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van Eekeren LE, de Vries SG, Wagenaar JFP, Spijker R, Grobusch MP, Goorhuis A. Under-diagnosis of rickettsial disease in clinical practice: A systematic review. Travel Med Infect Dis 2018; 26:7-15. [PMID: 29486240 DOI: 10.1016/j.tmaid.2018.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/14/2018] [Accepted: 02/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rickettsial diseases present as acute febrile illnesses, sometimes with inoculation eschars. METHODS We performed a systematic review of studies published between 1997 and 2017 to assess the underestimation of non-eschar rickettsial disease (NERD) relative to eschar rickettsial disease (ERD), as a cause of acute fever in patients with rickettsial diseases that commonly present with eschar(s): scrub typhus (ST), Mediterranean spotted fever (MSF), and African tick-bite fever. We compared ERD/NERD ratios according to study design: 'complete approach' studies, with testing performed in all patients with 'unspecified febrile illness'; versus 'clinical judgement' studies, with testing performed if patients presented with specific symptoms. RESULTS In 'complete approach' studies, ERD/NERD ratios were significantly lower, suggesting a considerable under-diagnosis of NERD in 'clinical judgement' studies. Based on these results, we estimate that the diagnosis of rickettsial disease was missed in 66.5% of patients with ST, and in 57.9% of patients with MSF. CONCLUSIONS Study design influences the reported eschar rates in ST and MSF significantly. NERD is likely to be a vastly underdiagnosed entity, and clinicians should consider and test for the disease more often. PROSPERO REGISTRATION NUMBER CRD 42016053348.
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Affiliation(s)
- Louise E van Eekeren
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Sophia G de Vries
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Jiri F P Wagenaar
- Leptospirosis Reference Center, Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - René Spijker
- Medical Library, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands.
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Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM. A review of the global epidemiology of scrub typhus. PLoS Negl Trop Dis 2017; 11:e0006062. [PMID: 29099844 PMCID: PMC5687757 DOI: 10.1371/journal.pntd.0006062] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/15/2017] [Accepted: 10/21/2017] [Indexed: 12/18/2022] Open
Abstract
Scrub typhus is a serious public health problem in the Asia-Pacific area. It threatens one billion people globally, and causes illness in one million people each year. Caused by Orientia tsutsugamushi, scrub typhus can result in severe multiorgan failure with a case fatality rate up to 70% without appropriate treatment. The antigenic heterogeneity of O. tsutsugamushi precludes generic immunity and allows reinfection. As a neglected disease, there is still a large gap in our knowledge of the disease, as evidenced by the sporadic epidemiologic data and other related public health information regarding scrub typhus in its endemic areas. Our objective is to provide a systematic analysis of current epidemiology, prevention and control of scrub typhus in its long-standing endemic areas and recently recognized foci of infection. Scrub typhus is a serious public health problem in the Asia-Pacific area. There is an estimated one million new scrub typhus infections each year, and over one billion people around the world are at risk. Without appropriate treatment, the case fatality rate of scrub typhus can reach 30% or even higher. Scrub typhus has long been a neglected infectious disease so many aspects of the disease, including its diagnosis to prevention, are unknown. We here provide a comprehensive review of the epidemiology, prevention and control of scrub typhus.
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Affiliation(s)
- Guang Xu
- Department of Pathology, The University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - David H. Walker
- Department of Pathology, The University of Texas Medical Branch, Galveston, Texas, United States of America
- * E-mail:
| | - Daniel Jupiter
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Peter C. Melby
- Department of Internal Medicine, Division of Infectious Diseases, The University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Christine M. Arcari
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas, United States of America
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Bonell A, Lubell Y, Newton PN, Crump JA, Paris DH. Estimating the burden of scrub typhus: A systematic review. PLoS Negl Trop Dis 2017; 11:e0005838. [PMID: 28945755 PMCID: PMC5634655 DOI: 10.1371/journal.pntd.0005838] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 10/10/2017] [Accepted: 07/28/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Scrub typhus is a vector-borne zoonotic disease that can be life-threatening. There are no licensed vaccines, or vector control efforts in place. Despite increasing awareness in endemic regions, the public health burden and global distribution of scrub typhus remains poorly known. METHODS We systematically reviewed all literature from public health records, fever studies and reports available on the Ovid MEDLINE, Embase Classic + Embase and EconLit databases, to estimate the burden of scrub typhus since the year 2000. FINDINGS In prospective fever studies from Asia, scrub typhus is a leading cause of treatable non-malarial febrile illness. Sero-epidemiological data also suggest that Orientia tsutsugamushi infection is common across Asia, with seroprevalence ranging from 9.3%-27.9% (median 22.2% IQR 18.6-25.7). A substantial apparent rise in minimum disease incidence (median 4.6/100,000/10 years, highest in China with 11.2/100,000/10 years) was reported through passive national surveillance systems in South Korea, Japan, China, and Thailand. Case fatality risks from areas of reduced drug-susceptibility are reported at 12.2% and 13.6% for South India and northern Thailand, respectively. Mortality reports vary widely around a median mortality of 6.0% for untreated and 1.4% for treated scrub typhus. Limited evidence suggests high mortality in complicated scrub typhus with CNS involvement (13.6% mortality), multi-organ dysfunction (24.1%) and high pregnancy miscarriage rates with poor neonatal outcomes. INTERPRETATION Scrub typhus appears to be a truly neglected tropical disease mainly affecting rural populations, but increasingly also metropolitan areas. Rising minimum incidence rates have been reported over the past 8-10 years from countries with an established surveillance system. A wider distribution of scrub typhus beyond Asia is likely, based on reports from South America and Africa. Unfortunately, the quality and quantity of the available data on scrub typhus epidemiology is currently too limited for any economical, mathematical modeling or mapping approaches.
