Scrub typhus in rural Rajasthan and a review of other Indian studies

Background: Scrub typhus is an acute febrile illness which has been reported from various parts of India with Rajasthan recently joining the list of affected states. Aim: To report a series of paediatric scrub typhus cases from rural Rajasthan. Study design: Retrospective review of children with scrub typhus admitted to the wards and paediatric intensive care unit (PICU) of a tertiary-care hospital. Methods: The study was undertaken over an 8-month period from May to December 2013. All patients with a clinical presentation and/or serological confirmation of scrub typhus who tested negative for malaria, enteric fever, dengue, leptospirosis and urinary tract infection (UTI) were included. A range of investigations were undertaken including IgM-ELISA for scrub typhus, followed by appropriate medical management. Results: Thirty patients satisfied the inclusion criteria. The mean (SD, range) age of the patients was 8.56 (3.43, 316) years. The most common clinical features were fever (n=30, 100%), headache (n=20, 66%), myalgia (n=15, 50%), hepatosplenomegaly (n=18, 60%) and pallor (n=5, 16%). Typical features such as eschar and rash were observed in only one (3.3%) and three (10%) patients, respectively; none had generalised lymphadenopathy or conjunctival congestion. IgM-ELISA for scrub typhus was positive in 28 patients (93.3%) and 27 responded to doxycycline within 24-72 hours. One of the three patients who required PICU support responded to intravenous chloramphenicol and, of the other two (6.6%), one died of acute respiratory distress syndrome and the other owing to acute renal failure. Conclusion: A high index of suspicion is essential for early diagnosis and prevention of complications in scrub typhus together with prompt referral from rural areas to a higher centre. Awareness of the disease manifestations may further help to prevent excessive investigations in patients presenting with nonspecific febrile illness and reduce the economic burden to the family and society in resource-constrained settings.