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 [1,2].

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 [3,4].

Scrub typhus is an acute febrile illness caused by O. tsutsugamushi [5]. In Scrub typhus infection, cardiac manifestations are frequent and are associated with increased morbidity but not mortality. Early recognition and focused management of cardiac complications may help reducemorbidity and mortality associated with Scrub typhus infection [6].

Nonspecific ECG changes in Scrub include sinus tachycardia, bradycardia, atrial flutter or fibrillation, atrial standstill, heart block, PR-interval prolongation, ST-T change, prominent U waves, ventricular premature beats and Q-T prolongation. Relative bradycardia is a common feature in Scrub typhus and may be seen in over 50% of patients. Myocarditis leading to clinically evident heart failure has been described in the pediatric population as well, with fatal outcome [7].

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

Aims and Objectives

To determine the Cardio-logical manifestations among patients with Scrub typhus.

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

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

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

• 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.

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.

Cardio-Logical Manifestations

In our study tachycardia was present in 96 (94.1%), hypotension in 37 (36.3%) and feature suggestive of congestive heart failure in 1 (0.9%) patient. On ECG, 1st degree heart block in 1 (0.9%) patient, complete heart block in 1 (0.9%) patient, atrial fibrillation and flutter in 1 (0.9%) patient. Other ECG findings like sinus tachycardia and nonspecific T wave changes were present in 24 (23.5%) patients. Echocardiography was done in patients with ECG changes and it revealed minimal pericardial effusion in 2 (1.9%) patients with normal myocardial function and ejection fraction.

Scrub typhus is an underappreciated cause of acute febrile illness in many parts of India [8,9]. 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 [10].

In our study tachycardia was present in 96 (94.1%), hypotension in 37 (36.3%) and feature suggestive of congestive heart failure in 1 (0.9%) patient. On ECG, 1st degree heart block in 1 (0.9%) patient, complete heart block in 1 (0.9%) patient, atrial fibrillation and flutter in 1 (0.9%) patient. Other ECG findings like sinus tachycardia and nonspecific T wave changes were present in 24 (23.5%) patients. Echocardiography was done in patients with ECG changes and it revealed minimal pericardial effusion in 2 (1.9%) patients with normal myocardial function and ejection fraction. All patients responded to treatment of scrub typhus. 1st degree and complete heart block reverted back when patients started on treatment of scrub typhus. Similar results had been seen by C Y Fang and Marin-Garcia J et al. in their studies [11,12]. Endothelial cells invasion by rickettsia causes vasculitis and responsible for myocarditis and pericardial effusion [11,12].

Electrocardiographic abnormalities were present most commonly in the acute illness. Findings support the impression that, with few exceptions, prompt treatment of scrub typhus with antibiotics prevents the serious cardiac complications seen prior to the antibiotic era [11,12].

Marin-Garcia J et al. in their study reported cardiac complications are seen in 5-25% of patients including hypotension due to shock, myocarditis and arrhythmias. Pericardial effusion had been reported as a manifestation of scrub typhus, with 58% incidence of pericarditis by autopsy in this rickettsial infection. Endothelial cell invasion by rickettsia during infection causes vasculitis, which may lead to hemorrhagic pericardial effusion [11,12].

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 Cardio-logical Findings associated with Scrub typhus which provides useful clue in diagnosis. Early recognition and focused management of cardiac complications may help reduce morbidity and mortality associated with Scrub typhus infection

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