Pancreatitis and MODS Due to Scrub Typhus and Dengue Co-Infection

SCRUB TYPHUS PRESENTING AS ACUTE PANCREATITIS: A RARE CASE

Scrub typhus is an insect-borne disease caused by Orientia sutsugamushi which may cause disseminated vasculitis and perivascular inflammatory lesions resulting in significant vascular leakage and cause end organ damage. Scrub typhus can lead to severe complications such as acute respiratory distress syndrome (ARDS), myocarditis, hepatitis and meningoencephalitis. Some unusual presentations of scrub typhus are peritonitis, gastric ulceration, duodenal ulcer perforation and acalculous cholecystitis. But acute pancreatitis is a relatively rare complication of scrub typhus. Here we report a rare case of scrub typhus in the form of acute pancreatitis.

Rickettsiosis with Pleural Effusion: A Systematic Review with a Focus on Rickettsiosis in Italy

Background: Motivated by a case finding of Mediterranean spotted fever (MSF) associated with atypical pneumonia and pleural effusion in which Rickettsia conorii subsp. israelensis was identified by molecular methods in the pleural fluid, we wanted to summarize the clinical presentations of rickettsiosis in Italy by systematic research and to make a systematic review of all the global cases of rickettsiosis associated with pleural effusion. Methods: For the literature search, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. We chose to select only the studies published in last 25 years and confirmed both with serological and molecular assays. Results: Human cases of rickettsiosis in Italy were reported in 48 papers describing 2831 patients with very different clinical presentations; the majority was MSF accounted to R. conorii and was reported in Sicily. Pleural effusion associated with infection with microorganisms belonging to Rickettsiales was described in 487 patients. It was rarely associated with microorganisms different from O. tsutsugamushi; also rarely, cases of scrub typhus were reported outside Southeast Asia and in the largest majority, the diagnosis was achieved with serology. Conclusions: MSF, especially when caused by R. conorii subsp. israelensis, may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis

Acalculous Cholecystitis in a Young Adult with Scrub Typhus: A Case Report and Epidemiology of Scrub Typhus in the Maldives

Scrub typhus is a neglected tropical disease predominantly occurring in Asia. The causative agent is a bacterium transmitted by the larval stage of mites found in rural vegetation in endemic regions. Cases of scrub typhus frequently present as acute undifferentiated febrile illness, and without early diagnosis and treatment, the disease can develop fatal complications. We retrospectively reviewed de-identified data from a 23-year-old woman who presented to an emergency department with complaints of worsening abdominal pain. On presentation, she appeared jaundiced and toxic-looking. Other positive findings on abdominal examination were a positive Murphey’s sign, abdominal guarding and hepatosplenomegaly. Magnetic resonance cholangiopancreatography demonstrated acalculous cholecystitis. Additional findings included eschar on the medial aspect of the left thigh with inguinal regional lymphadenopathy. Further, positive results were obtained for immunoglobulins M and G, confirming scrub typhus. The workup for other infectious causes of acute acalculous cholecystitis (AAC) detected antibodies against human herpesvirus 4 (Epstein–Barr virus), suggesting an alternative cause of AAC. Whether that represented re-activation of the Epstein–Barr virus could not be determined. As other reports have described acute acalculous cholecystitis in adult scrub typhus patients, we recommend doxycycline to treat acute acalculous cholecystitis in endemic regions while awaiting serological confirmation.

Viral-Attributed Acute Pancreatitis: A Systematic Review

Infectious etiologies are rare cause of acute pancreatitis (AP). We sought to investigate the frequency of viral-attributed AP (VIAP) and describe its natural course and clinical features. Comprehensive review of PubMed and EMBASE in English until December 31, 2019, was performed. AP diagnosis and severity were defined per the Revised Atlanta Classification. Viral infections were diagnosed by serology and/or histology. A diagnosis of viral infection, with a concurrent AP diagnosis, a temporal resolution of both entities, and the attempt to exclude the most common etiologies of AP defined VIAP. Two independent reviewers reviewed eligible publications. Bias risk was assessed with the Murad tool. A total of 209 cases identified in 128 publications met inclusion criteria. Mean age was 38.9 ± 1.28 years. Male-to-female ratio was 2.2:1, and 28% of patients were immunocompromised. Viral hepatitis (A, B, C, D and E) was the most common virus and accounted for 34.4% of cases, followed by coxsackie and echoviruses (14.8%), hemorrhagic fever viruses (12.4%), CMV (12.0%), VZV (10.5%), mumps and measles (3.8%), primary HIV infection (3.8%), HSV (1.9%), EBV (1.9%), and the remainder of cases (2.9%) attributed to adenovirus, influenza H1N1, and multiple viruses. Severity of AP was: 43.1% mild, 11.7% moderately severe, 32.4% severe. Death occurred in 42 (20.1%) patients. A significant portion of VIAP patients were immunocompromised (28.0%) and accounted for 71.4% of mortality cases. Mortality was higher than that reported for AP from other etiologies in the literature.

