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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 119-121

Acute respiratory distress syndrome complicating scrub typhus in pregnancy


1 Department of Medicine, ESIC Postgraduate Institute of Medical Sciences and Research, Basaidarapur, New Delhi, India
2 Scientist-C, Indian Council of Medical Research, New Delhi, India

Date of Submission17-Sep-2021
Date of Decision01-Oct-2021
Date of Acceptance21-Oct-2021
Date of Web Publication21-Mar-2022

Correspondence Address:
Dr. Rajesh Chetiwal
Department of Medicine, ESIC Postgraduate Institute of Medical Sciences and Research, Basaidarapur, New Delhi - 110 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_106_21

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  Abstract 


Scrub typhus is caused by Orientia tsutsugamushi (formerly Rickettsia) and is transmitted to humans by an arthropod vector of the Trombiculidae family. Recent reports suggest that there has been resurgence of rickettsial infections in the Indian subcontinent. As the clinical features of scrub typhus are nonspecific and closely mimic that of other tropical infections, its diagnosis is often delayed or missed. It may cause serious complications such as myocarditis, meningoencephalitis, acute renal failure, acute liver failure, pneumonia, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation, and multiorgan dysfunction syndrome. Early diagnosis is important because the response to treatment is excellent and may help prevent complications. Here, we report a case of scrub typhus in a pregnant woman complicated by ARDS; however, timely diagnosis and institution of therapy helped save two precious lives.

Keywords: Acute respiratory distress syndrome, rickettsia, scrub typhus


How to cite this article:
Kumar A, Tanwar S, Gupta S, Chetiwal R. Acute respiratory distress syndrome complicating scrub typhus in pregnancy. Indian J Med Spec 2022;13:119-21

How to cite this URL:
Kumar A, Tanwar S, Gupta S, Chetiwal R. Acute respiratory distress syndrome complicating scrub typhus in pregnancy. Indian J Med Spec [serial online] 2022 [cited 2022 May 23];13:119-21. Available from: http://www.ijms.in/text.asp?2022/13/2/119/340031




  Introduction Top


Scrub typhus is an acute febrile infectious illness that is caused by Orientia tsutsugamushi, an obligate intracellular Gram-negative bacterium, which was first isolated in Japan.[1] The disease is transmitted through the bite of the larval stage of infected trombiculid mites or chiggers. Humans are accidental hosts. It is widely endemic in the tropical and subtropical regions of Asia including India. Clinical manifestations range from nonspecific febrile illness with constitutional symptoms such as fever, rash, myalgia, and headache to fatal complications such as acute respiratory distress syndrome (ARDS), myocarditis, acute hepatic failure, acute renal failure, meningoencephalitis, hemorrhagic features, and multiorgan dysfunction. ARDS is a severe and potentially fatal complication of scrub typhus.[2] The disease is uncommon during pregnancy, but when present, it can have serious consequences for the mother and developing fetus. Only a few cases of scrub typhus complicated by ARDS in pregnancy have been reported in the literature to date. Here, we report a case of scrub typhus in a 24-year-old pregnant female complicated by ARDS. With a high clinical suspicion and timely institution of appropriate treatment along with assisted ventilation, we could save two precious lives.


  Case Report Top


A 24-year-old female with 28 weeks pregnancy presented to the emergency department with 4 days history of high-grade fever associated with chills and rigors, headache, myalgia, and dry cough with a history of shortness of breath for the past 2 days. On examination, the patient was febrile and tachypneic (respiratory rate 22/min), pulse rate was 114/min, blood pressure 130/70 mmHg. Cardiovascular examination was within normal limits. Respiratory examination revealed fine crepitations over the right base. Her oxygen saturation (SpO2) was 96% on room air. There was no rash or scar. The patient was admitted with a provisional diagnosis of the lower respiratory tract infection. She was started on intravenous ceftriaxone and supportive care. Routine laboratory evaluation showed a hemoglobin of 10.7 g%, hematocrit of 27%, white blood cell count of 14 × 109/l, with 60% neutrophils, 32% lymphocytes, 1% monocytes, and 1% eosinophils, a platelet count of 200 × 109/l, and random blood sugar of 98 mg%, with normal serum urea and creatinine levels. Serum glutamic-oxaloacetic transaminase and serum glutamic pyruvic transaminase were mildly raised (102 and 80 IU/L). Total bilirubin and coagulation profile were within normal limits. A peripheral blood smear for malaria parasites, serological tests for leptospirosis, dengue, hepatitis B surface antigen, anti-hepatitis C virus, HIV, and Widal gave negative results. Her arterial blood gases (ABGs) analysis was satisfactory.

