We present five cases of paediatric Scrub typhus from Community Health Centre, Namchi, South Sikkim emphasize timely diagnosis of scrub typhus for appropriate management. Response to doxycycline was good, with fever subsiding within 48-72 hrs of starting the treatment. Four out of five cases completely recovered once appropriate medication was given.

Key words: Child, India, Scrub typhus, Sikkim.

Non-specific presentation and lack of characteristic eschar leads to misdiagnosis and under reporting of scrub typhus. Further, non-availability of diagnostic facilities in native areas makes it even more difficult for the physicians to correctly diagnose and treat. We present five cases of pediatric scrub typhus from Community Health Center, Namchi, South Sikkim.

Details of all five cases of pediatric scrub typhus are presented in Table I. Suspicion of rickettsial disease was kept in mind after malaria and typhoid were ruled out. All cases were discussed with NCDC, Delhi and samples were drawn and sent immediately before starting doxycycline. Response to doxycycline was good, with fever subsiding within 48-72 h of starting the treatment. In all five cases significant titer of antibodies more than 160 in OX K antigen in Weil Felix test were found, and were also positive for IgM antibodies to Orientia tsutsugamushi by Scrub typhus detect IgM ELISA kit (Inbios , USA). Other additional important clinical findings included thrombocytopenia, anemia and low serum albumin.

Table I Clinical Profile of Pediatric Scrub Typhus Patients in South Sikkim, India.

Scrub typhus usually presents with fever, rash and complications involving respiratory, cardiac or central nervous system. Inoculation of O. tsutsugamushi through the bite of chigger is often painless and unnoticed [9]. Scrub typhus is common in rural areas. Out of five cases presented, 4 lived in Kuccha house and went for open field defecation which predisposes them to chigger bite. Appropriate history, and finding of eschar are often pathognomonic but can be missed by inexperienced observers. Lack of knowledge among physicians can lead to under diagnosis and improper treatment. Routine laboratory tests are normal; elevated transaminases and hypoalbuminemia can be used as pointer to investigate for rickettsial diseases. In resource poor countries, initial Weil felix test followed by ELISA based test for O. tsutsugamushi and Rickettsia conorii can make proper diagnosis. Although Indirect immunoflourescence assay (IFA) or Indirect Immuno-peroxidase test (IIP) and polymerase chain reaction (PCR) based tests are considered gold standard in confirmation of rickettsial diseases, they can only be performed in sophisticated laboratories, which was not possible in our case. We made the diagnosis based on clinical symptomatology along with two different tests (weil felix and IgM ELISA) and prompt response and recovery in response to doxycycline. Further studies are required to estimate the exact magnitude of disease in Sikkim.

Contributors: All authors contributed to all aspects of the manuscript preparation.

Funding: None; Competing interests: None stated.

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