Da Cheng Qi Decoction Alleviates Cerulein-Stimulated AR42J Pancreatic Acinar Cell Injury via the JAK2/STAT3 Signaling Pathway

Background

Acute pancreatitis (AP) is a common acute abdomen inflammation, characterized by the dysregulation of digestive enzyme production and secretion. Many studies have shown that Da Cheng Qi Decoction (DCQD) is a secure, effective prescription on AP. In this study, cerulein-stimulated AR42J cells damage model was established to further explore the feasibility and underlying mechanism of DCQD as a potential inhibitor of JAK2/STAT3 pathway for the treatment of AP.

Methods

Cell viability of DCQD was measured using a cell counting Kit-8 assay. Pancreatic biochemical markers such as amylase, lipase, and C-reactive protein production were measured by assay kits, respectively. Cytokines (TNF-α, IL-6, IL-10, and IL-1β) were assayed by ELISA. Protein location and protein expression were detected by immunofluorescence staining and Western blotting, respectively. Gene expression was assessed by real-time PCR. For mechanistic analysis of the effect of DCQD on JAK2/STAT3 signaling pathway, selective JAK2 inhibitor (Fedratinib) and STAT3 inhibitor (Stattic) as well as STAT3 activator (Garcinone D) were used.

Results

DCQD protected cells by regulating cerulein-induced inflammation and reducing the secretion of pancreatic biochemical markers. Moreover, DCQD could not only inhibit the nuclear translocation of p-STAT3, but also decrease the mRNA expression of JAK2 and STAT3 as well as the ratio of p-JAK2/JAK2 and p-STAT3/STAT3 in protein level. Additionally, DCQD could regulate the mRNA and protein expression of JAK2/STAT3 downstream effectors, Bax and Bcl-XL. The activated effect of cerulein on JAK2/STAT3 pathway was also reversed by JAK2 inhibitor Fedratinib or STAT3 inhibitor Stattic. And the overexpression of JAK2/STAT3 pathway, via STAT3 activator Garcinone D, did exert damage on cells, which bore a resemblance to cerulein.

Conclusion

The activation of JAK2/STAT3 pathway may play a key role in the pathogenesis of cerulein-stimulated AR42J pancreatic acinar cell injury. DCQD could improve inflammatory cytokines and cell injury, which might be mediated by suppressing the activation of JAK2/STAT3 signaling pathway.

Infectious causes of acute pancreatitis: A systematic review

BACKGROUND

Infectious etiologies of acute pancreatitis (AP) are rare and include viruses, bacteria, mycobacteria, parasites, and fungi. We aimed to conduct a comprehensive review on infectious etiologies of AP analyzing the frequency, clinical features, and outcomes of individuals presenting with this condition.

METHODS

Eligible articles reporting on AP attributed to infectious etiologies were included. A comprehensive literature search of PubMed from time of inception and until September 6,2019 was performed using all relevant MeSH (medical subject heading) keywords. Articles were assessed for eligibility and independently reviewed by two reviewers for clinical features of AP, local complications, and mortality. Methodological quality of included studies was evaluated using the Murad tool.

RESULTS

A total of 212 articles were included, of which 168 (79.2%) were at high risk of bias. 320 cases of AP were identified. Viruses were the leading etiology of infection attributed AP (65.3%) followed by helminths (19.1%), and bacteria (12.5%). Protozoa, mycobacteria, and fungi accounted for the remaining 3.1% of cases. Mean age was 40.5 ± 18.4 years and M:F ratio was 1.94:1. Mortality occurred in 50 patients. Mortality rate was higher in the virus attributed AP patients than AP from other infectious etiologies (21.8% vs. 7.0%, p < 0.0005).

INTERPRETATION

Literature quality on infection attributed AP is limited. Virus attributed AP appears to carry a higher mortality than other etiologies of infection attributed AP.

