, and the atypicalappearance of eschars in skin folds and moist skin (Rajapakse, S. et al., 2012).


The groin, axilla, waist, neck and other exposed parts of the body are common sites. When present, it occurs prior to the onset of fever and other symptoms and develop on the front of the body (~80%. Towards the end of the first week, a maculopapular rash starting on the trunk and spreading to the limbs may be seen (Xu, G. et al., 2017).


Scrub typhus is a well documented disease in the state of Himachal Pradesh, but there have been no studies on ecshar which is associated with the exposure to Orientia tsutsugamushi in the paediatric age group population. Therefore, this study was done to determine the prevalence as well as the most common sites of eschars over the bodies of patients with Scrub typhus


Aims and Objectives

  • To determine the prevalence as well as the most common sites of eschars over the bodies of 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. Eshar was present in 39(38.24%) patients. Among these 39 patients 21(53.8%) were males while 18 (46.2%) were females.


Location of Eschar

It was most commonly seen in inguinal 9(23.1%), abdomen 7(17.9%), chest (17.9%), axilla 6 (15.4%), lower limbs 4 (10.3%), forearm 3(7.7%), head and neck 2(5.1%) and multiple sites 1(2.6%). There was a significant difference in the distribution of eschars between males and females with a preponderance of the chest and abdomen among females and the inguinal and axilla in males.


Table No 1: Distribution of Eschars (N=39)

Sr. No.


Location of Eschar

Total

n= 39(%)

Male

n= 21(%)

Female

n= 18(%)

1


Head/Neck

2(5.1%)

1(4.8%)

1(5.6%)

2


Axilla

6(15.4%)

4(19.1%)

2(11.1%)

3


Fore arm

3(7.7%)

2(9.5%)

1(5.6%)

4


Chest

7(17.9%)

3(14.3%)

4(22.2%)

5


Abdomen

7(17.9%)

2(9.5%)

5(27.8%)

6


Inguinal

9(23.1%)

7 (33.3%)

2(11.1%)

7


Lower Limbs

4(10.3%)

2(9.5%)

2(11.1%)

8


Multiple sites

1(2.6%)

0(0%)

1(5.6%)












Figure Image is available at PDF File

Figures: Location of eschar at different sites of body


Discussion

Scrub typhus is an underappreciated cause of acute febrile illness in many parts of India (Kamarasu, K. et al., 2007; & 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). The eschar represents the site of inoculation, where initial multiplication occurs before widespread dissemination. An eschar is typically painless and non-pruritic, and hence its presence is not reported by patients. A diligent search for eschar is often rewarding. It clinches a diagnosis of scrub typhus, enabling early initiation of treatment (Kim, D. M. et al., 2007; & Chrispal, A. et al., 2010).


A pathognomonic eschar is a typical feature of scrub typhus and is of high diagnostic value. Presence of eschar is an important finding for the diagnosis of scrub typhus, rickettsialpox, and another mite- or tick-borne rickettsiosis. The presence of eschar in a patient with scrub typhus varies widely in different studies from 9.5% to 86% of patients (Kim, D. M. et al., 2007; Kumar, K. et al., 2004; & Kundavaram, A. P. et al., 2013). But in the present study, Eschar was present in 39(38.24%) patients. Among these 39 patients 21(53.8%) were males while 18 (46.2%) were females.


In the present study, eschar was most commonly seen in inguinal 9(23.1%), abdomen 7(17.9%), chest (17.9%), axilla 6 (15.4%), lower limbs 4 (10.3%), forearm 3(7.7%), head and neck 2(5.1%) and multiple sites 1(2.6%). There was a significant difference in the distribution of eschars between males and females with a preponderance of the chest and abdomen among females and the inguinal and axilla in males similar to different studies all over the world (Kim, D. M. et al., 2007; Kundavaram, A. P. et al., 2013; & Kim, D. M. et al., 2010). A thorough physical examination, especially of the hidden areas such as the genitalia, buttock folds, scalp, and postaural areas, is imperative in identifying this value diagnostic clue of scrub typhus.


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 practitioners and paediatricians should be sensitised regarding signs, symptoms and risk factors of scrub typhus, so that all cases of febrile illness presenting during this period should be evaluated for this disease.


The pathognomonic eschar of scrub typhus, which is usually found on the genitalia, abdomen, chest, and axillary folds, is one of the most valuable clues in the diagnosis Therefore, the clinicians could early diagnose a scrub typhus if they are aware of the changing form of eschar over time, and would be able to promptly manage the patient with appropriate antibiotics.


References

  1. 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

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

  3. 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.

  4. Kim, D. M., Kim, S. W., Choi, S. H., & Yun, N. R. (2010). Clinical and laboratory findings associated with severe scrub typhus. BMC infectious diseases10(1), 1-7.

  5. 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.

  6. Kumar, K., Saxena, V. K., Thomas, T. G., & Lal, S. (2004). Outbreak investigation of scrub typhus in Himachal Pradesh (India). The Journal of communicable diseases36(4), 277-283.

  7. Kundavaram, A. P., Jonathan, A. J., Nathaniel, S. D., & Varghese, G. M. (2013). Eschar in scrub typhus: a valuable clue to the diagnosis. Journal of postgraduate medicine59(3), 177.

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

  10. Rajapakse, S., Rodrigo, C., & Fernando, D. (2012). Scrub typhus: pathophysiology, clinical manifestations and prognosis. Asian Pacific journal of tropical medicine5(4), 261-264.

  11. 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.

  12. 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)

  13. Xu, G., Walker, D. H., Jupiter, D., Melby, P. C., & Arcari, C. M. (2017). A review of the global epidemiology of scrub typhus. PLoS neglected tropical diseases11(11), e0006062.

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