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Alam AM, Gillespie CS, Goodall J, Damodar T, Turtle L, Vasanthapuram R, Solomon T, Michael BD. Neurological manifestations of scrub typhus infection: A systematic review and meta-analysis of clinical features and case fatality. PLoS Negl Trop Dis 2022; 16:e0010952. [PMID: 36441812 PMCID: PMC9731453 DOI: 10.1371/journal.pntd.0010952] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Scrub typhus has become a leading cause of central nervous system (CNS) infection in endemic regions. As a treatable condition, prompt recognition is vital. However, few studies have focused on describing the symptomology and outcomes of neurological scrub typhus infection. We conducted a systematic review and meta-analysis to report the clinical features and case fatality ratio (CFR) in patients with CNS scrub typhus infection. METHODS A search and analysis plan was published in PROSPERO [ID 328732]. A systematic search of PubMed and Scopus was performed and studies describing patients with CNS manifestations of proven scrub typhus infection were included. The outcomes studied were weighted pooled prevalence (WPP) of clinical features during illness and weighted CFR. RESULTS Nineteen studies with 1,221 (656 adults and 565 paediatric) patients were included. The most common clinical features in CNS scrub typhus were those consistent with non-specific acute encephalitis syndromes (AES), such as fever (WPP 100.0% [99.5%-100.0%, I2 = 47.8%]), altered sensorium (67.4% [54.9-78.8%, I2 = 93.3%]), headache (65.0% [51.5-77.6%, I2 = 95.1%]) and neck stiffness 56.6% (29.4-80.4%, I2 = 96.3%). Classical features of scrub typhus were infrequently identified; an eschar was found in only 20.8% (9.8%-34.3%, I2 = 95.4%) and lymphadenopathy in 24.1% (95% CI 11.8% - 38.9%, I2 = 87.8%). The pooled CFR (95% CI) was 3.6% (1.5%- 6.4%, I2 = 67.3%). Paediatric cohorts had a CFR of 6.1% (1.9-12.1%, I2 = 77%) whilst adult cohorts reported 2.6% (0.7-5.3%, I2 = 43%). CONCLUSION Our meta-analyses illustrate that 3.6% of patients with CNS manifestations of scrub typhus die. Clinicians should have a high index of suspicion for scrub typhus in patients presenting with AES in endemic regions and consider starting empiric treatment whilst awaiting results of investigations, even in the absence of classical signs such as an eschar or lymphadenopathy.
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Affiliation(s)
- Ali M. Alam
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Conor S. Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jack Goodall
- Tropical & Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Tina Damodar
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Lance Turtle
- Tropical & Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- The Pandemic Institute, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
| | - Ravi Vasanthapuram
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Tom Solomon
- The Pandemic Institute, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
| | - Benedict D. Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Behera B, Satapathy AK, Ranjan J, Chandrasekar S, Patel S, Mishra B, Mahapatro S, Das RR. Profile of Scrub Typhus Meningitis/Meningoencephalitis in Children with and without Scrub Typhus IgM Antibody in CSF. J Neurosci Rural Pract 2021; 12:786-791. [PMID: 34737516 PMCID: PMC8559072 DOI: 10.1055/s-0041-1734003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this article was to study the spectrum of scrub typhus meningitis/meningoencephalitis (STM) cases in children. Children ≤14 years of age with acute undifferentiated febrile illness were included. Immunoglobulin M (IgM) enzyme-linked immunosorbent assay was done in blood and cerebrospinal fluid (CSF) of children with suspected STM. Demographic, clinical, and laboratory details were expressed as descriptive statistics. Factors associated with neurological involvement were identified on univariate analysis. A total of 76 children had ST during the study period (meningitis/meningoencephalitis = 8 [10.5%], of which 5 [62.5%] had detectable ST IgM antibodies in CSF). The included children were 4 to 12 years of age with boys > girls. Headache and vomiting were common in those with STM, whereas hyponatremia and thrombocytopenia were common in those without STM. All children with STM recovered with sequelae in one child (right lateral rectus palsy). There was no mortality. STM has an incidence of 10.5% in children with ST from Eastern India. Headache and vomiting were significant predictors of STM, whereas hyponatremia and thrombocytopenia were significant predictor of non-STM.
