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ORIGINAL ARTICLE
Year : 2019  |  Volume : 33  |  Issue : 1  |  Page : 43-46

Scrub typhus: An unusual cause of acute abdomen


Department of Surgery, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication14-Oct-2019

Correspondence Address:
Ksh Raju Singh
Department of Surgery, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_19_19

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  Abstract 


Background: Scrub typhus is one of the causes of acute abdomen in surgical emergency.
Objectives: The objective was to study the clinical profile and outcome among patients of scrub typhus presenting as acute abdomen.
Materials and Methods: A community-based cross-sectional study was conducted for 15 months in eight patients who presented as acute abdominal pain with scrub typhus in a tertiary hospital. Clinical analysis, routine investigations, and rapid IgM-based immunochromatographic assay for scrub typhus are performed in every patient.
Results: A total of eight females, aged ≥20 years were included in the study. Six of the patients presented with acute abdomen, two of them had features of generalized peritonitis, two had a history of loose stools, another two had a history of constipation, and one of them presented with history of bleeding per rectum. As systemic presentation, all eight patients had fever, six of the patients had nausea and vomiting, four had tachypnea, four had presented in shock, two of the patient presented with an eschar, and four had a history of headache. All patients were treated conservatively. One patient died due to multiorgan dysfunction syndrome and severe thrombocytopenia.
Conclusion: Scrub typhus can rarely present as acute abdomen. High index of suspicion is required in cases of acute abdomen not responding to standard treatment.

Keywords: Acute abdomen, conservative treatment, multiorgan dysfunction, scrub typhus


How to cite this article:
Singh KR, Singh CG, Khumukcham S, Marak ND, Kumar P, Parasmani H, Kharshiing GA. Scrub typhus: An unusual cause of acute abdomen. J Med Soc 2019;33:43-6

How to cite this URL:
Singh KR, Singh CG, Khumukcham S, Marak ND, Kumar P, Parasmani H, Kharshiing GA. Scrub typhus: An unusual cause of acute abdomen. J Med Soc [serial online] 2019 [cited 2019 Nov 18];33:43-6. Available from: http://www.jmedsoc.org/text.asp?2019/33/1/43/269103




  Introduction Top


Scrub typhus is a mite-borne disease caused by Orientia tsutsugamushi, which is transmitted to humans through the bite of the larva of trombiculid mites, which presents as an acute febrile illness with headache, myalgia, breathlessness, and an eschar. However, this illness can present unusually with fever and severe abdominal pain mimicking acute abdomen. Over one-third of patients with scrub typhus present with gastrointestinal symptom.[1],[2] Scrub typhus is widespread in so-called “tsutsugamushi triangle” which extends from Pakistan, India, and Nepal in the West to Southeastern Siberia, Japan, China, and Korea in the North to Indonesia, the Philippines, Northern Australia, and the Pacific islands in the South.[3] The WHO identifies scrub typhus as a reemerging disease in Southeast Asia and Southwestern Pacific region with a case fatality rate of 30% if left untreated and affecting 1 million people annually.[4] In Manipur, seasonal outbreaks have been reported, especially in the months of May to October, with regularity in the past few years since 2006.[5] The present study aimed to describe clinical profile and outcome among patients of scrub typhus presenting as acute abdomen.


  Materials and Methods Top


A hospital-based cross-sectional study was conducted for 15 months from August 2017 to November 2018 in the Department of Surgery in a tertiary hospital. After approval by the ethical committee, we studied eight patients presenting as acute abdomen and serologically confirmed to have scrub typhus infection admitted in the surgical ward. Our aim was to study the clinical profile and outcome among the patients of scrub typhus presenting as acute abdomen. Inclusion criteria were patients presenting with acute abdomen confirmed to have scrub typhus. Exclusion criteria were those patients who are not responding to medical management of scrub typhus due to additional abdominal surgical conditions [Figure 1].
Figure 1: Results and observations

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Scrub typhus was suspected in those patients of acute abdominal conditions with clinical sign and symptoms such as fever with rash and/or eschar or persistent fever in spite of treatment with standard antibiotics for 48 h. Blood samples were obtained after obtaining informed consent from the patients. All patients suspected to have scrub typhus were subjected to scrub typhus antibody detection by ELISA test and also Widal agglutination test. Renal and liver function tests, complete blood count, urine analysis, chest X-ray, and ultrasonography of the whole abdomen were performed for all the patients. Computed tomography scan and magnetic resonance imaging of the abdomen were performed when indicated. Presence of IgM antibodies to scrub typhus antigens by ELISA was considered to be serological confirmation of the diagnosis.