Clinical characteristics and effective treatments of scrub typhus-associated hemophagocytic lymphohistiocytosis in children

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon and life-threatening disorder that may rarely complicate the clinical course of Orientia tsutsugamushi disease (scrub typhus). Here, we describe the clinical features, laboratory parameters, management, and outcome of 16 children with scrub typhus-associated HLH. All patients satisfied the HLH-2004 diagnostic criteria. All patients had fever of unknown origin and multisystem damage. Raised hepatic transaminases and abnormalities in routine blood test were observed in all children. Imaging tests showed abnormalities in 10 cases. Six patients were treated with intravenous azithromycin for 5 days, and 10 with intravenous chloramphenicol for 7–10 days because of non-response to 3-day azithromycin treatment. Five patients were treated with intravenous albumin and 3 with intravenous immunoglobulin. Two patients with severe symptoms (shortness of breath, cyanosis) were treated with dexamethasone (0.3 mg/kg/d). Fifteen patients recovered completely after 8–22 days of treatment. One patient died. The occurrence of severe complications draws attention to the need for early diagnosis and effective treatment. Anti-rickettsial antibiotic treatment (azithromycin or chloramphenicol) without the need for chemotherapy may be beneficial in such cases, instead of treatment according to the 2004 HLH protocol.

Clinical and paraclinical profile, and predictors of outcome in 90 cases of scrub typhus, Meghalaya, India

BACKGROUND

India is an integral component of "tsutsugamushi triangle" which depicts a part of the globe endemic to scrub typhus. Owing to frequent outbreaks witnessed in different parts of the country in the recent past, scrub typhus is described as a re-emerging infectious disease in India. The present study aimed to study the clinical and paraclinical profile, complications and predictors of outcome among 90 cases of scrub typhus diagnosed in a hospital of north-eastern India from Sept 2011 to Aug 2012.

METHODS

A longitudinal study was conducted in a hospital of Meghalaya, India between Sept 2011 and Aug 2012. Diagnosis of scrub typhus was arrived by SD BIOLINE tsutsugamushi (solid phase immunochromatographic assay) rapid diagnostic test for antibodies (IgM, IgG or IgA). Descriptive analyses of age, gender, geographic area, symptoms and signs, treatment, laboratory findings, complications, and outcome were conducted. Relative risk (RR) with 95 % confidence interval (CI) was computed for Multiple Organ Dysfunction Syndrome (MODS) and mortality. Binary logistic regression was applied to the significant correlates (P < 0.05) on univariate analysis to identify the predictors of MODS and mortality in scrub typhus.

RESULTS

As many as 662 clinically suspected scrub typhus patients were tested and 90 (13.6 %) were diagnosed to have scrub typhus. Out of 90 patients, 52.2 % (n = 47) were males and their mean (SD) age was 36.29 (13.38) years. Fever of <7 days (n = 75, 83.3 %), myalgia (n = 56, 62.2 %), pain abdomen (n = 24, 26.7 %), headache (n = 24, 26.7 %), nausea/vomiting (n = 21, 23.3 %), dry cough (n = 21, 23.3 %), hepatomegaly (n = 24, 26.7 %), splenomegaly (n = 22, 24.4 %), and lymphadenopathy (n = 20, 22.2 %) were the predominant clinical features. Eschar was seen in 10 patients (11.1 %). One third (n = 30) of the patients developed at least one systemic complication. Acute hepatitis (n = 15, 16.7 %), pneumonitis (n = 14, 15.6 %), and acute kidney injury (n = 11, 12.2 %) were the common complications. MODS was seen in 14.4 % (n = 13) and 38.5 % (n = 5) of the patients with MODS died. Overall, case fatality rate was 5.15 % (n = 5). On univariate analysis, platelets <100 000/mm³, serum creatinine >1.5 mg/dl, and transaminase (AST, ALT or both) >500 U/L were associated with MODS (P < 0.001) and mortality (P < 0.05). In addition, serum bilirubin >3 mg/dl was also associated with MODS (P < 0.001). On applying binary logistic regression, serum creatinine >1.5 mg/dl was a predictor of MODS (OR: 76.1, 95 % CI: 4.9-1175.6) and mortality (OR: 18.03, 95 % CI: 1.38-235.1).

CONCLUSION

In this study setting, approximately one-seventh (13.6 %) of the acute undifferentiated febrile illness were due to scrub typhus. Systemic complications were common (33.3 %). Serum creatinine >1.5 mg/dl was a predictor of MODS and mortality.

Bacterial coinfections in dengue virus disease: what we know and what is still obscure about an emerging concern

PURPOSE

Dengue virus is the most frequent arthropod-borne viral infection worldwide. Simultaneously to the growth of its incidence, cases of bacterial coinfection in dengue have been increasingly reported. The clinical course of dual infections may worsen for reciprocal interactions and delays in the diagnosis, so that clinicians should be aware of this eventuality. Therefore, we reviewed literature to provide an overview of the epidemiological, clinical, and physiopathological issues related to bacterial coinfections and bacteremia in dengue.