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Affiliation(s)
- Bijayini Behera
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Amit Kumar Satapathy
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Jai Ranjan
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Shyam Chandrasekar
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Subhakanta Patel
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Baijayantimala Mishra
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Samarendra Mahapatro
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Mahajan V, Guglani V, Singla N, Chander J. Spectrum of Multiorgan Dysfunction in Scrub Typhus Infection. J Trop Pediatr 2021; 67:6363912. [PMID: 34480177 DOI: 10.1093/tropej/fmab074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES We planned this study to determine the clinical spectrum and compare incidence of multiorgan dysfunction in children hospitalized with scrub typhus with other etiologies of tropical fever. DESIGN Prospective cohort study. SETTING Pediatric emergency and PICU services of a university teaching hospital situated in the sub-Himalayan region. PATIENT Children aged 2 months to 14 years with acute undifferentiated fever of more than 5 days. INTERVENTIONS Detailed fever workup was performed in all children. We compared scrub typhus IgM positive children (cases) with remaining febrile children who were negative for scrub IgM assay (controls) for mortality and morbidity. MAIN RESULTS We enrolled 224 febrile children; 76 children (34%) were positive for scrub typhus IgM ELISA. Scrub typhus group had a significantly higher incidence of multiorgan dysfunction [OR 3.5 (95% CI 2.0-6.3); p < 0.001] as compared to non-scrub typhus group requiring supportive care. The incidence of altered sensorium [OR 8.8 (95% CI 3.1-24.9)], seizures [OR 3.0 (95% CI 1.1-8.3)], acute respiratory distress syndrome [OR 17.1 (95% CI 2.1-140.1)], acute renal failure (5% vs. 0%), meningitis [OR 6.2 (95% CI 1.2-31.6)], thrombocytopenia [OR 2.8 (95% CI 1.5-5.1)], transaminitis [OR 2.7 (95% CI 1.6-4.8)], requirement of oxygen [OR 17.8 (95% CI 4.0-80.3)], positive pressure support [OR 3.7 (95% CI 1.2-10.5)] and shock requiring inotropes [OR 3.0 (95% CI 1.3-6.7)] was significantly higher in scrub typhus group as compared to the non-scrub typhus group (Table 1). CONCLUSIONS Pediatric scrub typhus who were hospitalized had severe systemic manifestations when compared to other causes of fever.
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Affiliation(s)
- Vidushi Mahajan
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh 160030, India
| | - Vishal Guglani
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh 160030, India
| | - Nidhi Singla
- Department of Microbiology, Government Medical College and Hospital, Chandigarh 160030, India
| | - Jagdish Chander
- Department of Microbiology, Government Medical College and Hospital, Chandigarh 160030, India
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Alam A, Agarwal P, Prabha J, Jain A, Kalyan RK, Kumar C, Kumar R. Prediction Rule for Scrub Typhus Meningoencephalitis in Children: Emerging Disease in North India. J Child Neurol 2020; 35:820-827. [PMID: 32580611 DOI: 10.1177/0883073820933148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the proportion of scrub typhus meningoencephalitis among children with acute encephalitis syndrome and to outline its differentiating features. To develop a prediction rule for scrub typhus meningoencephalitis. METHODS A prospective cohort study was conducted at a tertiary care public hospital in Northern India. Consecutive patients of acute encephalitis syndrome who met our inclusion criteria were enrolled over 2 years. Standardized workup including serum IgM against Orientia tsutsugamushi was performed. Clinical and laboratory features were compared between IgM-positive and IgM-negative patients. The area under the receiver operating characteristic curve of the score derived from "independent predictors" was measured. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated at different cut-offs of the score. RESULTS Scrub typhus IgM enzyme-linked immunosorbent assay was positive in 66/352 patients (18.8%). Longer duration of fever and prodromal stage along with eschar, hepatomegaly, lymphadenopathy, and pneumonia were significantly more prevalent in scrub typhus meningoencephalitis. However, petechiae were frequent in non-scrub typhus patients. Leucocytosis, lymphocytosis, thrombocytopenia, hypoalbuminemia, and elevated levels of serum bilirubin, serum transaminases, and cerebrospinal fluid protein were associated with scrub typhus meningoencephalitis. Logistic regression revealed fever for >8 days, pneumonia, absence of petechiae, cerebrospinal fluid protein >1000 mg/L, and serum glutamic oxaloacetic transaminase >100 IU/L as independent "predictors" of scrub typhus meningoencephalitis. The area under the receiver operating characteristic curve (95% confidence interval) of the prediction score was 0.832 (0.78-0.89). Score at cutoff ≥1 had 91% sensitivity, 96.1% negative predictive value, and at cutoff ≥4 had 99.7% specificity, 88.9% positive predictive value, 83.1% negative predictive value, 40.3 positive likelihood ratio, 0.88 negative likelihood ratio for identifying scrub typhus meningoencephalitis. CONCLUSION Prediction score may help physicians in peripheral areas to identify and treat scrub typhus meningoencephalitis, an emerging cause of acute encephalitis syndrome in India.