  Results Top


A total of nine patients presented as acute abdomen with scrub typhus in our unit during this study. These patients were admitted in the surgical ward for their acute abdomen. One patient who was not responding to medical treatment of scrub typhus due to associated surgical condition, that is, emphysematous osteomyelitis of the right hip with intraperitoneal extension of abscess was excluded. Eight patients presenting with acute abdomen and confirmed to have scrub typhus were included in the study. All patients were female. One patient died due to multiple-organ failure in intensive care unit (ICU). Seven of them were from rural areas and one from urban area. Six patients were in the age group of 20–50 years, while two of them were ≥50 years. Six of the patients (75%) presented as acute pain and tenderness on the right side of the abdomen. Two of them (25%) had loose stool, while 2 (25%) had generalized peritonitis, two patients (25%) had constipation, and one patient (12.5%) had bleeding per rectum [Table 1]. Systemic presentations such as fever was present in all eight patients (100%), nausea and vomiting in six patients (75%), tachycardia in 6 (75%), tachypnea in 4 (50%), shock in 4 (50%), and history of headache in 3 (37.5%), while 2 (25%) presented with the characteristic eschar of scrub typhus [Table 2]. Laboratory parameters were studied. Two patients (25%) had hemoglobin <9 g/dl, one patient (12.5%) had total leucocyte count of >11,000/mm3, and three patients (37.5%) had platelets count <150,000/mm3. Liver function test of four patients (50%) showed elevated enzymes, while albumin level was <3 g/dl in six patients (75%). Kidney function test of four patients (50%) was found to have creatinine >1.5 mg/dl [Table 3]. Complications such as cholecystitis developed in six (75%) patients, hepatitis in four patients (50%), adult respiratory distress syndrome in three patients (37.5%), and pancreatitis in two patients (25%) as confirmed by significantly raised serum lipase and amylase. Two patients (12.5%) developed encephalitis and one patient (12.5%) developed multiple-organ dysfunction syndrome (MODS) who had severe thrombocytopenia and managed in ICU and later on expired [Table 4]. Seven patients improved considerably after starting of azithromycin 500 mg once-daily infusion or capsule doxycycline 100 mg BD.
Table 1: Abdominal sign and symptoms

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Table 2: Systemic presentation

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Table 3: Laboratory parameters

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Table 4: Complicationsa

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  Discussion Top


Scrub typhus, a zoonosis, was known in Japanese folklore to be associated with the jungle mite or chigger which was named “dangerous bug” (tsutsugamushi). The illness was described by Hashimoto in 1810. Ogata in 1931 isolated the organism and named it Rickettsia tsutsugamushi. Now, it has been reclassified as O. tsutsugamushi.[6]

Scrub typhus remains a public health problem in the Southwest Pacific and Southeast Asia, including India as it is an integral part of “tsutsugamushi triangle,” which depicts a part of the globe endemic to scrub typhus with a report of the recent outbreak in part of Manipur, India.[5],[7],[8] The clinical manifestations of scrub typhus are proteans, with the most common nonspecific symptoms such as fever, chills, headache, and cough with an unusual presentation of abdominal pain.[9] Clinical severity of the scrub typhus ranges from mild (inappreciable) to severe (fatal).[10] Severe complications include prominent encephalitis, interstitial pneumonia, acute respiratory distress, myocarditis and pericarditis, cardiac arrhythmia, acute renal failure, acute hepatic failure, and acute hearing loss.[11] Over one-third of patients with scrub typhus present with gastrointestinal symptoms which typically include associated abdominal pain/tenderness, indigestion, nausea, vomiting, hematemesis, melena, and diarrhea[1] The major endoscopic features that can develop in scrub typhus are superficial mucosal hemorrhage, multiple erosions and ulcers without any predilection sites, and unusual vascular bleeding.[12] It can present as peritonitis, acalculous cholecystitis, acute appendicitis, and pancreatic abscess.[1],[13],[14],[15]

Recent outbreak of scrub typhus has been reported in India and Northeastern part of India, including Manipur.[16] The prevalence of an eschar is 7% to 80% and it is rare in Southeast Asian patients.[17] In our study, only 25% have an eschar. Owing to endemicity in India, high clinical suspicion is required to prevent mortality in a patient not responding to standard treatment.

In our cases, acute cholecystitis and acute appendicitis were initially suspected on the basis of history and the physical examination findings. Some of the patients presented with severe acute abdomen mimicking generalized peritonitis. Most of the patients were confirmed to have acute cholecystitis, with none of them showing evidence of cholelithiasis in ultrasound whole abdomen. Complications involved mainly hepatobiliary, renal, and pulmonary system. Kundavaram et al. reported a case in which a female underwent exploratory laparotomy and cholecystectomy due to acute cholecystitis, but the condition improved only after diagnosis and treatment of scrub typhus. Lee et al. reported a case of scrub typhus in which the patient underwent emergency laparotomy and appendicectomy in view of peritonitis, and later on diagnosed to have scrub typhus. Lee et al. also reported a case of peritonitis due to gastric perforation caused by scrub typhus. Yang et al. also reported two cases of scrub typhus that underwent surgical exploration. Hayakawa et al. and Deshpande et al. reported a case of cholecystitis and acute appendicitis which were managed nonoperatively. In our cases, none of the patients underwent surgical intervention, as we were able to diagnose associated scrub typhus reasonably early and started antiscrub typhus antibiotic, seven out of the eight patients responded and improved rapidly to the medical treatment. One patient developed severe thrombocytopenia and MODS who later on died in ICU.


