Rickettsioses in Children - A Review

Scrub typhus presenting with massive splenomegaly in an adolescent boy

Scrub typhus is a serious public health problem in the Asia Pacific region. Early diagnosis and treatment can prevent complications and mortality. Splenomegaly in isolated scrub typhus is mostly mild or subclinical and rarely massive. We report an adolescent boy with scrub typhus presenting with fever, massive splenomegaly and severe anemia. Clinicians should be aware of atypical presentations of scrub typhus, which is easily treatable with minimal investigations.

Prevalence, clinico-laboratory features, and the functional outcome of children with scrub typhus meningoencephalitis-a cohort study

Scrub typhus is being reported as the most common cause of childhood meningoencephalitis (ME) in India. Hence, we planned to estimate the proportion of scrub typhus infection among children aged 1 month to 12 years with the clinical diagnosis of ME and to evaluate their demographic, clinical and laboratory characteristics. This cohort study was conducted in the Department of Pediatrics of a tertiary care teaching hospital in south India. One hundred and twenty-seven consecutive children aged 1 month to 12 years with the clinical diagnosis of ME were the participants. Their socio-demographic factors, clinical details, laboratory reports and outcomes were analyzed. The etiological agent was identified in 71 (56%) children. Orientia tsutsugamushi (Scrub typhus) was the most common infection (24.4%), of all children with ME. Children aged ≥5 years were frequently affected by scrub typhus ME. Eschar, capillary leak, hepatomegaly and splenomegaly were the predominant clinical features of scrub typhus ME. Thrombocytopenia and deranged liver function tests were common in scrub typhus ME. To conclude, Orientia tsutsugamushi was the most common organism identified in our study. Prompt recognition of some tell-tale clinical signs of scrub typhus (such as eschar, thrombocytopenia and hepatosplenomegaly), and timely initiation of antibiotics would lead to better outcomes as evident from the study.

From Telemedicine to the ICU-Fever and Rash in a 9-Year-Old Girl

A 9-year-old girl presented to her primary care pediatrician via telemedicine during the initial months of the coronavirus disease 2019 pandemic because of 4 days of warmth perceived by her mother, decreased energy, and a new rash on her upper extremities. After 10 additional days of documented fever >38°C, worsening fatigue, and 1 day of nausea, vomiting, and diarrhea, she was allowed to schedule an in-person visit with her pediatrician after testing negative for severe acute respiratory syndrome coronavirus 2. She appeared ill on arrival to clinic, and her pediatrician recommended evaluation in an emergency department. Her initial laboratory testing revealed nonspecific elevation in several inflammatory markers and leukopenia, and she responded well to intravenous hydration. Over the next 2 weeks, her fever persisted, constitutional symptoms worsened, and she developed progressively painful cervical lymphadenopathy and pancytopenia. She was evaluated in clinic by several specialists and eventually was urged to present to the emergency department again, at which time she was admitted to the PICU. After consulting additional specialists and waiting for laboratory results, the team reached a definitive diagnosis and initiated therapy; however, she experienced rapid clinical decline shortly thereafter. The specialists who assisted with identification of the underlying etiology of her symptoms were able to work together to manage the subsequent complications.

Imported scrub typhus in Europe: Report of three cases and a literature review

BACKGROUND

Scrub typhus is a vector-borne rickettsial infection, which can cause relevant morbidity and mortality. While the number of cases is around a million per year globally, the infection is seldom diagnosed in travellers from Europe.

METHODS

We herein report three cases diagnosed in Italian travellers and review the literature about imported cases in Europe in the last 60 years.

RESULTS

Three participants to the same hiking trip to the forest of northern Laos presented fever and other symptoms, including eschars (2 individuals) and skin rash (2 individuals). Overall, they didn't report complications, and recovered soon after doxycycline treatment. Diagnosis was retrospectively confirmed with PCR in one of them. The review collected data from 40 patients. Almost all of them (95%) presented fever, more than a half had headache, skin rash, eschars, arthromyalgias. 73% of them were hospitalized, and 16.2% needed intensive care. Diagnosis was confirmed by serology in almost all cases (94.6%). Most patients (88%) were treated with doxycycline. All patients survived, although one case resulted in incomplete tetraparesis.

CONCLUSIONS

Scrub typhus should be considered in all travellers coming back from endemic areas and presenting with acute febrile illness. Laboratory diagnosis can be challenging, as specific tests are not widely available. In case of clinical suspicion, a prompt treatment with oral doxycycline could avoid severe complications.