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Journal of Postgraduate Medicine, Vol. 57, No. 3, July-September, 2011, pp. 262-263 Letter Altered sensorium in scrub typhus B Remalayam, S Viswanathan, V Muthu, S Mookappan Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, Tamil Nadu, India Code Number: jp11076 PMID: 21941079 Sir, Scrub typhus is ubiquitous in the Indian subcontinent and can end fatally. We describe an unreported neurological complication associated with scrub typhus. This 43-year-old man presented with fever of 11 days, headache for 2 days, and unconsciousness 1 day prior to admission and had received intravenous antibiotics and antipyretics for 2 days in a nursing home. He had tachycardia, tachypnea, normotension, fever [101 F], icterus, hepatomegaly, without focal neurological or meningeal signs. Pending investigations, artesunate, and ceftazidime were instituted. Investigations: Hemoglobin 12 g/ dl, hematocrit 34.4, total counts 15 400/ mm 3 , platelets 39 000/ mm 3 , urea 15 mg/dl, creatinine 0.9 mg/dl, total bilirubin 5.6 mg/dl [direct 4 mg/dl], aspartate aminotransferase 640 U/l, alanine aminotransferase 479 U/l, alkaline phosphatase 235 U/l, serum protein 5.7 g/ dl, serum albumin 2.8 g/dl, prothrombin[PT] prolongation of 5 s [INR-1.3], activated partial thromboplastin time[aPTT] prolongation of 20 s, Weil--Felix test [WFT] OX-K titers in >1:320 dilutions, sterile blood and urine cultures, negative malarial and dengue antigens and acute subdural hematoma on computed tomography [Figure - 1]. Emergency decompression neurosurgery was not attempted on day 1 in view of coagulopathy and thrombocytopenia; five units of platelets and four units of fresh frozen plasma [FFP] were given. A search after WFT revealed a scrotal eschar [Figure - 2] and doxycycline was administered. Following hypotension on day 2, chloramphenicol was added for dual cover. His sensorium worsened and his coagulopathy did not normalize with further transfusions and he succumbed to refractory shock 54 h after admission. The rickettsial species Orientia tsutsugamushi transmitted by Leptotrombidium deliense (Leptotrombidium scutel in cooler months) mites causes scrub typhus in humans [1] Typically, an acute febrile illness with rash, eschar, lymphadenopathy and organomegaly is observed. Though it is endemic in our area, [1] subdural hematoma due to scrub typhus was initially not in the diagnostic reckoning. A positive WFT and later, finding an eschar helped us. WFT, in our setting has proven to be highly specific even with titres as low as 1:80. [1] Complications by and large include acute respiratory distress syndrome (ARDS), pulmonary hemorrhage, gastrointestinal hemorrhage, meningitis, myocarditis and acute renal failure. [2] Central nervous system involvement is generally seen in all patients, but focal neurological deficits are rare. [4] Mononuclear meningitis, meningoencephalitis, Guillain-Barre syndrome, and acute disseminated encephalomyelitis have been described. [3],[4] Vascular injuries like cerebral infarction [3] and thalamic hemorrhage [5] [thrombocytopenia and disseminated intravascular coagulation (DIC) related have also been reported. Subdural hematoma in scrub typhus has not been described previously in English literature. Hemorrhagic complications are generally due to focal or diffuse vasculitis and perivasculitis related vascular endothelial damage especially in the heart, brain, and skin, pulmonary and gastrointestinal system. [4] Thrombocytopenia, aPTT and PT could not be corrected with repeated transfusions and vitamin K for the patient to undergo surgery. Fibrinogen degradation products testing were not available at that time. Our patient was a teetotaler with negative viral markers and only had transaminases elevation, hyperbilirubinemia, and INR of 1.3-not enough to suggest a severe liver disease causing a bleeding diathesis. Hence we believe vasculitis and possibly an associated DIC due to rickettsial infection could have predisposed towards a subdural hematoma. His undrained hematoma could have led to neurological damage and death in the presence of multiorgan failure (respiratory, cardiac and hepatic). Rare complications of common illnesses occur and are easily missed by casual clinical examination and attending physicians need constant vigil. References
Copyright 2011 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp11076f1.jpg] [jp11076f2.jpg] |
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