  Conclusion Top


Scrub typhus can rarely present as an acute abdomen. High index of suspicion is required in cases of acute abdomen with atypical features and those not responding to standard conservative management. Overtreatment is better than undertreatment in certain cases of scrub typhus. Further studies with large sample size are required for better understanding of the subset of scrub typhus presenting as acute abdomen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee CH, Lee JH, Yoon KJ, Hwang JH, Lee CS. Peritonitis in patients with scrub typhus. Am J Trop Med Hyg 2012;86:1046-8.  Back to cited text no. 1
    
2.
Kundavaram AP, Das S, George VM. Scrub typhus presenting as an acute abdomen. J Glob Infect Dis 2014;6:17-8.  Back to cited text no. 2
    
3.
Jamil M, Lyngrah KG, Lyngdoh M, Hussain M. Clinical manifestations and complications of scrub typhus: A hospital based study from North Eastern India. J Assoc Physicians India 2014;62:19-23.  Back to cited text no. 3
    
4.
Gurunathan PS, Ravichandran T, Stalin S, Prabhu V, Anandan H. Clinical profile, morbidity pattern and outcome of children with scrub Typhus. Int J Sci Stud 2016;4:247-50.  Back to cited text no. 4
    
5.
Huidrom S, Singh LK. Clinical and laboratory manifestations of scrub typhus: A study from a tertiary care hospital in Manipur. Indian J Microbiol Res 2017;4:434-6.  Back to cited text no. 5
    
6.
Mahajan SK. Rickettsial diseases. J Assoc Physicians India 2012;60:37-44.  Back to cited text no. 6
    
7.
Thap LC, Supanaranond W, Treeprasertsuk S, Kitvatanachai S, Chinprasatsak S, Phonrat B. Septic shock secondary to scrub typhus: Characteristics and complications. Southeast Asian J Trop Med Public Health 2002;33:780-6.  Back to cited text no. 7
    
8.
Sivarajan S, Shivalli S, Bhuyan D, Mawlong M, Barman R. Clinical and paraclinical profile, and predictors of outcome in 90 cases of scrub typhus, Meghalaya, India. Infect Dis Poverty 2016;5:91.  Back to cited text no. 8
    
9.
Yang CH, Young TG, Peng MY, Hsu GJ. Unusual presentation of acute abdomen in scrub typhus: A report of two cases. Chin Med J (Taipei) 1995;55:401-4.  Back to cited text no. 9
    
10.
Yi SY, Tae JH. Pancreatic abscess following scrub typhus associated with multiorgan failure. World J Gastroenterol 2007;13:3523-5.  Back to cited text no. 10
    
11.
Wang CC, Liu SF, Liu JW, Chung YH, Su MC, Lin MC. Acute respiratory distress syndrome in scrub typhus. Am J Trop Med Hyg 2007;76:1148-52.  Back to cited text no. 11
    
12.
Kim SJ, Chung IK, Chung IS, Song DH, Park SH, Kim HS, et al. The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus. Endoscopy 2000;32:950-5.  Back to cited text no. 12
    
13.
Hayakawa K, Oki M, Moriya Y, Mizuma A, Ohnuky Y, Yanagi H, et al. A case of scrub typhus with acalculouscholecystitis, aseptic meningitis and mononeuritis multiplex. J Med Microbiol 2012;61:291-4.  Back to cited text no. 13
    
14.
Deshpande GA, Mittal R, Jesudasan MR, Perakath B. Surgical manifestations of scrub typhus: A diagnostic dilemma. Natl Med J India 2015;28:12-3.  Back to cited text no. 14
    
15.
Lee SY, Kim ES, Son D, Lee HL, Choi SJ, Lee JS, et al. Scub typhus: Two cases presenting as abdominal pain. Infect Med 2009;26:158-60.  Back to cited text no. 15
    
16.
Luce-Fedrow A, Lehman ML, Kelly DJ, Mullins K, Maina AN, Stewart RL, et al. Areview of scrub typhus (Orientia tsutsugamushi and related organisms): Then, now, and tomorrow. Trop Med Infect Dis 2018;3. pii: E8.  Back to cited text no. 16
    
17.
Chakraborty S, Sarma N. Scrub typhus: An emerging threat. Indian J Dermatol 2017;62:478-85.  Back to cited text no. 17
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