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Affiliation(s)
- Ana Bonell
- Oxford University Clinical Research Unit, National Hospital of Tropical Diseases, Hanoi, Vietnam
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Laos
| | - John A. Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Daniel H. Paris
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Medicine, University Basel, Basel, Switzerland
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Abstract
Background: Scrub typhus is rampant in northern, eastern, and southern India. Central nervous system involvement in the form of meningitis or meningoencephalitis is common in scrub typhus. As specific laboratory methods remain inadequate or inaccessible in developing countries, prompt diagnosis is often difficult. Aim: The aim of this study was to characterize neurological complications in scrub typhus from northeastern region of India. Subjects and Methods: We did a prospective study of scrub meningoencephalitis at North Eastern Indira Gandhi Regional Institute of Medical Sciences among patients admitted to hospital between October 2009 and November 2011. The diagnosis was made based on the clinical pictures, presence of an eschar, and a positive Weil–Felix test (WFT) with a titer of >1:160 and if required a positive scrub IgM enzyme-linked immunosorbent assay. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits, and magnetic resonance imaging (MRI) brain performed if needed. Results: Twenty-three patients of scrub typhus meningitis that were serologically confirmed were included in the study. There were 13 males and 10 females. Fever ≥1 week was the most common manifestation (39.1%). Interestingly, none had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 17 cells/μL, 90%, 86 mg/dL, 0.6605 and 3.6 U/mL, respectively. All patients were treated with doxycycline. There was no mortality in our study. Conclusions: Absence of Eschar does not rule out scrub typhus. Clinical features and CSF findings can mimic tuberculous meningitis so misdiagnosis may lead to unwarranted prolonged empirical antituberculous therapy in cases of lymphocytic meningoencephalitis. Delay in treatment can be potentially fatal. WFT still serves as a useful and affordable diagnostic tool for this disease in resource-poor countries.
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Affiliation(s)
- S R Sharma
- Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - H Masaraf
- Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - K G Lynrah
- Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - M Lyngdoh
- Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
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Gupta R, Singh V. Indian tick typhus - an uncommon cause of hepatitis: a case report. J Clin Diagn Res 2014; 8:MD01-2. [PMID: 24995203 DOI: 10.7860/jcdr/2014/7037.4308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 03/12/2014] [Indexed: 11/24/2022]
Abstract
Although viruses remain the most common cause of hepatitis, other causes like rickettsial hepatitis are also well known. However, this aetiology has not been well recognized and it has been rarely reported in the Indian literature. Here, we are discussing a case of acute hepatitis, its clinical presentation, diagnosis and treatment, which was later found to be caused by Indian tick typhus (a spotted fever group rickettsia), which was diagnosed on the basis of serology and its clinical response to doxycycline. Further literature review has been done, to discuss various clinical presentations and prevalence of rickettsial infection in this part of the world.
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Affiliation(s)
- Rahul Gupta
- Senior Resident, Department of Hepatology, Postgraduate Institute of Medical Education and Research , Chandigarh, India
| | - Virendra Singh
- Professor, Department of Hepatology, Postgraduate Institute of Medical Education and Research , Chandigarh, India
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Dass R, Deka NM, Duwarah SG, Barman H, Hoque R, Mili D, Barthakur D. Characteristics of pediatric scrub typhus during an outbreak in the North Eastern region of India: peculiarities in clinical presentation, laboratory findings and complications. Indian J Pediatr 2011; 78:1365-70. [PMID: 21630069 DOI: 10.1007/s12098-011-0470-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 05/05/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To identify and report a recent outbreak of scrub typhus cases recorded from October 2009 to January 2010 in the state of Meghalaya, India. METHODS The case sheets of all the children were retrieved and reviewed retrospectively. Twenty four (24) patients, who were both clinically and serologically confirmed as scrub typhus cases were included in the study. RESULTS Fever for more than 1 wk duration was the most common manifestation (100%) followed by splenomegaly (45.8%), eschar (41.7%), cough (37.5%), hepatomegaly (33.3%), headache and body ache (25%), pain abdomen (25%), vomiting (20.8%), altered sensorium (16.6%), seizures (12.5%) lymphadenopathy (12.5%), and loose stools (8.3%). Meningoencephalitis was the most common complication (29.2%) followed by pneumonia (16.3%) and subconjunctival hemorrhage (8.3%).Cortical blindness, septic shock, peritonitis, myocarditis with CCF, pancytopenia, acute renal failure, coagulopathy, prolonged oxygen dependency and urinary tract infection (UTI) were found in one of each case. Hyponatremia (66.7%), elevated liver enzymes without significant rise of bilirubin (58.3%), hypoalbuminemia (52.2%) and thrombocytopenia (26%) were the other significant laboratory findings. Patients were treated with chloramphenicol, doxycycline and azithromycin. There was no mortality. CONCLUSIONS This is the first outbreak report from the north eastern region of India with varied clinical presentations, laboratory investigations and complications. Weil Felix test still remains fruitful for diagnosing this disease in a resource limited set up.
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Affiliation(s)
- Rashna Dass
- Department of Pediatric Disciplines, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong, Meghalaya, India.
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