METHODS

Clinical studies and case reports regarding bacteremia and bacterial coinfections in dengue and the interactions between the pathogens published on PubMed were reviewed.

RESULTS

We found 26 case reports, only 3 studies on concurrent bacteremia and 12 studies reporting data on bacterial coinfections in dengue. According to the three available studies, the 0.18-7 % of dengue infections are accompanied by concurrent bacteremia, while the 14.3-44.4 % of dengue-related deaths seem associated to bacterial coinfections. Comorbidities, advanced age, and more severe dengue manifestations could be risk factors for dual infections. A longer duration of fever and alterations in laboratory parameters such as procalcitonin, hyponatremia, leukocyte count, and renal function tests can raise the suspicion.

CONCLUSIONS

Despite the real burden and consequences of this emerging concern is still not computable accurately due to the lack of a significant number of studies on large cohorts, clinicians need a greater awareness about it to early recognize warning signs, to properly use available diagnostic tools and to readily start antibiotic treatment able to prevent worsening in mortality and morbidity.

Acute pancreatitis associated with scrub typhus

Scrub typhus, or tsutsugamushi fever, is a zoonosis of rural Asia and the western Pacific islands. The causative organism, Orientia (formerly Rickettsia) tsutsugamushi, is transmitted to humans by the bite of a larval Leptotrombidium mite (chigger). Scrub typhus may have gastrointestinal presentations, such as acute acalculous cholecystitis, duodenal ulcer perforation, peritonitis and gastric ulceration. Acute pancreatitis with scrub typhus has been reported rarely. We report a patient of scrub typhus complicated by acute pancreatitis and acute kidney injury.

Clinical and Laboratory Characteristics of Dengue-Orientia tsutsugamushi co-Infection from a Tertiary Care Center in South India

Background

Concurrent infection with multiple pathogens is common in tropics, posing diagnostic and treatment challenges. Although co-infections of dengue, malaria, leptospirosis and typhoid in various combinations have been described, data on dengue and scrub typhus co-infection is distinctly limited.

Methodology

This study was a retrospective analysis of dengue and scrub typhus co-infection diagnosed between January 2010 and July 2014 at a tertiary care center. Clinical and laboratory features of these cases were compared with age and gender-matched patients with isolated dengue fever and isolated scrub typhus. Positive test for dengue non-structural 1 (NS1) antigen was considered diagnostic of dengue whereas scrub typhus was diagnosed by IgM scrub antibodies demonstrated by ELISA.

Results

There were 6 cases of dengue-scrub co-infection during the review period which fitted clinical and laboratory profile with a mean age of 42.5 years. Fever, headache, and arthralgia were common. Normal hemoglobin, significant thrombocytopenia, transaminitis, and hypoalbuminemia were identified in these patients. Compared to patients with isolated dengue, those with co-infection had higher pulse rate, lower systolic blood pressure, normal leucocyte counts, higher levels of liver enzymes, greater prolongation of partial thromboplastin time (aPTT) and lower serum albumin. Co-infection was characterized by a lower nadir platelet count compared to scrub typhus, and lesser time to nadir platelet count and longer duration of hospital stay compared to either isolated dengue or scrub typhus.

Conclusion

Dengue-scrub typhus co-infection may be under-diagnosed in tropics, particularly confounded during dengue epidemics. Normal leukocyte counts, early drop in platelets and hypoalbuminemia in dengue patients could be clues to concurrent scrub typhus infection. Prompt recognition and treatment of scrub typhus in such cases may reduce unnecessary hospital stay and cost.

Diagnostic evaluation of rapid tests for scrub typhus in the Indian population is needed

BACKGROUND

Owing to frequent outbreaks witnessed in different parts of the country in the recent past, scrub typhus is being described as a re-emerging infectious disease in India. Differentiating scrub typhus from other endemic diseases like malaria, leptospirosis, dengue fever, typhoid, etc. is difficult due to overlapping clinical features and a lower positivity for eschars in Asian populations. Hence, the diagnosis heavily relies on laboratory tests.

DISCUSSION

Costs and the need of technical expertise limit the wide use of indirect immunoperoxidase or immunofluorescence assays, ELISA and PCR. The Weil-Felix test is the most commonly used and least expensive serological test, but lacks both sensitivity and specificity. Hence, the diagnosis of scrub typhus is often delayed or overlooked. With due consideration of the cost, rapidity, single test result and simplicity of interpretation, rapid diagnostic tests have come into vogue. However, evaluation of rapid diagnostic tests for scrub typhus in the Indian population is needed to justify or discourage their use.