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Affiliation(s)
- Areesha Alam
- Department of Pediatrics, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Pranshi Agarwal
- Department of Pediatrics, 76140King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Jayanti Prabha
- Department of Pediatrics, 76140King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amita Jain
- Department of Microbiology, 76140King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Raj Kumar Kalyan
- Department of Microbiology, 76140King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Chandrakanta Kumar
- Department of Pediatrics, 76140King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Rashmi Kumar
- Department of Pediatrics, 76140King George's Medical University, Lucknow, Uttar Pradesh, India
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Clinical Characteristics and Predictors of Severity of Pediatric Scrub Typhus in a Tertiary Level Hospital in South India. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2020. [DOI: 10.5812/pedinfect.92752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Govil N, Parag K, Khandelwal H, Bhardwaj B. Successful management of acute respiratory distress syndrome in scrub typhus: A rare entity. SAUDI JOURNAL FOR HEALTH SCIENCES 2020. [DOI: 10.4103/sjhs.sjhs_4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Basu S, Saha A, Sarkar S, Sinha MK, Das MK, Datta R, Hazra A, Datta Kanjilal S, Datta S. Clinical Profile and Therapeutic Response of Scrub Typhus in Children: A Recent Trend from Eastern India. J Trop Pediatr 2019; 65:139-146. [PMID: 29800384 DOI: 10.1093/tropej/fmy027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The aim of this study was to assess the clinico-laboratory parameters, complications and therapeutic responses in children with scrub typhus in Eastern India. MATERIALS AND METHODS In this prospective, observational study, all children (age, <12 years) with suspected scrub typhus with a compatible clinical scenario were enrolled consecutively over six months. Cases confirmed by means of a positive IgM serology or a positive Weil-Felix reaction (OXK = 1/80 or above) were administered enteral doxycycline (4.5 mg/kg/day). RESULTS Out of 94 recruited children, 61 had confirmed scrub typhus (mean age = 6.1 years, M:F = 1.1:1) with or without complications and having a considerably higher incidence of neurological presentation (meningoencephalistis n = 21, 34.4%). The most frequent manifestations included vomiting (n = 39, 63.9%), abdominal pain (n = 33, 54.1%), lymphadenopathy (n = 36, 59%), hepatosplenomegaly (n = 32, 52.5%), pedal edema (n = 32, 52.5%) and eschar formation (n = 30, 49.2%). Low hemoglobin levels, leukocytosis, thrombocytopenia, hypoalbuminemia, hyponatremia, increased liver enzymes and increased C-reactive protein were associated with delayed defervescence (>48 h). CONCLUSION Scrub meningoencephalitis, with a notably higher incidence, showed favorable therapeutic response. Prompt and empiric doxycycline therapy could be lifesaving.
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Affiliation(s)
- Suprit Basu
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Arpan Saha
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Sumantra Sarkar
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Malay Kumar Sinha
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Mrinal Kanti Das
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Ranjabati Datta
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Sumana Datta Kanjilal
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
| | - Supratim Datta
- Department of Pediatric Medicine, Institute of Postgraduate Medical Education & Research (I.P.G.M.E.& R.), 244, AJC Bose Road, Kolkata, India
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Narayanasamy DK, Arun Babu T, Vijayadevagaran V, Kittu D, Ananthakrishnan S. Predictors of Severity in Pediatric Scrub Typhus. Indian J Pediatr 2018; 85:613-617. [PMID: 29368107 DOI: 10.1007/s12098-018-2612-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 01/02/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To identify the factors that can predict the severity of scrub typhus in children. METHODS This prospective study was conducted at a tertiary care teaching hospital between November 2014 to October 2016. All children <12y of age admitted with fever for more than 7d and positive IgM ELISA for scrub typhus were included in the study. These children were followed during the hospital course and their laboratory results, response to treatment and complications were documented. Cases of 'severe scrub typhus' were identified based on criteria from published adult and pediatric studies. RESULTS Out of 930 children with fever for more than 7d, IgM ELISA for scrub typhus was positive in 230 children. Ninety one (40.6%) cases fulfilled the criteria of 'severe scrub typhus' in children. Out of 45 factors, 27 potential factors were studied. The multivariate analysis identified 5 factors, breathlessness (OR: 6.85, 95%CI: 2.69 to 9.87), altered sensorium (OR: 11.48, 95% CI 3.43 to 10.19), leucocytosis (OR: 3.38, 95% CI 1.12 to 10.16), hypoalbuminemia (OR: 10.78, 95% CI 2.66 to 48.76), and hyponatremia (OR: 10.08, 95% CI 2.11 to 23.42) to be significantly associated with the 'severe scrub typhus' cases. CONCLUSIONS Breathlessness, altered sensorium, leucocytosis, hypoalbuminemia, and hyponatremia predict severity in childhood scrub typhus. Presence of these factors should alert the treating physician regarding the need for intensive monitoring, treatment or referral.
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Affiliation(s)
- Dinesh Kumar Narayanasamy
- Department of Pediatrics, Indira Gandhi Medical College and Research Institute (IGMC&RI), Pondicherry, India
| | - Thirunavukkarasu Arun Babu
- Department of Pediatrics, Indira Gandhi Medical College and Research Institute (IGMC&RI), Pondicherry, India.
| | | | - Devi Kittu
- Department of Preventive & Social Medicine, Indira Gandhi Medical College and Research Institute (IGMC&RI), Pondicherry, India
| | - Shanthi Ananthakrishnan
- Department of Pediatrics, Indira Gandhi Medical College and Research Institute (IGMC&RI), Pondicherry, India
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