On the 3rd day of admission, the patient's dyspnea worsened with a respiratory rate of 40/min and pulse oximetry showed decreased oxygen saturation (86% on room air). Bilateral extensive crepitations were present on chest auscultation. She was shifted to the intensive care unit. Her chest X-ray showed bilateral nonhomogenous opacities consistent with ARDS [Figure 1] and ABG analysis showed pH-7.42, pO2-33.9 mmHg, pCO2-30.9 mmHg, HCO3-18.7 mmol/L, and a PaO2/FiO2 ratio of 161.4. Two-dimensional echocardiography revealed normal cardiac function and BNP was within the normal limits. The patient's respiration was supported by noninvasive positive pressure ventilation. With a high clinical suspicion of scrub typhus, she was started on intravenous azithromycin 1 g on day 1 and subsequently 500 mg per day. Serology was found to be positive for IgM antibodies to scrub typhus. The patient responded dramatically and her condition improved rapidly. On day 5 of intensive care, there was a significant clinical improvement and assisted ventilation was removed on day 7. The fetal scan was normal and she was discharged on the 12th day of hospital admission.
Figure 1: Chest X-ray showing bilateral diffuse nonhomogenous opacities

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  Discussion Top


Scrub typhus, caused by Orientia tsutsugamushi, is a zoonosis endemic to a geographically distinct region known as “tsutsugamushi triangle.” In India, the disease had broken out in epidemic form during World War II in Assam and West Bengal.[3] It is known to occur all over India. However, the reported number of cases of scrub typhus from different parts of the country, particularly from large tertiary care hospitals does not give a true picture of its prevalence as the disease is grossly underdiagnosed in India. Recent reports suggest that there is a resurgence of scrub typhus infection in India and that the resurgence is associated with considerable morbidity and mortality.

Scrub typhus is quite rare in pregnancy. The clinical features during pregnancy are not different from nonpregnant women.[4] Common clinical features include abrupt onset of fever, sore throat, cough, myalgia, headache, rash, and the formation of an eschar. In the present case, all these features were present except for characteristic eschar and rash. The presence of an eschar is considered the most important clinical finding for the diagnosis of scrub typhus; however, it is present only in 60% of the cases.[5] In pregnancy, the disease may be associated with increased risk of fetal loss, preterm delivery, and small for gestational age infants.[4],[6] Vertical transmission of the disease can also occur causing neonatal scrub typhus.[7] ARDS is one of the most serious complications of scrub typhus, yet only a few cases of this disease complicated by ARDS have been reported in the literature. The mortality rates among ARDS patients can be as high as 25%.[2] It is even a more grave complication if occurs in a pregnant woman with scrub typhus. In India, scrub typhus is rarely diagnosed because of its nonspecific clinical presentation, a low index of suspicion and the lack of diagnostic facilities. Delay in diagnosis and in the initiation of appropriate treatment can result in severe complications. Serological tests are the mainstay of diagnosis. Doxycycline is the drug of choice in scrub typhus, but it is contraindicated in pregnancy. Azithromycin is the preferred drug in pregnancy with comparable efficacy and favorable maternal and fetal outcomes. Rifampicin is seen to be effective in the areas where scrub typhus appears to respond poorly to standard anti-rickettsial drugs.


  Conclusion Top


The present case study emphasizes that scrub typhus should be kept in the differential diagnosis of acute febrile illness in endemic areas such as India. The clinical features in pregnancy are the same as in nonpregnant females. Therefore, it is prudent to keep a high level of clinical suspicion as appropriate management of scrub typhus is critical for avoiding complications as well as adverse outcomes.

Consent

Written informed consent was obtained from the patient for publication of this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tamura A, Ohashi N, Urakami H, Miyamura S. Classification of Rickettsia tsutsugamushi in a new genus, Orientia gen. nov., as Orientia tsutsugamushi comb. nov. Int J Syst Bacteriol 1995;45:589-91.  Back to cited text no. 1
    
2.
Wang CC, Liu SF, Liu JW, Chung YH, Su MC, Lin MC. Acute respiratory distress syndrome (ARDS) in scrub typhus. Am J Trop Med Hyg 2007;76:1148-52.  Back to cited text no. 2
    
3.
Tallersall RN. Tsutsugamushi fever on the India–Burma border. Lancet 1945;2:392-4.  Back to cited text no. 3
    
4.
Phupong V, Srettakraikul K. Scrub typhus during pregnancy: A case report and review of the literature. Southeast Asian J Trop Med Public Health 2004;35:358-60.  Back to cited text no. 4
    
5.
Tsay RW, Chang FY. Serious complications in scrub typhus. J Microbiol Immunol Infect 1998;31:240-4.  Back to cited text no. 5
    
6.
Kim YS, Lee HJ, Chang M, Son SK, Rhee YE, Shim SK. Scrub typhus during pregnancy and its treatment: A case series and review of the literature. Am J Trop Med Hyg 2006;75:955-9.  Back to cited text no. 6
    
7.
Suntharasaj T, Janjindamai W, Krisanapan S. Pregnancy with scrub typhus and vertical transmission: A case report. J Obstet Gynaecol Res 1997;23:75-8.  Back to cited text no. 7
    


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