CONCLUSION

Research studies are needed to find the most suitable test in terms of the rapidity of the result, simplicity of the procedure, ease of interpretation and cost to be used in the Indian populace.

Polyarthritis and massive small bowel bleed: An unusual combination in scrub typhus

Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin.

Lost in a haystack: the importance of physical re-examination

We report an unusual case of varicella zoster in a 19-year-old, who presented with persisting fever even after her lesions began forming scabs. Fever workup for secondary complications was negative. A re-examination revealed an axillary eschar. She recovered completely with doxycycline. This report suggests the importance of keeping in mind, epidemiological data of common diseases in the locality, as well as the significance of a thorough physical examination in patients with fever.

Pancreatitis in scrub typhus

Scrub typhus is a rickettsial infection prevalent in most parts of India. Acute pancreatitis with pseudocyst formation is a rare complication of this condition. This paper reports acute renal failure, pancreatitis and pseudocyst formation in a 48-year-old female with scrub typhus. Ultrasonography of the abdomen revealed a bulky pancreas with fluid seen along the body of the pancreas in the lesser sac. The infection was successfully treated with doxycycline and supportive treatment. Pancreatitis was managed conservatively. This case report highlights the importance of identifying and managing uncommon complications of a common tropical disease for optimum outcome.

Acute pancreatitis due to scrub typhus

Scrub typhus is endemic in large parts of India and can cause multi-organ failure and death. Acute pancreatitis as a complication is very rare and is potentially fatal. This case series describes seven adult patients who presented with an acute febrile illness and were diagnosed to have scrub typhus with acute pancreatitis. The mean age of the seven patients with acute pancreatitis was 49.4 years, and mean duration of fever prior to presentation was 7.7 days. All seven patients had abdominal pain, and three had a pathognomonic eschar. The mean serum lipase level was 1,509 U/L (normal value: <190 U/L) and the mean serum amylase level was 434 U/L (normal value: <200 U/L). Six patients had evidence of multi-organ dysfunction. Hematological and respiratory system dysfunction was seen in five patients, hepatic and renal dysfunction in four, and central nervous system dysfunction in three patients. Three patients who had ≥4 organs involved, died (mortality rate: 42.8%). Our case series shows that pancreatitis in scrub typhus is an extremely rare complication and when present, is associated with increased mortality (42.8%). Physicians may be familiar with the various complications of scrub typhus but less so with acute pancreatitis and hence may be underdiagnosed.

Pancreatitis in scrub typhus: a rare complication

Scrub typhus is a zoonosis transmitted by a trombiculid mite which introduces bacteria of Orientia tsutsugamushi by its bite. The acute febrile illness is characterised by eschar at the site of the bite with maculopapular rashes and local and/or generalised lymphadenopathy. The disease is endemic in the tsutsugamushi triangle. Sikkim, a small Himalayan north-eastern state, is also not unaffected where outbreaks of the disease have been reported. The clinical spectrum of the disease ranges from mild to fatal depending on the virulence of the bacterial strain, susceptibility of the host and promptness of the treatment. In severe cases, there can be multiple organ involvement. Pancreatitis is a serious and unusual complication of this disease, which was seen in our presentation. A 22-year-old man, diagnosed to have scrub typhus, developed pancreatitis in the second week of the illness and responded well to medical treatment.

Unusual and rare manifestations of dengue during a dengue outbreak in a tertiary care hospital in South India

Dengue is the most rapidly spreading mosquito-borne viral disease in the world, and as a larger proportion of the population is being affected, more unusual manifestations are being reported. Very few studies have documented unusual manifestations of dengue in South India. This prospective study was undertaken from July 2011 to June 2013 to document rare manifestations of dengue fever in 175 hospitalized patients. The clinical diagnosis was confirmed by the detection of NS1Ag, dengue IgM, or IgG by ELISA and/or a RT-PCR and CDC real-time PCR for dengue virus (DENV) RNA. The daily profiles of the hematological and biochemical investigations were followed and recorded. Unusual and rare manifestations of dengue were documented for 115 patients (66 %). Hepatitis was observed in 70 % of the cases. Pleural effusion was seen in 11 %, acute renal failure in 10 %, neurological complications such as encephalitis in 7.4 %, myocarditis in 9 %, and bleeding gastric ulcers in 3.4 % of the cases. DENV serotype 2 was more prevalent in patients with unusual manifestations of dengue in our study. The WHO classification system does not include unusual and rare manifestations; hence, it is essential to be aware of these manifestations and closely monitor them for better clinical management and outcome of patients.

Scrub typhus meningitis in South India--a retrospective study

Background

Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports

Methods

A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness- a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits.

Results

Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol.

Conclusion

Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.